Epilogue

None of us really had any warnings about my Dad's death. I mean, in retrospect there were a few things, but nothing that any rational person would have paid attention to. And you can beat yourself up all you want about "I should haves" and they won't change a thing. He was obviously depressed, but none of us ever suspected he'd go that far.

Death is inevitable for all. We grow up knowing that, in all likelihood, our parents will go before us and we'll go before our own kids. That's the natural order of life on Earth. There are exceptions, but, for most people, we know way in advance that the day will come when our parents aren't there. My parents watched their parents pass on, now it's my turn to watch mine do the same, and someday my kids will do the same with me. The physicists can argue all kinds of cool things about the nature of time, but here on Earth it pretty much has the same affect on all of us.

But nothing can really prepare you for the actuality of it really happening. Suddenly finding you can't email or call your Dad, like you just did the day before. I still see articles and think "I'll forward this to Dad, he'll love it..." and then stop.

Nor can it prepare you for the shock of what mine did. The phone call from my mom that fortunately came in the few minutes between patients. The tone of her voice and exact words. The frantic conversation with Mary about rescheduling the rest of the day. Seared memories that I'll carry with me to the end.

Dad was successful in life. He had health, family, and money to enjoy. All the reasons we think of for someone to kill themselves... he had none of them. But depression. And it can kill.

One thing I come back to repeatedly is the "why?" If he'd died of a heart attack... that would be so much easier to handle. The fact that a loved one would intentionally do something like this, to themselves and their family, is just devastating. You understand that they're not themselves or thinking clearly, but that doesn't make it any easier.

Of course, the gun didn't kill him immediately. Mom, my sister, and I stood at the bedside in ICU that afternoon, with various friends and other relatives who arrived. How word spread I still have no idea. I reviewed his CT scan myself. I kicked around moving him to a hospital with a neurosurgeon I trusted, but was stopped by the realization that this is what Dad wanted. Even though a good neurosurgeon would have been able to save his life, I've seen enough of this stuff to know he'd never be my Dad again. To this day that decision still haunts me, even though I know I did the right thing. It always will.

So, we let him go. Even with the tube out, and a shitload of Morphine and Ativan, his body wouldn't give up. So we all finally decided to say goodbye and leave forever. School was getting out, and I had to pick up my kids and figure out how to tell them.

Months before my wife had found an old alarm clock in the attic, and set it up in her home office to have a clock there. The alarm had never been set.

At 8:39 that night, we were all startled by a loud noise we'd never heard before. A search through the house found it was the clock's alarm going off, for no clear reason. The kids denied having touched it, and when I checked it was set for the default alarm of 12:00.

After staring at it for a few minutes, I called the ICU. "This is Ibee Grumpy. Has my Dad died yet?" "Why, yes, we were just about to call you. He died at 8:39."

We have an old musical wind-up cable car in the front hall that my wife picked-up on a trip to San Francisco 20 years ago. Nobody ever touches it. But for the next several nights it would randomly play a few notes after midnight and wake me up.

I'm a scientist. I don't believe in these things. But, on the other hand, I admit there are more things in heaven and earth than are dreamt of in our philosophies. Who knows?

The next day, while at my parent's house, I read through Dad's internet browser records. A lot of sites on how to beat depression, what to expect from your depression medications... not a single page about suicide or guns going back over a year. Oddly, the last internet site he'd visited was the day before he died... and it was this one.

I'd spoken to him a day or two before, and exchanged emails with him the day before. I sit and wonder why he didn't call me in his last minutes to ask for help. My wife's answer nailed it: "Because he didn't want to be stopped."

I still talk to him a lot. I probably always will. I'm not angry at him. But the one thought I'm left with more than any other will be with me for the rest of my life:

"Dad, it wasn't supposed to end this way."

Him

It was an old gun.

The man had bought the gun in 1967. He was a young lawyer, with a toddler and another on the way.

His wife was a schoolteacher, supporting their small family while he started a law practice. His father had been a cloth-cutter at a factory in Chicago, and worked long hours to support his family and pay for his son to go to law school. The older man had always believed in "give a man a fish, he'll eat for a day... teach a man to fish he'll eat for a lifetime" and wanted to do that for his son.

After graduating from law school the young man and his wife (they'd known each other since they were 15 & 14) felt like their future was elsewhere, and moved west. They left behind the only family they had and only place they'd ever lived. Most would follow them in a few years.

The man was 25 when his only son was born. A month later the man's father died at 66. It devastated him, and took him a year to recover. He was an only child and returned to Chicago to close things out, and his mother decided to move West to join the young family.

One day, after he'd won a divorce case, the lady's ex-husband threatened to kill him. Since the ex had a history of violence, the lawyer bought a small handgun and some ammo. He hoped to never use it, but also wanted to be able to protect his family. It wasn't even much of a gun. Just a .22 pistol, the closest thing to a pop gun among actual firearms.

The threat never materialized. The ex moved away, and the lawyer hid the gun in an old suitcase in his closet and forgot about it.

