It's Not About The Pus

To Dr. Sandra Lee. Heartfelt thanks for humanizing medicine and for inspiring along the way...

Several years ago, my daughter Emma introduced me to some videos on YouTube of a dermatologist from California who posted her sometimes shocking but always intriguing encounters with patients who suffered from a variety of dermatologic issues. Of all of these videos, it seemed like the ones which made Emma happiest to watch were the videos in which this doctor's treatment resulted in gallons of pus draining from some part of the patient's body.

Well, okay--Emma liked pus and blackheads. Well, pus and blackheads and massive lipomas (fat-based tumors). Well, pus and blackheads and massive lipomas and big hairy moles. Well...

You get the picture.

With some great finesse and skill, and with a good mix of humor and learning, Dr. Sandra Lee, better known as Dr. Pimple Popper, was able to help many embarrassed patients survive their dermatologic issues, all the while captivating my daughter's interest. "Eewww, gross," Emma said. "Let's watch it again!"

Suddenly, my job as an ER physician was boring. Stories of heart attacks, strokes, traumas, broken bones, asthma attacks, allergic reactions, even drunks vomiting on me at 3 am--none of them held any excitement compared to the ten-year old massive cyst that Dr. Lee excised from a women's scalp or the golf ball-sized lipoma she removed from the upper back of a man who hid it by wearing a draped shirt. Yes, it was intriguing even for me to watch. How was I going to compete with Dr. Lee popping juice out of everything she touched?

I lost my daughter to the wonders of Dr. Lee. "Dr. Pimple Popper is so great, Dad!"

Not only Emma, but soon my friends and family were asking if I did "the stuff that Dr. Pimple Popper does." They too couldn't seem to get enough of the various videos posted on YouTube. And like Emma, more pus equaled more entertainment. Pus that flew across the room--well, that created a giddiness that could not be contained.  

"Yes," I would answer, "sometimes I have to drain an abscess from someone's armpit or groin due to an ingrown hair. Sometimes I have to drain abscesses from wounds, too." For good measure, I added, "And sometimes I have to drain a thrombosed hemorrhoid." I know there are many more invasive procedures we perform in the ER that could be considered similar, but I couldn't think of them quickly enough. At least, I thought, I would get asked what "thrombosed" meant, right?

I was wrong. After finding out that most of my procedures were performed on problems smaller than the size of a tennis ball, my people lost interest.

As the last few years passed, I was happy to catch an occasional YouTube video of Dr. Pimple Popper. Dr. Lee's contagious personality and warm smile, combined with her intelligence and skills, helped her to create a spectacular vehicle, by use of videos, to share the fascinations of her profession. She was a natural at bringing some amazing stuff to eager viewers who were insatiable for her.

On a recent trip with friends to Toronto to celebrate the arrival of 2019, we had returned to our hotel rooms one afternoon to rest for a few hours after a very late previous night of fun. While channel-surfing, I was excited to rediscover Dr. Lee and learn of her new television show on TLC. Desperately needing a nap, I committed myself to just watching her for ten minutes, maybe fifteen at most.

Fifteen minutes turned into two hours. In the blink of an eye.

This time, though, watching Dr. Lee was a very different experience. Yes, all of the fascinating lumps and bumps and lesions that needed squeezed, drained and excised still existed. Yes, white and brown and green and black pus still oozed from the majority of her patients. Yes, many of her patients still found brilliant ways to hide their ailments for years, under wigs and baggy clothing or with caked-on makeup.

This time though, among all the hoopla, I was able to appreciate Dr. Lee's magnificent mannerisms, her empathy, her compassion--her realness, so to speak--in dealing with her patients. Recognizing these things initially, I believe, had gotten lost within all the other excitement. I was more focused on how fast she could duck away from some flying pus rather than her gentle approach to patient care.

For example, after a patient was kindly greeted by office staff and placed in an exam room, the real magic began. Dr. Lee would softly knock on the door of the treatment room before entering, wearing a smile and exuding warmth. As she approached the patient, hand extended in greeting, she would establish eye contact with the patient and introduce herself with a gentle and calm voice (sometimes simply by her first name). From there, if anyone else was in the room, she would turn her attention to them, making sure to introduce herself, repeating the process until she was acquainted with each person in the room. After introductions, she would sit down (yes, sit!!!) and begin her interview with the patient, involving the patient's company, learning everything she could about the reasons a patient was visiting her. Respect was given and received. Eventually, a wonderful level of comfort was achieved.

