Category Archives: Patient Stories

Denial Redux

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Today I saw a new breast cancer patient in clinic.  She was a lovely lady of 64, who had retired last year from her job as a special education teacher.  Her medical history had been unremarkable until last November when she began to gain weight inexplicably.  She was also short of breath, but did not want to seek medical attention during the busy holiday season.  When she finally did see her primary care doctor in January, she had gained seventy pounds.  Her primary took one look at her bulging neck veins and swollen ankles and called an ambulance to take her to the hospital–she was in florid congestive heart failure.  She refused the ambulance, saying that she was fine, and that she needed to go home and take care of a few things, but that she would get to the hospital shortly on her own.  And so she did.

When she was being examined in the emergency room, the resident noticed a very large breast lump on her left side.  He asked her, “How long has THIS been here?”  She was vague in her response–it may have been “a few months” or it may have been “a few years”. It wasn’t hurting her, and she had other things to worry about–namely her 70 pound weight gain.   Mammograms and ultrasound while she was an inpatient led to a biopsy which showed malignancy.  Cardiac echo showed both coronary disease and cardiomyopathy.  She was treated with multiple cardiac medications and began to diurese, and her heart function improved dramatically, especially after a stent was placed in her left anterior descending coronary artery.   Finally she was able to go to surgery to remove the breast mass, and today she showed up for her consultation looking very chipper indeed–a slender 134 pounds down from 206, breathing normally, with no ankle edema.  The breast cancer turned out to be stage I, and she will receive radiation therapy in the next few weeks.

When I walked into the consultation room, I introduced myself and asked her to say her name, which was somewhat difficult to pronounce.  She laughed and said, “Just call me Cleopatra, because I am the Queen of Denial!”  Fortunately, I think she is going to be just fine.

Denial Is Not a River in Egypt

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If you desire healing,
let yourself fall ill
let yourself fall ill.”
― Rumi

Yesterday I saw a patient—an 80 year old woman with metastatic cancer involving her bones.  She had near complete replacement of her twelfth thoracic vertebra by tumor, and also significant destruction of her fourth and fifth lumbar vertebrae, demonstrated by PET-CT scan and bone scan.  She had so much pain in her legs that it was difficult to walk.  In attempting to discertain whether her pain was coming from her thoracic or her lumbar spine, I asked her a series of questions.  The only answers I got were that she had slipped while getting into the bathtub a few weeks ago and that her pain was in her left ankle and her right thigh, both of which had been X-rayed and were normal.  Questioning her about her bowel and bladder function was also unrevealing—sure, she had problems with both, but that was because of the radiation she received in 2009.  It would seem as though her cancer was causing her no pain at all, yet that was why her medical oncologist had asked for a stat referral.  After 30 minutes of discussing her bathtub mishap, her daughter had had enough.  She nudged her mother and said, “Mom, you KNOW that is not why we are here.”

My eighty seven year old father has been similarly reluctant to attribute his recent symptoms to his failing aortic valve.  Despite being told last summer that he had aortic stenosis, he asserted to his cardiologist that he had no chest pain, only a little shortness of breath with exertion.  He was able to walk downhill the eight tenths of a mile to his tennis club, but walking back up had become more difficult.  In December, he was still playing doubles tennis despite the fact that he had squeezing chest pressure which occurred with exercise, and was relieved by rest.  His cardiologist believed him—that his symptoms were pulmonary rather than cardiac.  The pulmonary doctor from Denver was summoned, and the lung consultation was exhaustive.  The conclusion was that my father had nothing wrong with his lungs.  My father, who by the way is a physician himself, could not admit that his symptoms were classic angina pectoris, and were worsening to the point where he was having them with minimal exertion. For the last two months he has insisted to every doctor who has interviewed him, “I have no chest PAIN, only a little squeezing pressure when I exercise.”  The result has been undiagnosed congestive heart failure which would have killed him, if he had not contracted an upper respiratory infection which landed him in the hospital and led to the real diagnosis.

