Thursday, February 28, 2008

'Henryi'



Two years ago I planted a clematis off of my back patio. I'd been looking for pretty white one to climb the arbor there, and couldn't resist this beauty with such a handsome name. It had one bloom it's first year; I wasn't even sure it would make it. But last spring it grew vigorously and gave me lots of creamy white blooms.
Henry is in the throes of neutropenia right now. He has a fever constantly. He's coughing and spitting blood. He's crying a lot. And we have a few days to go before his immune system is able to stand up to protect him.
This is what I've been fearing, and waiting for. We hoped he wouldn't be so uncomfortable, but expected it nonetheless. We've gone from "one week at at time" to "one day at a time", now to "one hour at a time". I try not to think past this hour, try just to focus keeping him as comfortable as possible now.
But that handsome bloom is in my thoughts a lot. As I type, I can see it's dormant stems twisting through the arbor. They are brittle, breakable now. One hour at a time.
Soon, it will warm. The sun will shine, it's leaves will bud, and later this spring I will hold that silky bloom between my fingertips. Henry and I will hold it together.

Tuesday, February 26, 2008

A Confession, an apology, and a challenge

I'm a Q-tip user. Every day.

It's my favorite part of the morning routine. Ok, maybe coffee trumps, but it's my favorite part after that. Out of the warm shower, wrap up in a fuzzy robe, and grab those Q-tips. A little swish, a little swirl, check to see what goodies I found, and I'm ready to start the day.

Hmmm. Except that doctors say you're not supposed to use Q-tips. "Don't put anything in your ear smaller than an elbow," I was taught to instruct patients.

So I'm sorry. Sorry to all those people who feel guilt about using Q-tips. I've tainted a most enjoyable ritual. I'm guilty of propogating a medical myth.

Just like your dear grandma is full of conventional wisdom, so is medical education. We as a physician community believe a lot of things that just aren't proven, but have been passed down from generation to generation. There was recently an article exposing eight common medical myths, but they didn't include the Q-tip.

Here's what I think. Some people make soft earwax, that drains easily. Some people make hard earwax, that gets stuck, dries out, and gets impacted. Both sets of people use Q-tips. When someone comes into the office with impacted earwax, they get asked the question. And when they guiltily admit to Q-tip usage, they get a finger wagging admonishment.

I did a cursory journal search regarding this issue. As expected, it hasn't been studied too much. I did find one article from 1994 that showed that Q-tip use was associated with cerumen impaction in left side but not on the right side. Hmmm. Not sure I buy that one.

Now, there are of course some common sense caveats. Don't push the Q-tip in too far. Don't use Q-tips if your ear hurts. And if you break the tip of a Q-tip off in your ear (not sure how one does that) please do not try to get it out with another one. And if you do try to get it out with another one, don't wait several weeks to fess up to your doctor about what you did ('cause then by the time she fishes it out it's pretty nasty.)

If you're one of those unlucky people who makes dry, sticky ear wax that gets impacted, it's probably best to avoid Q-tips, and see your doctor regularly to get cleaned out. If you're like most people, be smart, and swish away. Guilt-free.

And now the challenge: to all you docs out there, stop ruining this most innocent of pleasures.

Sunday, February 24, 2008

Mindfulness

Eastern thought focuses a lot more on mindfulness than we do here in the west. We run from one activity to the next, one responsibility to the next, one purchase to the next, one fast food meal to the next. We're often so busy stuffing down the Big Mac in order to get to the french fries that we don't notice the flavor of either (just the indigestion later.) After all, we ate it in our car at 75 mph, listening to our iPods and texting the office at the same time.

Cancer demands focus. It's not pleasant at first, mostly because the focus is on something so horrific. As the constant shock and grief wears off, a more gentle shift in my thought process has taken place.

I smell my daughters' hair more often. I notice the hawks in the trees along the highway on my trips to the hospital. I've started knitting scarves for friends. I laugh more at the stupid songs the kids sing. I'm not perseverating on planning for events 3 months in the future. I'm more deliberate about what I'm eating. I'm physically touching my family more often.