I could continue on with the importance of Dr. Lee's empathy and compassion while performing a detailed exam, explaining her findings of the exam, reviewing test results and options to treatment, and mapping out the future course of dealing with a patient's ailment, but it all seems rather obvious, right?

Or does it?

You would be surprised at the number of patients who go through the process of a medical encounter only to leave with confusion, frustration, or feeling worse than prior to their encounter. No introductions. Standing at bedside with arms folded, appearing disengaged and aggravated. Rushed conversation. No updates. Abbreviated result explanations and dispositions. This is the reality of an encounter for many patients.

Ugh.

Recently, a close friend of mine had to take his elderly mother to a rural ER twice, in a span of two weeks, for some serious and concerning symptoms. To hear him talk of the vast difference in the care they received, by the same facility but different treating teams, was upsetting. During the first encounter, introductions were made, respect was given, explanations were provided, and a detailed treatment plan was initiated. During the second visit, there were no introductions by either the physician or nursing team. His mother was dismissed or hushed each time she tried to explain her symptoms in some depth. They were made to feel like a nuisance. No rechecks were performed. They sat around for five hours wondering what was going on. Their questions brought no answers. "And Jim," he said, "only about five of the twenty rooms had patients in them." My buddy's family was truly disheartened and discouraged by the encounter.

Years ago, during my emergency medicine residency in Syracuse, we had a physician who gave lectures to us on the importance of empathy and compassion. Being young-guns in a big trauma center, Dr. Ruth's lectures were not nearly as exciting to my buddies and I as compared to lectures on how to drain an expanding epidural hematoma (a potentially fatal arterial brain bleed) or perform an emergency thoracotomy in a trauma patient (rapidly opening the chest between ribs to clamp a sheared aorta or contain bleeding from a punctured heart or lung, for example).

Yet, it was during residency when I truly realized the power and magnificence of empathy and compassion in medicine. Of respect and dignity. Of smiling and bringing into a patient's room good energy. Of sitting down if even but for a few minutes. Of introductions and eye contact to all in the room, not just the patient. Of a warm handshake. Of explaining findings of the exam, of the testing and procedures to be done and the ensuing results, and of a plan moving forward. Of rechecking the patient during their medical visit. Of properly closing the loop of their visit with a goodbye or good luck wish.

Of being human.

This was a crusade I took up while working with our residents as a core faculty advisor. I became Dr. Ruth, insisting on my residents bringing their very best to each patient encounter. While empathy and compassion and ease of conversation was inherent and easier for some residents, for others more time and work needed to be invested to improve this part of their patient encounters. An investment, I stressed, that was worth pursuing.

Yes, the ER gets busy. Crazy and insanely busy. I get it. I've witness it firsthand for 22 years as an ER attending physician. However, all of these things mentioned above take just a few extra minutes. Providing anything less is met with too many excuses. Occasionally, in the emergency setting, it truly is beyond our control that we simply can not provide more empathy or time to a patient (think about a car accident with four critical victims arriving at the same time). Otherwise, if it were me or my family or friend lying in that hospital cot as a patient, I would greatly appreciate those few extra minutes of kindness and compassion provided by the treating medical personnel.

What if it was you or your family member?

Returning to Dr. Lee's TV show, then, on that lazy afternoon in Toronto, I greatly appreciated her kind approach to each patient. Sure, she might have more time working in an office setting that is more predictable and controlled compared to my working environment in a big trauma center. Sure, she is being taped to splice together some great scenes and moments of the various care she provides. Sure, anyone might give a little more of themselves if they know they are being watched. However, Dr. Lee consistently demonstrated her excellent bedside manner with each patient encounter I watched. She excelled and inspired in a part of medicine that is often ignored and overlooked, all for the sake of moving more patients in and out and increasing the billing so more profits could be made.

I could have cared less about how much pus would fly out of her next abscess or where it would land. I was enthralled on simply watching a great doctor doing her job well, from every perspective.

I hope Emma was, too.

Thanks, Dr. Pimple Popper. It was never really about the pus...