I admire the stoics, the non-complainers.  I am not one of them.  When I have an ache or a pain, the entire world knows about it.  But there should be a limit to stoicism and that limit should be where the patient who is in denial is doing himself harm.  On Monday, my patient will undergo a CT simulation for radiation treatment of her thoracic and lumbar vertebrae before she suffers from a spinal cord compression and paralysis from her cancer.  On Tuesday my father will have his aortic valve replaced.  May they both emerge from their ordeals physically and mentally intact.  And may their doctors, including myself, learn to diagnose and treat these patients before they do themselves irreversible damage.

Thanks For Your Support

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My husband likes to say, “No good deed goes unpunished.”  I don’t always agree, but sometimes you just can’t argue that concept.  One of my favorite patients, a forty nine year old woman who I treated for head and neck cancer a year ago is a good case in point. Head and neck cancer is on the rise, and is linked, like cervical cancer, to infection with human papilloma virus which is sexually transmitted.  Patients who are treated for this type of cancer have a very rough time.  Typically, curative treatment these days involves combining chemotherapy and radiation, reserving surgery for salvage in the case of an incomplete response or recurrence.  Patients have severe mucositis, inflammation of the oral cavity and the throat, and oftentimes require a feeding tube for nutrition. They lose their sense of taste, they are hoarse, their mouths are intolerably dry, and they are fatigued and miserable.  The good news, however, is that the majority of these patients are cured, even with advanced stage disease.  Many go on to be advocates for others just starting on their journeys.

It was with this in mind that my patient’s ear nose and throat doctor asked if she would mind speaking to a man of similar age and circumstance who had been recently diagnosed.  Of course she agreed.  She had been through the war, won the battle and wanted to help if she could.  She called him and they spoke at length about treatment side effects.  But something seemed a little “off.” Soon he was calling and texting her daily.  He wanted to meet her.  She politely declined, but she invited him to attend an event at our cancer center celebrating survivorship, and the role of complementary therapies.  He wanted more.  Soon his urgent text messages dominated her cell phone, culminating in the question, “So how did you get your HPV infection?  You must really like oral sex!”   She got a restraining order.

I saw another patient a week ago with breast cancer for an initial consultation.  She was very nervous, unduly so considering that her cancer was detected very early and she had completed her lumpectomy and sentinel node dissection.  The tumor was tiny, the nodes were negative and she was not going to need chemotherapy.  When I could not dispel her anxiety, she finally confessed that another breast cancer patient of mine had sent her a picture on her cell phone of her breast at the end of treatment, at the peak of her skin reaction.  This other patient had undergone chemotherapy first, which sensitizes the skin to radiation; she was large breasted which also increases the skin reaction; and she had refused to follow advice regarding her skin reaction.  She had an area of moist desquamation—peeling skin—in the inframammary fold.  She is now completely healed, with no permanent skin changes, but in the interim she deemed it important to frighten a new patient nearly to the point of refusing therapy.

Many years ago another head and neck cancer patient said to me, “When I found out I had cancer, I joined a club that I never wanted to be a member of.”  Support groups can be wonderful—many of my patients tell me they have met their best friends at group support meetings.  But always beware of people with hidden agendas.  When it comes to cancer support, there are far too many of these.

Don’t Let Me Talk You Into It

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When I was young and foolish and just starting out in my career, I found it very hard to take “NO” for an answer.  If a patient needed radiation therapy, and he or she didn’t want to have it, I did my very best to talk that patient into it.   I have always been a very persuasive person—if I didn’t get the go ahead on the first formal consultation, there would be another, and even another, all gratis, with a few phone calls thrown in between.  Every question that could be asked was answered, no stone was left unturned. My waking dream was that if I was good enough at explaining, finally the lights would go on and the patient would understand that really, truly, the recommended treatment would be at the very least beneficial and in the extreme life-saving.   The indications for radiation are usually fairly clear—sometimes we treat for a positive margin by pathology after surgical removal of a tumor; sometimes the tumor is curable with radiation alone, or the radiation option is less risky for a patient than a surgical option; sometimes radiation therapy is simply the best option for palliation of symptoms.  There have been very few, if any times in my professional life when I have seen a patient with cancer, and I say, “By the way, radiation therapy is optional—take it or leave it.”

