Seen in a chart

I often have that last problem myself:

For the non-medical readers, it's supposed to say "volume depletion."

Thank you, M!

Thunk

Mr. Migraine: "My headaches have been terrible, especially with all the rain we've been getting."

Dr. Grumpy: "Hmmm. Well, we have room to increase your Spazinox dose, so let's try going to 100mg twice a day."

Mr. Migraine: "Will that help the headaches?"

Dr Grumpy: "I'm hoping so. Let me..."

Mr. Migraine: "I don't get it. How will increasing the dose make it rain less?"

Dr. Grumpy: "No, it makes it harder for your nerves to start a headache."

Mr. Migraine: "Okay... I guess that makes more sense."

Honesty

Seen in an ER chart:

March 17, 2016

Dr. Grumpy: "Come on, kids. We need to leave for school."

Frank: "Anyone seen my backpack?"

Craig: "Let me get a granola bar for breakfast."

Marie: "Can you get me one, too?"

Craig: "Okay."

Frank: "Oh, I left it in the car last night. Never mind."

Marie: "Craig, you can't wear that today."

Craig: (throwing granola wrapper in trash, shoving bar in his mouth) "Why not?"

Marie: "It's St. Patrick's Day. You're supposed to wear green."

Craig: "My green shirt is in the closet. This one was closer."

Marie: "You need to go change."

Craig: "I'm not going to change shirts. We have to leave."

Marie: "But you need to put green on!"

Craig: (reaches into trash can, grabs something) "Fine. Happy now?"

Spring break

Heading out for the kids' Spring Break. See you guys next week!*

*Okay, realistically I won't see you. All I ever see is my monitor. But you know what I mean.

20 years

About a week after my Dad's death, I had my med school 20th reunion. I'd already bought tickets, and Mrs. Grumpy insisted I go. A while back I wrote about my thoughts on it.

I flew in, got a rental car, checked into my hotel, and went over to campus. I left here 20 years ago, the day after graduation, and haven't been back since.

This was the view from my hotel. The alumni travel rep lied about it being a nice neighborhood.

"It's overlooking a grassy park."

The control panel for the elevator didn't exactly inspire confidence, either:

It was very strange. I arrived in the evening and went over to campus to walk around.

The classrooms were empty. I stood in the cavernous room where I'd been a first year medical student, failed the first anatomy test, and somehow pulled out a passing grade when it was over. I walked through the lounge where my friend Bryan had, I swear, used the microwave to heat up a squirrel he'd shot in his yard (he was from Wyoming) for lunch. The anatomy lab was now locked up with a security code, a precaution that hadn't been necessary 20 years ago.

The next day I spent more time re-discovering the campus.

When I checked in they gave me an ID tag, held to my shirt by a magnet. The warning on the back was in tiny letters, and most people likely wouldn't have noticed it until it was too late.

"Why am I suddenly so lightheaded?"

I entered the library, marveling at how much it still looked the same. Of course, now there were computers and iPads everywhere, but still the same big study tables I'd once memorized the Krebs cycle at. The same broken toilet in the basement bathroom, that likely has been plugged since I was last here.

My steps took me to the gym, where I stared down at the track and remembered a younger version of me who somehow found the time to run 5 miles a day and weighed 75 pounds less. What the hell happened to him?

They'd given me a bright red bag at check-in that said "ALUMNI" on one side, with a bunch of guides and requests for money in it. "Help us build the new administrative retreat chateau in the Alps."

My first impulse was to hide the red "ALUMNI" bag under my jacket, because carrying it openly would make me stand out.

Then I realized that I DO stand out. I mean, this is a small university campus, full of bustling 18-25 somethings. I'm a paunchy, balding, 50-something guy, and the bag doesn't matter. Hell, it probably keeps me from being arrested arrested for trespassing.

I quietly wandered through the meditation garden behind the old church. I'd spent a lot of time here, walking over when I needed a break. My favorite bench was still there, and as I sat on it again I thought of all the times I'd been there trying to find the will to go back and study, to not quit and fly home..., to just go on. Somehow I'd made it, and am still not sure how.