As always, big thanks for reading. What are your thoughts and experiences?   

Feel free to forward or share this post. To visit some of my favorites listed from the archives, visit Thank You...

I continue to be amazed with the amount of support and readership. My heartfelt appreciation to all...   

Another Birthday

Today is my birthday.  Yep, today.  On this fourth day of this fourth month of this year, I officially have turned 44.  Should I buy a lottery ticket with these numbers?  Something is whispering to me that if I ever had a realistic chance to win, it would be today.  Nah, who am I fooling--I think I'll just keep that errant dollar in my pocket.

44 is an odd age, though.  Am I middle-age?  Am I the new thirties?  Is my life half over?  Or more than half?  That thought makes me shudder.  I look at some of my patients in the ER, those in their 20's and 30's, and in my mind I am dealing with someone in my own age group.  Maybe they have less wrinkles and a fewer amount of life experiences, sure, but otherwise we are the same, aren't we?  That is until they call me "sir," a word I am growing less fond of the older I get.  And suddenly, I am reminded that no, I do not have as much in common with this college student sitting on the treatment cot in front of me as I might have thought.

Still, birthdays are pretty special when you are surrounded in your life by people who make a big deal of them.  Being one of seven kids, I've already received texts by four of my siblings and some nieces and nephews to "have a great day."  The phone calls will follow tonight, with multiple renditions (mostly bad) of the song "Happy Birthday" sung to the answering machine or myself.  When my mother was alive, she and Dad would always call and sing "Happy Birthday" in harmony from their two different receivers, Mom carrying the high notes and Dad trying to blend his deep, husky off-tune baritone to compliment her.  Since she passed on, Dad still keeps this tradition alive.  It is bittersweet, to say the least, to have Dad call and sing a solo "Happy Birthday" to me.  A big sigh typically follows, and longings for my mother's missed presence follow that.  The beauty in this, though, is that over the two years prior to Mom's lost battle to leukemia, we recorded every "Happy Birthday" sung by them to my family.

My kids and wife, though, are the real reason the excitement level in our house today is immense.  For the past week, there has been whispering between she and my kids that suddenly stops when I enter a room.  There has been hushed huddling in front of the desktop computer, a flurry of hands blocking the screen's view when I walk into the office.  There have been shopping trips to the mall, the kids returning with big grins on their faces and filled shopping bags held behind their backs.  "Don't look, Dad!"  has become the newest greeting in our house.  Tonight I will eat my favorite cake, chocolate from scratch (which includes a cup of coffee) topped with mounds of creamy peanut frosting, made lovingly by my wife from Mom's recipe.

So today, then, is the day.  My 44th birthday.  I was woken up with hugs, warm and heartfelt and accompanied by morning breath.  And chimes of "Happy Birthday, Dad!"  There is no better sweetness in this world than hearing these fluent, tender words from your children's innocent mouths.  Birthday wishes from my wife, too.  A flurry of activity followed as they got ready for school.  A grab of my hand by my youngest, who lead me to the dining room table to proudly show me the presents that await my opening.  Their homemade cards and homemade gift wrap make my smile double.

Then, too suddenly, the buses came to take my kids to school.  My wife left in the SUV to work her school-related job.  And, just like that, all of the excitement contained within our four walls just minutes earlier dissipated, a big balloon of happiness and anticipation popped... to be filled up again upon their return.  I go to sit alone in my office.

I have the morning and afternoon off, but work an odd evening into morning shift tonight.  So I sit here in my silent home, giving up the hope that cranked techno music from Robyn on YouTube will bring back all of that excitement.  It didn't.  Instead, a life lesson smacks me in the ass.  Hard.

My birthday and this swirling excitement that comes with it is not just because of the day.  Or the cake.  Or the presents.  It is because, simply, on this day, I am reminded of just how blessed I am to be surrounded by so many people in my life who love and care for me.  The simple texts, the emails, the phone calls, the snail mail birthday cards--all warm hands coming from near and far to wrap themselves around me on this day.  There are no better birthday gifts...

Sitting here, introspective and reflective of my life so far, I find that I am beyond grateful.  Grateful for it all.  The family.  The siblings and parents.  The nieces and nephews.  The cousins.  The friends.  I am a lucky guy.