Gradually, however, over the course of a long career I have been rethinking my strategy of talking patients into treatment.  Why?  Because it has become clear to me that the patients who I work the hardest to convince to get their therapy are the unhappiest patients I have.  These are the patients that, when having their breast treated, ask to see me on the second day and point to a rash on their leg, and say to me accusingly, “You told me THIS wouldn’t happen until the third week!”  When I explain that the rash on their calf has nothing whatsoever to do with the radiation aimed at their breast, they roll their eyes in disbelief.  I have come to realize that when reluctant participants are undergoing radiation therapy, everything that happens to them during the course of treatment (and for the rest of their lives in many cases) is the result of the evil X-rays.  Of course there are genuine complications of radiation, but losing one’s sex drive after having a skin cancer on the scalp treated, or developing a hemorrhoid after treatment of a lung cancer, or the breakup of a marriage after the life threatening illness of a spouse are not on the list.    It has to be the same body part that was treated—that’s how radiation works.  It’s all local.

Last week I saw a new patient, a genuinely lovely and intelligent woman of 70 years, who was diagnosed with breast cancer five years ago.  She had had a lumpectomy and a sentinel node dissection, and fortunately her cancer was found at Stage I.  But when it came to completing her breast cancer treatment, which included radiation to the breast followed by anti-estrogen hormonal therapy, she refused, despite the fact that her surgeon and medical oncologist argued strongly that she was depriving herself of standard-of-care management.  She stated back then, and again last week, “I will not do anything which will affect my quality of life.”  When she recurred, the tumor came back in the axillary lymph nodes, and the surgeon had a difficult time removing the nodes due to her previous axillary surgery, and microscopic disease was certainly left behind.  To have taken more tissue would have been to risk nerve damage and certain lymphedema.  So she was sent to me for radiation.  And, just like five years ago, despite the fact that we covered all side effects, risks and benefits during our 90 minute consultation, and she agreed to treatment, she now is once again questioning what the radiation may do to her quality of life.  Yesterday evening I called her on the phone at her request, to attempt to allay some of her fears.  I felt myself slipping into my old habits of persuasion, and I stopped.  I said to my patient, “You can have five weeks of fairly simple treatment now, or you can wait until you have another recurrence, and require additional surgery and a higher dose of radiation.  Which quality of life is worse?  Which will give you greater piece of mind?  You decide.  Don’t let me talk you into it.”

Really—don’t let me talk you into it.

Deep in the Heart of Texas

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One of the things I have learned since starting this blog last September is how many doctors enjoy telling their stories, and how many of them do it very well.  Dr. Kevin Pho is an internal medicine physician in New Hampshire who started a website where he brings together many voices of medicine—doctors, patients, educators and policy makers.  The website is www.kevinmd.com and I have spent many short lunch breaks at my desk, reading and laughing, or crying, or just plain recognizing kindred spirits as their stories fill my computer screen. The following piece, by Dr. Pamela Wible, appeared yesterday and took me right back to medical school in Texas.  I am “reblogging” it here, with Dr. Wible’s permission.  All you Texans out there—here’s a yellow rose for you!

Learning about human relationships and the art of medical practice

PAMELA WIBLE, MD | EDUCATION | JANUARY 31, 2013

 

An excerpt from Pet Goats and Pap Smears.

After two decades of formal education, today I’m finally set loose with real patients. It’the actual moment I’ve been waiting for my entire life.

We’re each assigned to a family doc for the month. I scroll down the list of third-year medical students, place my right index finger beside my name, slide it across the page, then read aloud: E. Sinks McLarty, Jr., M.D., III.