Eat, drink, and be merry, for tomorrow we die. I used to see this phrase as depressing or overly bacchanal. Now it's inspiring to me. Eventually, tomorrow I die. Eventually, tomorrow Henry dies. But here we are today.

Wednesday, February 20, 2008

Housekeeping

Dear Readers,

Thank you for visiting my blog, either once or regularly. I hope you gain something entertaining or insightful for your time.

Thanks also to those of you who leave comments. Some bloggers are very good at responding to their comments; I find that I'm not so much. But I read and appreciate every one.

This blog was born out of inspiration from reading other medical bloggers, combined with a long time desire to be an author someday. My goal was to be witty, interesting, and a little clever. Oh, and to look like Angelina Jolie, but I'm gonna need Dr. Bates for that one.

On October 13th life changed for me.

My blog has since changed too. I really didn't know if it was something that I'd choose to continue, but I have found it to be amazingly therapeutic. There are things that I can write here that I'm unable to express to "real" friends due to the degree of vulnerability that it creates. There's also been an amazing amount of support, to a degree that dumbfounds me at times.

As my blog has shifted, I sense that my readership has shifted. I'm not really certain about that, as I'm not computer-literate enough to know anything about my readers other than the comments that are left. I really enjoy writing about medicine and work, but I'm off for two months to be with my son during his extended hospitalization. I suspect that once I'm back in the office I'll revisit the snot, boils, and vaginal discharge that makes my job so much fun.

If you're a doctor-blogger-reader, check back in again in a few months. I suspect I'll be back. For those that are following my experience on the other side of the doctor schtick, keep reading. I appreciate your support.

Dr. Smak

Monday, February 18, 2008

The most important thing

I've learned a lot from Henry's oncologist.

He's young, quite young. Older in years than I, but very fresh out of training. His communication skills are those of a much more experienced physician, and I would do well to pick up a few things from him. He excels at answering questions, even silly ones, in a way that is very validating.

I think about the way that I answer some of my patients' questions. Am I dismissive? Trite? Sarcastic? Insulting? I'm sure I've been all of those things at times, albeit unintentionally. This is an area I hope to work on.

He also spends huge, superdoctor amounts of time with my husband and I. Some days he just sits silently in the hospital room with us to give our brains time to dredge up all of the questions that swirl around in the wee hours of the morning or the long drives back and forth from the hospital. And after we think of them all he sits longer, just to make sure.

Once I said to him, "You make us feel like Henry is the only thing you have to do."

"No", he said, "only the most important thing."

That scores big points with a mom.

And also started me thinking about my own practice.

Do my patients feel like they're my most important thing to do? A lot of them apologize for taking up my time, or start a sentence by saying "I know you're really busy...". Do I come across as too busy to be bothered, or too busy to care?

This bothered me for a while. I've decided that seeing 5 URIs in an hour doesn't exactly require the gravity of concern that a brain tumor does. Perhaps my patients shouldn't feel like a visit for that rash-that-was-there-yesterday-but-now-I-can't-see-it or the vomited-for-three-days-can-I-have-a-work-note is the most important thing I'll do all day. But for those there to discuss a turn in health, a severe depression, or suspicion of a child's developmental delay should feel like I care, and that I'll take all the time they need.

Saturday, February 16, 2008

Sad today

I'm sad today.

Sad that my baby boy won't be coming home for at least 2 months due to his treatments.

Sad that he won't see the daffodils come up.

Sad that he won't get to play with his sisters for a long, long time.

Sad that he won't sleep be sleeping in his own bed.

Sad that he is going to be feeling very sick by next week.

How long is two months to a 3 year old? Will it seem like home was 2 days ago, or will he forget what it's like? Will he lose hope that he'll ever leave the hospital? Will he stop trusting me?

What a lot to ask such a young boy to go through.

I'm so sad today.

Monday, February 11, 2008

Heads or Tails?

Flip a coin. Heads.

Flip a coin. Heads again.