After all of this, I looked at a brown envelope sitting on my desk, sent to me by one of my best friends through medical school--KT.  To know KT in this life, to have her friendship, is one of those precious gifts I sometimes take for granted.  She is, after my wife and Mom and sisters, one of the most remarkable women that I will ever know.  Her kindred spirit and friendship is unmatched.  And besides, how many other family physicians do you know still make social calls to their patients' homes?

What follows is a cursive note she sent (along with a beautiful book and two birthday cards).

Dear Jim,

     My friend, my brother...how does it feel to you to be celebrating a life so full?  I am acutely aware of the significance this year of similar double digits!
     At 11, I was hiding in the woods with my friends, telling secrets, crushing on Bobby Joe across the street (be still my heart!)  I was a child in a giant's body!
     At 22, I owned the world...I was a college graduate and I was going to medical school!  I was sizzling!  Life was mine to take!
     At 33, I was a mother, in love with my girl, struggling to mesh my original dreams of being a doctor with my dream, unexpectantly better, of motherhood.  I couldn't get enough of my daughter if I ate her!  She was and still is a force in my world!  What a ride I got, eh?
     At 44, I know contentment, really and truly.  But I also know worry...  My life and love has blossomed as my family came to be--a daughter, a son, a dog, and oh yeah, a husband.  I know I am not invisible--my achy hips let me know that every day!  But I am more alive now than ever before.  I have loved, lost, given and gained...
     What will the next half bring?  55?  66?  77? 88? And, oh yeah, I plan on doing 99.  You too?
     So, my brother in this walk...I wonder what you would say about 11, 22, 33, 44?  I think I can guess a few of the emotions.  We have been blessed in love and in friendship, haven't we?

Big hug, Jim!  Have an awesome birthday!  KT

How's that for a birthday gift?

May everyone have a birthday like mine today, where they are reminded of the beauty of the people in their lives.

Now, where are my presents???

As always, big thanks for reading.  May KT see the beauty and specialness in her writing voice here today.  To my family and friends, especially my wife and kids, thanks for making this a special day...I am smiling here.

How Do You Sleep?

One of the more common, non-emergent complaints I hear in the ER is about sleeping, or the lack thereof. Although the patient is usually being seen for a more serious, emergent issue, if their sleep is not solid, they tend to skillfully bring it up regardless of what else is going on.

"Maam," I said, "it appears by your EKG that you are having a heart attack."

Despite chest pain so intense that my patient was clutching her chest, she still stammered, "But what can we do about my sleep?"

Or, imagine my elderly male patient in the midst of a stroke, with the left half of his face drooping, his speech slurred, and drool sliding down his chin. "I shant schweep adt nichte."

"Pardon me, sir, but what did you just say?" I asked.

Thankfully, the nurse starting his IV understood him. "He said, 'I can't sleep at night.'"

See what I mean? I've even had a patient share her insomnia issues during a pelvic exam. Maybe if she had slept more and fooled around less, I wouldn't have had to do this exam for her itchy, malodorous discharge in the first place.

Barring the situational, temporary reasons (for example, a death in the family), sleep disorders are typically viewed as chronic, long-term illnesses and, as such, should be treated by one's family doctor. Sleep studies may be necessary, and there are several options of treatment to prescribe, all requiring close follow-up. All reasons for me not to treat a patient for this disorder. I will, in a pinch, prescribe a few days worth of medication for a patient if their daily life is being severely affected, but that's about it.

Several years ago, after some prompting by my wife, I underwent a sleep study. It seems that I was having bouts of snoring and gasping for air in my sleep, per my wife. I'm not sure how she knew this, seeing that her head hits the pillow and a six-to-eight-hour coma immediately follows. But yes, she insisted, this was happening. So I took her word for it and pursued the testing.

I arrived at the sleep lab suite around 7:30 p.m, nervous and not sure what to expect. After checking in, I was shown to a huge bedroom, professionally decorated, with a queen-size, pillow-top bed beckoning for my company. "Come, Jim" it whispered to me, "come and let me wrap my big, down-filled arms around you." I think I heard the 40-inch TV calling, too, but I could have been imagining that.