The next morning I find his office—a small nondescript building with his name on the side—and enter the waiting room, which features 1970s-style wood paneling, faded and covered with the grime of decades of cigarette smoke. Centrally located is a large oil portrait of E. Sinks McLarty, Sr., M.D., who opened the place nearly 100 years ago. I pass rows of empty chairs to the front desk, where I meet three bouncy women—all relatives of Dr. McLarty. I introduce myself to the friendly, frenzied group of chatty chart finders, then the garrulous gang scurries me down a narrow, smoke-filled hallway where I meet Dr. McLarty’s nurse, affectionately nicknamed “Olive Oyl.”

A friendly, slender, snappy-tongued woman with a gravelly voice, Olive Oyl chain-smokes at her desk. Her deep red lipstick and nail polish are the color of freshly clotted blood. She escorts me into a dimly lit room where I’m not at all sure I’m safe. There, on the couch, I meet Dr. McLarty—a seventy-year-old cowboy eating Metamucil wafers while puffing on a pipe. He wears Wrangler corduroys and sports a crew cut with some gray hairs shooting through. With his thick Texas twang, he slurs his words together around southern slangisms and medical anecdotes.

With pen, paper, and stethoscope, I follow Dr. McLarty around to see what I can glean from him. I’m immediately struck by his speech with patients. He calls all the men “pahdna” and all the women “shuga.” Isn’t that sexual harassment?

Dr. McLarty has no tolerance for big-government rules. When a patient needs a triplicate form signed, he snaps, “Well, now, shuga, that’s a bunch of horseshit!” or “I don’t give a ram dam or a rat’s butt!” While cursing, he signs the forms, gives one to the patient, and throws the other two across the room in a wad. “Hell, I’ll make toilet paper out of it one day,” he rambles as he tramps out of the room.

Dr. McLarty makes even the common cold an event to remember. “Okay, now, pahdna, let’s look in that there snoot. Ah, a little redness, nothing to say grace over. Let’s listen to your ticker while I gotcha here.” Slamming down the chart, he exclaims, “You’ve prob’ly got some of that damn crud we’ve seen going around!”

In the next room, an elderly woman complains of joint pain. His diagnosis: “You’ve got arthritis! Well, hell, you can see that. No need to pay for that, shuga. Now hold that cane in your left hand and tell Byron to give ya a damn golf ball to carry around in the right.” He didn’t cure her arthritis, but she looked like an avid golfer when she left.

After seeing a few patients in the morning, Dr. McLarty closes down for a two-hour lunch. We all squeeze into his office on the couch to watch soap operas. During a romantic interracial scene, they shake their heads in unison. “Oh, no! We don’t believe in that!”

So I offer the clan some of my chocolate soy ice cream and one gal gasps, “Oh, no! My husband wouldn’t like that!” Dr. McLarty puts down his Metamucil wafer and grabs a spoonful. “That’s pretty darn good!”

After lunch we’re getting ready to see a man named “Sunshine.” Before entering the exam room, Dr. McLarty pulls me aside and says, “This family’s been shot in the damn butt with bad luck!”

“What’s going on?” I ask.

“He got cancer. I’ve known a week, but gonna break it to him now.”

“Why didn’t you tell him last week?” I ask.

“If he lived by himself, I’d a told ’im right away this is how the cow ate the cabbage, but his wife, Lordy, ya couldn’t scrape her off the wall last night,” he rants as he trudges down the hall.

I gathered that Sunshine’s wife was extremely anxious.

We enter the room. Doc pats the old fellow on the shoulder and says, “Sunshine, now I ain’t gonna pull any punches by tellin’ ya we got a drug.” After a few cryptic sentences, he asks, “Ya get what I’m sayin’?”

Sunshine replies, “Yep! Lights out.”

That was the entire office visit.

Most of Doc McLarty’s patients are old white guys who have aged right alongside him. But this afternoon, we jump into Doc’s old pickup to see a young gal in the hospital. On exam, he notices her breast implants and asks, “Hey now, shuga, how long ya had these damn things blown up that way?” She answers politely and the interview continues without a hitch.