Flip a coin. Heads again.

Flip a coin. What are the odds of getting heads again?

Ok, so anyone who's made it through middle school knows the correct answer to that. But isn't there a little piece of your intuitive self that thinks that this time it's more likely to be tails?

I'm that way with Henry's prognosis.

We were told on the first night we met with the oncologist that he had a 1 in 4 chance of beating this. And though I know cognitively know it's not the case, somewhere in my brain I can't shake the thought that there's one seat on the trainride to cure and four kids trying to sit in it. A morbid game of musical chairs.

I see a string of paper cutout children, 20 of them, holding hands. When we get good news, I mentally flick one or two of them off of the string, and his odds get better.

And then I feel sick.

How fair is this? I've got survivor's guilt, and he's not even a survivor yet?

I know our family didn't get our good news, snatched from the eager clutches of another family. I know that. But sometimes it feels that way.

Sunday, February 10, 2008

Dee-Nye-Uhl

I've done a spectacular job of not thinking past Henry's first MRI. As a defense mechanism it worked brilliantly. Really, there was no end to the mental gymnastics that could have been done based on the various results that we could have gotten, so putting up the mental block made the most sense. We just put our heads down and did what needed to be done.

And we got great results. Frankly, better than I expected.

But, wow. As they say, it's not just a river in Egypt. And I've waded back out of the river to the heat, grittiness, and sunburn again.

Everyone is thrilled, as are we, with Henry's positive results. It's an irony that I'm more sad than I've been in a long time. The cancer is in my thoughts constantly. We have some treatment decisions to make, some really tough ones. Things that you really don't want to think about.

I read a lot of other "kids with cancer" blogs. It seems like most kids that eventually lose their fight with cancer had a period of remission, or disease responsiveness. Is that where we are?

It's hard to think about all of these things again. I had really put this all away, stashed in the coat closet behind the mismatched winter mittens and random vacuum attachments. I hope I can put it away again soon.

Wednesday, February 6, 2008

The pursuit of Happiness

Henry cried a lot as a baby. A lot.

He was easier as a young toddler, but still what we would call a 'needy' child.

Over the year before his diagnosis, he spent a lot of his days being cranky. But hey, he was 2. We didn't think much of it.

He was scared to death after his diagnosis and surgery. Who could blame him?

But since then...

He is just so happy.

Why?

Is it just the extra time under his belt? Is he enjoying the extra time and attention that he gets? Did he have a headache for a year? Am I a better parent since his diagnosis?

I guess I'll never know.

He is just so happy.

Monday, February 4, 2008

A rat's ass

67 year old male. ER visit for shortness of breath, cough.

Chest Xray in the ER negative for pneumonia. Some mild abnormalities seen, followup CT chest recommended. Chest CT without contrast due to renal insufficiency shows some mild abnormalities, but no pneumonia.

All bloodwork, EKG normal.

Patient admitted for 3 days for IV antibiotics for pneumonia. Sent home and followed up with me four days later.

Not feeling any better. Coughing a lot. Short of breath if he walks more than 20 feet. Really short of breath.

Every doctor in the country should now be thinking of this patient's diagnosis. Every 3rd year medical student who passed the first 2 years of school should be thinking of this patient's diagnosis. Hell, if as a layperson you watch enough ER and House you should be thinking of this patient's diagnosis.

I'm not brilliant. I went to a good school, and a good training program, but it wasn't Harvard.

But I give a rat's ass.

And my patient, now on lovenox for his pulmonary embolism, knows it.

This diagnosis wasn't hard. It was all too easy.

Next time you or your family member needs a doctor, look in his or her eyes. You'll know. Sure, we all need a Mayo Clinic specialist from time to time, but most of the time, you just need someone who looks at a patient like someone worth thinking about.

Friday, February 1, 2008

"Excellent"

What a fabulous word to come out of your kid's oncologist's mouth. He was describing Henry's first post-chemo MRI, which we had today.

It's not exactly clean, and there's yet a long road ahead of us.

But damn, it's nice to get some good news.