After the tech showed me to my private bathroom, I changed into some appropriate sleepwear. You might be asking yourself--what's appropriate? I'm going to let your imagination answer that question. Just be aware, though, that they videotape you through the night as you sleep. And then post that video on YouTube. Just joking. Suffice it to say, I would suggest that one wear more than just the usual home sleepwear. And newer, too. Please, on behalf of all the sleep-lab techs in the world, don't show up in a stained, big-daddy Hanes t-shirt. Or tighty-whiteys. Or a moth-eaten thong. Or nothing at all. Especially nothing at all!

After changing, I climbed into bed. Soon, the tech came into the room. I was nervous, obviously, and likened this anxiety to how a 60 year-old fat, balding guy must feel while lying in his hotel bed, waiting for his prostitute to arrive.

The tech, a nonchalant, easy-going guy, explained the whole process to me. "First, we 'll attach these electrodes to your head, then your chest and finally your arms. After that, we'll leave you alone. You can do whatever you want--watch TV, read a book, whatever--until around 10 p.m. If you aren't sleeping by then, we'll ask you to turn off everything. Don't forget," he continued, "besides monitoring you, we'll be watching you on video." He pointed to the cameras in the upper corners of the room while he spoke. "Any questions?"

No questions, but just a silent prayer. "Dear God, I beg of you, keep me from scratching myself or making a fool of myself tonight. Amen." I added a bargain for good measure. "Oh, and if you do, God, I promise to give every ER patient a turkey sandwich, a warm blanket, and unlimited lemon pudding during the next week."

The tech left the room. I looked around, all this comfort surrounding me, and all I could do was think "How the hell am I going to sleep with all these wires hooked up to me?"

Well, I read a little, I flicked through the 1000 available TV channels, and finally, around 10 p.m., I turned off the lights. There's no way, I thought to myself, that I'm going to fall asleep. I pictured my wife at home, smiling, arms and legs spread out, sleeping soundly alone in our bed. I had the bad feeling that I had been set up.

Next thing I knew, though, I was being nudged in the shoulder. "Hey," I heard, "it's time to wake up." Through groggy, squinting eyes, I peered slowly around, clearing my mind's disorientation. That's right, I reminded myself, I was in the sleep-lab and, wouldn't you know, just had my best night's sleep in about ten years.

"You did great," the new male tech said. "Let's get you up and out of here." I got up, moved to the side of the bed, and he removed all of my electrodes. I got a quick shower, cleaning all the gel off of my head and body, brushed my teeth, got dressed, and headed home. I didn't need to hear the official results, I already knew--everything would come back normal.

Yeah, well, I'd like to call a penalty--the sleep-lab guys cheated. Unlimited channels, private room with bathroom included, big pillow-topped bed with down-filled comforter, the bed all to myself--who the heck couldn't sleep within those luxuries? The wires were but a mere distraction.

Have any of you had a sleep-lab study done? Similar experiences? Would you like to share how it went? What you wore? Let me lower my voice three octaves, like the great Barry White's, to a whisper and ask again. "Hey you, yeah you, how you doin'? What did you wear during your sleep lab?"

It took me some time, but I have my sleep all figured out now. Three, no four, things work for me. One, no alcohol. It's been shown to interrupt your sleep cycles, so I cut out my nightly glass of wine. Two, a great book. Three, Tylenol PM. Just one, occasionally. And four, in a pinch, 1/2 of a 10 mg Ambien tablet. I still have half of a thirty-day supply prescribed from last November. Take it on an empty stomach and within a half-hour, I'm a little woozy. Next thing I know, I wake up and it's morning time. And life is good. Bring on the day!

This isn't medical advice, just what works for me. Sometimes, though, it works too well. After taking a Tylenol PM several nights ago (I'm in the midst of several busy ER shifts), I woke up the next morning, horrified. On the ottoman beside our bed, my laptop computer sat with the top opened. Here, after taking my Tylenol PM, I had the brilliant idea to email a few people about their kind comments left on my blog. Rereading those emails this morning, I could only laugh and send those readers a follow-up email, apologizing for the ramblings. Forgive me if you got one.

Okay, I gotta run. I feel the Tylennnnnolll PPPPPMM kkickkkkkingggg innn aaagainnnnnnnn. Seriously. As we used to say when I was younger, "Good night, sleep tight. And don't let the bed bugs bite."

As always, big thanks for reading. Next post will be Wednesday, March 10. See you then...