We only saw one kid that month. As the boy raced around the exam room, Dr. McLarty quickly warned, “Hey now, pahdna, get back up there on that there table. We don’t want ya to bust your gazoo!”

I’ll always savor my month with E. Sinks McLarty, Jr., M.D., III. I didn’t learn much about diagnosing or treating disease, but I learned a lot about human relationships and the art of medical practice.

I sure miss him.

So, after fifteen years, I track him down to thank him.

He answers on the first ring.

With my heart pounding, I ask, “Is this really Dr. McLarty?”

“Yep, this is Doctor McLarty. Who the hell is this?” he shouts.

“I’m a medical student you mentored long ago, and I just want to say thank you.”

“Well, thank you, sweetie, but I got cancer of the bladder and just had therapy today, and I’m bleedin’ like hell!” Before I can express my sympathy, he quickly blurts out, “What comes around goes around. Thanks for calling on me, but I gotta go pee again!”

He hangs up on me.

That’s it.

I never even tell him my name—not sure he would have remembered me—but I do get to thank him before lights out.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears.

How Old is Too Old?

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Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

What Comes Next?

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Multi-tasking has never been my forte and so I like to keep my schedule organized.  Mondays, I see all of my on-treatment patients.  Tuesdays and Thursdays I see new patients in consultation.  Wednesdays are reserved for treatment planning and research projects.  But Fridays—well, Fridays are usually the best day of the week.  Not only is the weekend approaching, with time to spend on my menagerie and the ever present home improvement projects, but on Fridays I see my follow up patients.  Nothing is more gratifying than seeing a patient who was near death from a locally advanced head and neck cancer a year ago leading a normal life now, back at work, and grateful not only to be free of disease, but also for the excuse to leave work early on a Friday afternoon for a follow up visit.  Together we’ve shared many a TGIF moment!

Sometimes, however, the first follow up visit that a patient makes is not such a cheerful encounter. Yesterday was such a moment.  A young breast cancer patient came in for her first follow up a month after completing all treatment for her early stage, but high risk breast cancer—she had her lumpectomy and sentinel lymph node dissection, followed by four rounds of dose intensive chemotherapy, and finally, her radiation therapy to the breast. She is a beautiful young woman, and despite her hair loss from the chemotherapy, her presence and broad smile lit up the radiation therapy department every day when she came in for treatment.  But when she arrived yesterday, something had changed.   Despite her artfully sculpted short fringe of hair, her colorful bangle earrings and her pretty red lipstick, she answered my nurse’s questions with terse replies, fighting back tears.  When I entered the exam room, the floodgates opened.  I was horrified, took her in my arms and said, “What has happened?  What is the matter?”  Through her tears she managed to blurt out, “I just don’t know what comes next!”

There have been many scientific papers written on the phenomenon of depression post cancer treatment, mostly relating the depression to physical symptoms such as fatigue and other side effects of treatment. I know that there is a different reason because I see it at least once every Friday.  Cancer, especially those like breast cancer and head and neck cancer which require multimodal treatments, is a disease that keeps you busy.  Once the diagnosis has been made, and the treatment plan is laid out, the patient has a new career.  Just as with any other job, there is new terminology to be learned, new orders to follow, and new sensations, both emotional and physical to experience and cope with.  People are surprisingly resilient—after the initial anger and “woe is me” moments, most patients get their game on.  They take care of their incisions, they appear for their blood work, they shore up their reading material and their support systems for their chemotherapy, and they organize their schedules around their daily radiation treatments.  In short, they put one foot in front of the other, one day at a time, and they count the days until their treatment will end (and trust me, never argue with a patient who tells you they have only 12 more radiation treatments when you think they have thirteen—the patient is ALWAYS right!)