The man's law practice grew, and he became a successful attorney. He found his niche in life, and was good at it. He loved his work, but was also devoted to his family. As his kids grew he took time off whenever he could to do things with them. One day he and his wife called them in sick to school, so they could take them to the zoo instead. The family traveled to Hawaii. Up and down throughout western America. Europe. Mexico. Canada. Disneyland. The beach. River trips. National parks. Hawaii. Alaska. Nothing incredibly exotic, but fun. While not wealthy, they were comfortable. He worked very hard.

On a 1979 trip to Mexico City, his son remembers watching an old beggar shuffling down the street holding a bucket in one hand and shaking maracas in the other. He had no teeth, and both eye sockets were empty. The man watched the beggar, then walked over and put a handful of coins in the bucket. The beggar silently made the sign of the cross.

In a city full of people asking for money, this was the only time the man ever did that, and he told his son that some people truly needed help, and that was one of them. The boy never forgot that.

The boy grew up remembering hearing his dad get up early, like 4-5 in the morning. He'd listen to him get dressed, then the loud clumping of dress shoes going down the tiled hall to the garage, then the door lock, and his car drive away. Sometimes, if his son was awake during the summer, the man took him to work with him. He put his son in charge of making photocopies for his office when he was there. The boy loved this. Made him feel important. Sometimes, if he heard the man getting ready, the boy would cough loudly to show that he was up, hoping to get taken to the office on a school day... but it didn't work that way.

On rare occasions the kids got to go see their Dad in court. It was cool, watching him examine and cross-examine people. They could see why he was so highly regarded in local circles.

Life, as it will, goes on. The kids grew. One year, while poking around, the son as a teenager found the old gun. He quietly left it alone, locked in the suitcase. Once, during a teenage depression, he thought about it again, but never went back to see it. It was soon forgotten again.

As his kids grew the man took them on special trips. His son to Washington D.C., the girl to watch her favorite football team play in Los Angeles. He took them both Las Vegas, where he played (and won) tournament blackjack, and taught both kids to play, too. His son became a car geek for a few years. One morning, just to let the teenage boy look up close at a Lamborghini Countach that was on display, the man pretended to be interested in buying a Mercedes at a dealership.

The man and his wife aged well. He made it through a heart attack and his wife survived breast cancer. Together they traveled to Australia, Japan, Europe, Israel, Hong Kong... Places that when they were young they'd only dreamed of someday being able to see. Hard work and life had been good to this family.

Like kids do, they left the nest. The boy had always dreamed of being a doctor, and the man helped him get there. Tuition in the 1980's wasn't what it is today, but it wasn't cheap. The man, like his father, believed that you should do your best to support your kids' education so they could support themselves. His son came out of medical school with far less debt than he normally would have, and was able to start a practice and his own family. The man's daughter, to her surprise, discovered that being a mom was all she'd ever wanted, and so did that full time with her own kids.

The man and his wife saw time go by. Age brings both the good and bad, but for them it was still good. Love, 5 grandchildren, and their 50th anniversary. They celebrated the last in the company of family and many friends, most of whom had been at their 25th anniversary, too. We all have to get old, but doing so in the presence of good friends helps. Life has tragedy, comedy, and love, and it's good to have others to share them with.

A few months later the man became depressed, and it gradually worsened. There was no real reason for him to be depressed - he had everything anyone could possibly want -  but he did. He went to his regular doctor, then to a psychiatrist, and they both tried hard to help him.

Depression is REAL. And it hurts. The world is full of people who don't believe in it and deny that it's an illness. I encounter them in my practice and on trips to visit in-laws. One loves to use the phrase "people just need to put on their big-boy pants," as if her simplistic insight would magically solve everything.

I see politicians and insurance executives on the news claiming mental health doesn't need to be covered because it's not a "real" disease. In a world where fortunes are spent on breakthroughs for rare diseases a more common one - depression - takes a back seat because it's not a "real" disease. The most common treatment given is to tell people to suck it up and deal with it. And, speaking from personal experience, that only makes it worse.

The attitude of many toward mental illness today is not better than 200-300 years ago, when its victims were chained up in dungeons and forgotten.

But the man, fortunately, had good insurance. He was able to see a psychiatrist, and afford medications. And he tried hard. He really wanted to get better. He took them as directed, trying one after another, living with side effects. His family tried hard to support him. Calling him often, visiting when he was willing to see them, and telling him how much they loved him. But none of it seemed to help.

Then, one day when his wife had gone out to the store to get some things, he remembered the old gun.

Dad, I miss you so much.

Patient quote of the day

"When I wake up every morning I have blood pressure."

Statistics

Saw this in a report:

The way it reads, I can't help but to interpret it (albeit erroneously) to mean that 99% of people taking aspirin for secondary prevention of CV (cardiovascular events) did experience a life-threatening GI bleed.

Stages of weekend call

Food

Stage 1: I'll get something healthy, maybe a salad, in the cafeteria.

Stage 2: Are there any bagels left in the doctors lounge?

Stage 3: There are Graham Crackers in the nurses station galley.

Stage 4: I see old Cheetos under the ICU fridge.



Transportation

Stage 1: I'll take the stairs up to 5. I need the exercise.

