Posts Tagged ‘death’

Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 2019

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

 

 

 

Advertisements

A friend’s death 1

March 12, 2018

RMB sketch sfg with sax 1970

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

I wrote about my friend Bob in this blog starting October 10, 2010. A disc exploded in his mid-back, he had severe medical problems in the aftermath of his surgery.

Bob and I met in the fall of 1969 at Yale. He came fresh from trips to Antarctica and Barrow where he worked with the Naval Arctic Research Lab.  We lived in the same house off-campus my junior and senior years. We saw each other through the roller-coasters of college dating, and the difficult years of career takeoffs.  He provided a shoulder to weep on during the emotional case-hardening of medical school; I danced at his first wedding.  When I graduated I visited him and his wife in the east, and he gave me my first car.  He danced at my wedding, too, and I supported him through the agony of both his divorces.

We kept in contact over the years; I visited in the east when I went for continuing medical education, he visited me several times in New Mexico and Iowa. One year we hunted ducks in the Yucatan together.

Our kids regard us as uncles.

Bob’s health never recovered from his spinal accident. After years of repeated hospitalizations, he died about a month ago.  The family held a small, private gathering at the time of his cremation, and last weekend I traveled out to California for the more public service.

Bob had an enormous intellect and a fund of knowledge that rivaled Wikipedia. But no matter who he talked to, he could find out what that person knew more about than he did, and he would listen and learn while he made the other person talk.  Bob never succumbed to the arrogance that wide knowledge can bring.   He listened whole heartedly and empathetically.

When outsiders heard the two of us converse, they would erroneously infer constant one-upping and miss the joy of learning that we volleyed back and forth.

Of course all heroes must have a flaw. I am among the many both drawn by Bob’s brilliance and charisma, and frustrated by his sense of time.

He also had talents I didn’t realize.

I didn’t realize he loved to play poker.

In the ‘60’s he turned down an acting scholarship.

I had forgotten he could sketch, and his family gave me a copy of a page they’d found in one of his sketch books.

 

The caption:  “Bag the words.  Steve Gordon and secondarily his axe.  10/9/1970”

 

 

 

Discharge summaries

September 8, 2012

The patient’s in-hospital chart,

I’ll finish right now, if I’m smart

The time I can ration

To complete the dictation,

To describe the finish and start.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Completion of a hospital medical record demands a discharge summary.  Nobody ever showed us what a good discharge summary looked like in med school.  We learned from examples, mostly bad.

Med student discharge summaries didn’t count.  In residency I went for thorough at the expense of brevity.  I regurgitated the history and physical, admitting lab and x-ray results, admitting diagnosis, hospital course, and discharge planning in excruciating and unnecessary detail, going through the layers of paper chart day by day. Sometimes the discharge summary went to three pages, single spaced. 

In the Indian Health Service I had to cut back on my words.  However intelligent and hardworking a transcriptionist might be, lack of training in medical terminology made for a lot of errors to correct to finish the product.  Just as well; when I took to typing out my own discharge summaries I pared down the turgid phraseology and left out a lot of irrelevant numbers.  The documents became more useful.

Medical chart completion ranked low on my priorities for most of the time I spent in private practice.  I found motivation only in the periodic letters I got from Medical Records telling me I’d be suspended from the staff if I didn’t finish my charts.

Through my career the grace period, from the day of discharge to the date of suspension, has shrunk from a year in the 70’s to six months in the 80’s, and has now remained at a well-enforced 90 days for the last 15 years. 

But the pace of medicine keeps accelerating.  We strive to follow the patient less than a week after discharge, and the follow-up doc usually didn’t see the patient in the hospital.  The discharge summary becomes less of a formality and more of a necessary and useful document.  I usually dictate the summary at the time of discharge, standing in the hallway.

My format has changed.  A line or two for the story of why the patient came to the hospital, a paragraph each for relevant past medical/personal/family/social history and abnormal physical findings.  A paragraph for lab and x-ray, followed by a paragraph for hospital course, discharge medications plans, and final diagnosis. 

Even at that, a long, a complicated hospitalization (one recently lasted 29 days)can give rise to a two-page discharge summary, but most take a page or less.

In that short space, the necessary confines for a useful document, I can give the facts but not the meaning.  I don’t get to use phrases like self-defeating behavior or inadequate reality testing or stinkin’ thinkin’ or self-imposed social isolation.  If I dictate patient refused counseling, I don’t get to go into the nitty-gritty of why.

The hardest discharge summaries end with “The patient continued to deteriorate and died on…”  Such a stock phrase gives a hollow echo of the drama and irony playing out the final act on the hospital stage, but such phrases I use on a regular basis.  And every time, I can’t help but pause.  The patient gets a moment of silence from me, whether I intend to or not. 

The transcriptionist, I am sure, hears in my voice how my world diminishes with every patient’s death.