The hard part is when the treatment ends.  Fears that have been shoved deep under while the patient is so busy just getting through each day of treatment surface with a vengeance.  The demons of what might have been, and what might yet be creep through the doorjambs and windowsills of dreams.  For patients who overcame the shock of their diagnosis, and who battled through the side effects of their treatment—this is their time for pause, contemplation, realization and reaction.  And when it happens, I tell patients that there is only one thing to do and that is to seek professional help. Cancer is a life changing event. Denial only carries us so far.  Caring for the emotional needs of a cancer patient is not easy, and cannot always be managed by a spouse, a parent, a child or a well-meaning best friend.  When this happens to my patients—when they fall into this post treatment abyss– I tell them to get the help they need, even if it requires antidepressant medication.  This, even more than the treatment that I have offered, can be life-saving.  There is no shame in it.  From what I have seen, lux ex tenebris.  Whatever comes next, come what may.

There Comes a Time

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Written while returning from my Galapagos trip, posting now.

It’s happening—the moment that we all dread as we age, that point in time where we realize that we are becoming our parents.  When I was a child, my father was a busy man, completing his residency in plastic surgery, establishing a practice, climbing the academic ladder.  He didn’t have much spare time for us kids, but occasionally he would make an effort to take us on an outing—the circus perhaps, or the zoo.  On those outings, I remember one thing above all.  As we walked along beside and behind him, he would methodically point out every physical imperfection he could see on passersby—a bulbous nose here, a weak chin there, a jagged scar perched on an otherwise perfect cheek or a poorly repaired cleft lip.  The world of the unbeautiful was his oyster and he knew what to do to fix it.

On our recent trip to the Galapagos Islands, I found myself scanning faces and bodies in a similar fashion, but I am no Pygmalion out to transform the luckless Galatea’s of the world.  What my roving eyes were seeing under that equatorial sun were skin lesions aplenty—a benign nevus here, a senile keratosis there, but then, more importantly, an obvious basal cell carcinoma above the upper lip of one of my fellow explorers.  And then came my dilemma:  do I say something to the hapless traveler?  Can I convey in a casual sentence or two, “By the way Joe, you have a skin cancer on your face.  You should have that looked at when you get home, but don’t worry about it!  It isn’t a melanoma, the life threatening kind of skin cancer.”  What to me is a simple helpful hint might be to my companion a bomb dropped in the middle of that peaceful archipelago.  I took the easy way out.  I exercised my right to remain silent rather than risk ruining his vacation.

There was one incident, however, on a bumpy Zodiac ride from the good ship Endeavor to our first sandy beach landing for snorkeling.  Our naturalist guide Xavier had applied a coating of zinc oxide over his nose and cheeks so thick it looked like Comanche war paint.  Yet still, that greasepaint could not disguise an obvious bump arising from his right malar prominence.  He admitted to me that his doctor in Guayaquil wanted to “cut it off.”  Quickly I motioned for my father and together we performed the first National Geographic skin examination of the tour.  As the zinc oxide was wiped away, simultaneously we crowed, “It’s benign!!!”

A day later, Xavier admitted to me that he was so relieved he called his wife and children on the mainland to tell them the good news.  Have I mentioned that dermatology was a field I strongly considered while in medical school?   Reporting from afield…. Miranda.

Please Allow Me to Introduce Myself by Dr. Rhonda Houston

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They call me Houston at the hospital. Sometimes they add “ Dr.” or “Dr. Miss” before Houston, but either way, I’m still Houston. As in, “Houston, we have a problem.” I work at a behavior health facility. I said I would work the trenches for a semester about 15 years ago and I’ve never left the hospital setting. I love the clients! I promised to share some stories and quotes of the day I’ve collected over the years. I thought of this story today when this particular client returned, as she has multiple times over the years. When she is stable, she is quite interesting and intelligent. But when she is not—well, let’s just say she is never boring.