Stage 2: I'll only use the elevator if it's more than 2 floors up.

Stage 3: I'm taking the elevator to go down 1 floor.



Tests

Stage 1: Ordering an MRI and a few carefully selected labs to narrow the problem down.

Stage 2: Ordering an MRI, MRA, labs, and an echocardiogram to start by covering the bases

Stage 3: Ordering an MRI, MRA, CTA, echocardiogram, EEG, VNG, EMG/NCV, CT-myelo, pneumoencephalogram, and every lab in the book... figuring your call partner will sort it out on Monday.



New consults

Stage 1: I'll be right in to have a look at her.

Stage 2: Can I see her in the morning?

Stage 3: Call Dr. Brain after 7:00 a.m. tomorrow.




Signature line

Stage 1: Thank you for this interesting consult.

Stage 2: Thanks for this consult.

Stage 3: Scribbled name.



Handwritten chart note

Stage 1: A neatly written paragraph summarizing the key history, pertinent exam findings, and your impression and orders.

Stage 2: A brief note listing your impression and orders.

Stage 3: "Patient seen, note dictated."

Modern medicine

I was seeing Mrs. Hufnagel recently, and trying to get a hand on what medicine changes and labs she's had since her last visit (she's not the most precise historian).

After tearing some hair (actually, a lot of hair), out, I finally called her internist's office, and asked them to fax over her most recent chart note.

They sent this over:


Better yet, when I called them again, they verified that it's the entirety of her most recent note. After all, the Medicare quality measures are the only things of value anymore.

Thought for the day

"We have all these jokers running for President and the biggest news story any given day is whose ass looked better in a bikini. Then we have these heroes spend months in space for the greater good and hurtle back to Earth in a tin can and no one gives a shit. We don't need to make America great again. We need to make being intelligent great again."

- Geri

Great physical exams

Seen in a chart:

Thank you, H!

The buzz

Mary: "Hi, this is Mary, from Dr. Grumpy's office. I'm calling to remind you about your 2:45 appointment tomorrow."

Mr. Apoidea: "I'm not sure I'll be able to make it. I'm being stalked by bees."

Mary: "Excuse me?"

Mr. Apoidea: "There are bees following me, whenever I leave my house. I've been stung a few times this week. You'd think I'd bathed in honey or something."

Mary: "Okay, so would..."

Mr. Apoidea: "I'm hiding in my basement now, and they haven't found me yet. I'm going to stay here for a few days to see if they leave, and will call you when I'm ready to come in."

(click)

Skool nerse time

This is Mrs. Grumpy,

Dear Kids,

There are a lot of innovative ways to cut class and/or get sent home, and I think it's commendable that you guys work together so well.

Sometimes even I get fooled.

Last Thursday, for example.

Getting a bunch of kids in with stomach aches isn't that unusual, especially since I can't test for them. But when a second crop began showing up with skin irritations and rashes on their hands, faces, and mouths... it certainly got my attention. I even called the state and poison control to see if there were reports coming from other schools along those lines (there weren't).

Until someone came in with bad eye pain, which I had to flush out with water... and they spilled the beans. Before that I really had no clue what you were all up to.

Apparently one of you cute tykes smuggled in several Carolina Reapers with your lunch. Some bravely tried to show off by eating them, while others just vigorously rubbed pieces on their skin to induce redness and swelling. And a few accidentally ended up getting it in their eyes, nasal tissues, and (in one horrifying case) rear end. ("It was an accident, Nurse Grumpy!" Uh-huh, sure.)

Fortunately, no students were permanently harmed in this debacle, though many parents were quite inconvenienced by me having to call them about what was going on. And the majority of them began laughing hysterically.

To recap:

1. Mrs. Decimal says you still have to make up the math test.

2. Your parents think you are idiots.

3. Scoville units are not to be taken lightly.

Have a nice day.

Why don't you just ask?

Seen in a hospital chart:

Random pictures

Okay, time to hit the mail bag for stuff you guys have sent in.


First is this Engrish sign:

Next up is this school job opening for, um, not sure:

Then there's a fortune cookie...

"Confucious say, when alone, use the self-service pumps."

Then there's this sign. "Lobster Happy Hour" apparently doesn't apply to the lobster:

Here's a vintage drug company promo piece. You'd think Viagra would have been a better choice:

Speaking of Viagra, here's a great pharmacy sign. Love the stick figure.

 

And, lastly, is this page from a telephone directory:

One of these things is not like the others

Source: Alaska Airlines

Thank you, Laurie!

Max and Min

A bit of background explanation for my non-medical readers is required.

In pharmacology, the points at which a drug reaches the highest and lowest concentrations in the body are called Cmax and Cmin, respectively.


Last week I was at a meeting where the speaker kept pointing to graphs and saying things like "we obtained Cmin from testing healthy volunteers," "Cmin samples were analyzed by Whatzefukk chromatography," and "Overall, we were surprised by the Cmin values that were obtained."

And through it all... She didn't seem to realize what Cmin sounded like phonetically.

Immature as I am, it was hard not to snicker.