I stopped in front of a statue from 1920, placed there to give thanks for those who'd been spared the twin horrors of WWI and the flu pandemic, and to remember those who hadn't. Hard to believe that at that point it was believed WWI would be the final limit on man's inhumanity to man, while time would go on to prove it wasn't even close.

I walked across the street to my old apartment complex, and stared up at the place I'd lived in for 4 years while becoming a doctor. I'd grown up a lot emotionally in there. I thought of my roommate, Enzyme, and the crazy couple next door. And the night we sabotaged them.

Back then it had been rough in a lot of ways. I'd never left my hometown before, and in the mid-80's was moving halfway across the continent to go to medical school. Dad and I loaded up a big U-Haul and made the 3-day drive here. He'd paid for my apartment. I drove by places where he and I had once gone, and I wanted to send him a picture to show what it looked like now. And had the sickening realization that I can't anymore.

Some of the events of alumni weekend were comical. They included a pub crawl. I don't know about other people, but, at 20 years out from medical school, my ability to consume and handle alcohol isn't what it once was. When I last saw the sign-in sheet it only had one name on it (brave soul).

When I'd graduated, the front hallway of the med school had a huge display of posters, showing the pictures and names of every graduating class going back over a hundred years. As med students we'd look at the spot where our class would be featured... someday. I'd moved away before they put it up, so one of the things I'd really wanted to do was finally see my picture up in the hallway.

So I went into the hallway... and the display was gone. Of course, no one who works there now has any recollection of a display EVER being there. One told me she'd once heard a rumor about it, and that the posters might be in storage somewhere with a plan being to turn them into a digital display at some point (presumably before the sun becomes a red giant)... But I didn't get to see my picture up.

I took the tour of my medical school later that day. It included the dreaded anatomy lab, which still smells like it did when I was there, and likely as it did since the first time classes were held there (anyone who went to medical school knows, and hates, the "anatomy lab smell." It never comes out in the laundry).

The medical students now have THEIR OWN EXERCISE ROOM, with machines and everything, attached to the med school. Kids today. When I was their age, I had to walk to the school gym, through snow, uphill both ways.

Going through the student resource rooms it was good to see the school was still as technologically cutting edge now as it was then. I was told these gadgets are still in frequent use:

WTF do you get the plastic sheets? Or still using the same ones?

"We keep these around to get alumni donations."

On the night of the reunion party I took the elevator up to the 4th floor, and an elderly couple got in with me. She clearly had Parkinson's disease. Her husband was frail and old, stooped over a cane. I suddenly realized he'd been one of the key internal medicine attendings when I was there, the brilliant physician-sleuth we all dreamed of being. We were all both terrified and in awe of him, and here he was, looking so much smaller than I ever remembered. I introduced myself, and thanked him for all he'd done to help make me a doctor. Then I held the door for them when we got to the stop for his class's gathering.

The actual reunion, was, as these things are, interesting. It was good to see my classmates again, and see where life had taken them. All are still in practice, scattered across the country like pins on a map. I've never been a particularly outgoing person, but was happy to chat with my old classmates for a few hours. The tables in the back were taken up by their spouses, who looked horribly bored. I'm glad Mrs. Grumpy decided to stay home.

It's hard to believe that, when we first met, we were all young and, for the most part, really believed in what we were doing. Medicine was a religion, a calling, at the time. To some extent I think we still believe in what we do, but 20 years of fighting insurance companies, narcotic seekers, sleepless weekends on call, 70-80 hour weeks, diminishing reimbursements, bogus disability claims, and living in fear of malpractice suits will dim the fire. But they're all still good people, and it was nice to find we still care. We're different, with varying religious and political beliefs, but we still have more in common than not. Unlike government officials it was easy to discuss such things respectfully and without animosity, and still like each other.

At some point in the evening, as it got late, something told me it was time to leave. I don't know what it was. Whatever I'd been looking for by coming back here... I'd found it. Not being a person who does goodbyes well, I didn't say any. I set my drink down on a table and quietly slipped away. I had no regrets.

I walked back to my rental car across the darkened campus. It was a nice evening. I passed the occasional student heading to the library or gym. The groups sitting under trees talking. The young lovers holding hands. I liked it here, but it wasn't my place anymore. That was 1000 miles away, and I had a plane flight in the early morning.

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!