One of my very favorite stories happened years ago. Then I had an office in the outpatient setting. So the front door was always unlocked. I was coming back from lunch, sandwich in hand, and as I stepped through the door the clerk eyeballed me, motioned with her hand and whispered the familiar “Houston…we have a problem.” Coming down the hall was a fit middle aged woman wearing spandex shorts, spandex top, black leather bikers vest, and black leather boots that went up to her knees. Her hair was long and curly. Her eyes blazed as she came right up to my face and told me how lovely I looked. Oh My! I put on my most pleasant professional voice and asked how I could help. Out streamed a whole bunch of words that made no sense, stuff about the Devil and God. In between she made sexual comments about most everyone that walked by. I knew immediately she needed our help. As I was trying to gain her confidence, I was also trying to figure out how to get her to a safe place out of the milieu.

My first thought was to offer her lunch. In a surly voice she replied, “No thank you, I ate Tabasco sauce for breakfast.” I have to admit, at this moment it was almost impossible for me to keep my composure– I just wanted to burst out laughing! I offered something to drink and she chose coffee. I slipped out and over to the intake department to give them a heads up and to clear a room. I nabbed the coffee, adding some cold water, just in case it went flying. One learns these tricks early in the field of mental health. Upon return I offered the coffee. In a surly husky voice she asked “Did you put poison in this?” Her eyes narrowed to a glare. “No.” I replied, “You didn’t ask for poison, just coffee.” “Ok, I’ll drink it then.”

As she sipped her coffee, I offered to allow her to stay so she could have a warm bed for the night. She liked that idea. I was able to walk her over to the intake room where we started paperwork. First, I started the form where we asked for another contact–a relative, or perhaps a good friend, in case of emergency. After she tossed out several names she finally decided “Lucifer!” I repeated, “Lucifer?” She said, “Yes, Lucifer– you can trust him.” I wrote down Lucifer on the form and asked for a phone number. That glare came back and she hissed, “YOU know his number.” Suddenly an angel appeared, backlit by the light of the doorway. To my relief, it was an intake person who swiftly and thankfully took the client up to her room.

Miranda here–This is from my friend Rhonda, and should probably rightfully be called  ”Why I am Not a Psychiatrist #4.”

Dear Diary

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I was talking to a friend the other day about the fact that what we now call “blogs”, we used to call diaries.  Then I said to her, “I should pull out the diaries that I kept in college and in medical school and see what my old self had to say.”  And so I did.  The first entry was October 28, 1974.  The last one was June 10, 1977.  After that, I just got too busy to write anything down—that is, until now.

One thing is for sure—I didn’t want to embarrass my future self.  I was so much more discrete back then.  I hardly ever mentioned anyone by his or her full name, which is a shame now since I cannot remember who the heck B.C and E.S  were, which somehow dilutes the profundity of my observations about them.  And I left out the really juicy parts which is even more of a shame—I mean, isn’t that what diaries are for?  Certainly not to quote Cat Stevens, which I did rather liberally, and with great feeling.

Still, upon review, there were a few things that I read tonight where I recognize the self that I have become.  In February of 1977, on my core Internal Medicine rotation, I watched a 34 year old man die of complications of lupus, a disease which was significantly less treatable then than now.  He had developed pneumonia, with fluid on both lungs which required chest tube drainage.  I wrote, “He’s been asleep since we let the fluid out.  Sometimes these days I have to turn my head and walk away from a patient’s bed so that they won’t see that I’m crying.”

In March of 1977, I had started my general surgery rotation.  I wrote, “Today I wheeled a patient out of the operating room into recovery, a nineteen year old girl who woke up from the anesthesia screaming, “Don’t let my Daddy rape me again!  Please don’t let my Daddy rape me again!”  I wonder what the hell I am doing here.”   That day I wrote a letter to a friend, saying, “I am so happy that you’re still here watching and listening and caring.  I mean somebody better be, because no matter what they say about life being too short and all, it seems like this is going to be a long haul.”

And the last entry, June 10, 1977—“What seemed so menial, so mundane becomes the only way.  Medicine is the only way.  I think I see now; medicine is not for those who hate and fear death, but for those who hate and fear loneliness.”

Sometimes it’s nice to look back and see that somehow, it all worked out.