Rounds from Dawn to the Newborn Nursery.

July 26, 2012

 

Sunrise in the ICU

I started the day making rounds

Checking the lungs and heart sounds 

 

It started with dawn,

Where has the day gone?

Beauty is where beauty is found.

 

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I started so early that when I saw my first hospital patient, a perfect sunrise broke as I entered the room on the top floor of the hospital.  The water content of the atmosphere blocks the view of the sun most days till the red disc has ascended well above the horizon, but with the hot dry weather we’ve had, there was the sun, just peeking up.  And the ICU offered a spectacular view of the city in the morning.

The patient couldn’t speak and could barely respond.  Even if the patient can’t talk, I speak to him or her, tell them who I am, the date, where they are and why they’re there, and I try to give a few headlines from the news.  In this case I called attention to the phenomenal sunrise, but the patient didn’t look. 

From the ICU on 6th floor I went to see a new admission on 5 Medical, and discharged a patient who had recovered enough to go home.  Striding down the corridor to the opposite end of the hospital I came to 5 Behavior Health, the psychiatric service.  I did medical consultations on two patients admitted during the previous 24 hours.

The psychiatric portion of the service consists mostly of people who didn’t ask for their problem but got it anyway.  A surprising number of schizophrenics also qualify as bipolar.  More than 90% smoke, and a lot of them come down with type I diabetes as their pancreas withers away.  They lose years of life.  A majority of schizophrenics also have drug and alcohol problems, and they can’t learn from their mistakes.

Our society has failed our schizophrenics.  At one time institutionalized, they were turned onto the streets when the institutions closed, and went right into the criminal justice system.  The ones who stay out of incarceration use a lot of health care.

Fourth floor holds the oncology (cancer) and surgery nursing units on the south.  Contrast being the essence of meaning, I talked to those who know they have no cure and to those with a reasonable expectation of cure.

The pediatrics wing sits on the north end of the fourth floor, and I had no patients there.  Fewer and fewer children need admission to the hospital as the years wear on.  Vaccinations have prevented most measles, mumps, chickenpox, polio, rotavirus, pneumococcal, and meningococcal disease.  We see a tenth of the croup that we used to.

On the third floor orthopedics unit I did two consultations for people after total joint replacement, and on the second floor I took care of two newborns.

Death, the ultimate drama and the ultimate irony, came to three of my patients during the day.  One in middle age died surrounded by grieving family.  One went unexpectedly and alone.  A third died so old and full of years that few remained to note the death, though many, on reading the obituary, will sigh and reflect on how the passing impoverished the world. 

 

 

Housecalls to drama and irony

January 8, 2011

In time, all will come to an end,

And be mourned, if at least by a friend

      Don’t bring on your death    

      With tobacco or meth,

There’s no need to hurry a trend.

Every hospice program has to have a medical director; I took on the responsibility for Care Initiatives Hospice in Sioux City a year ago.  The patient load doesn’t justify a full-time physician; in general I work for them eight hours a month.  My duties include attending a weekly meeting, signing papers, and taking phone calls from the nurses when patients come on to the program or die.

As of this year, 2011, if a patient has survived on Hospice for more than six months, the doctor has to visit the patient face-to-face.  I called on such patients Thursday.

Because of confidentiality, I cannot write about details of patient cases, nor where they live.

Some of those born long ago approach their finality without vision or hearing or awareness; some have all their faculties.  Those over ninety who maintain clear contact with the world as we know it rarely object to their demise. 

Few half that age come to hospice with equanimity. 

I entered houses where death will soon visit.  Each person has uniqueness and I cannot write about identifying details.  I can mention a clock that plays Amazing Grace at noon.  Or the beautiful grandfather clock which has not been wound, next to a table supporting a very good dry wall hammer; I did not ask what repairs were underway.

 I can write about alcohol, drugs, anger, grief, and the natural tendency people have to love.

I have a few words in a lot of esoteric languages, and I used all of my vocabulary in one of them. 

If a person dies at a young age because of bad decisions, the people who love him or her will suffer from a large emotional backlog of unfinished business.  The grief stemming from the time during and after death will ripple through the family and community and bring unintended effects.

Even under the best of circumstances, when a parent dies the children find a rift.  I have seen otherwise sane people use the smallest of excuses so that one thing leads to another until both sides nurture a grudge so bitter that it justifies silence for decades, or forever.

Long ago I invented the acronym DOCS, the Distant Obstreperous Child Syndrome.  When the death of a parent nears, the offspring who has been the most distant geographically (and, hence, emotionally) will focus the most anger at the healthcare team.

Drama and irony weave in and out of the human condition, and the ultimate drama comes with the ultimate irony.  We will all come to an end; no one gets out of this game alive.  Some approach finality at half the years of others; some of those held the self-destruct button down too long, some had plain bad luck.