Babies

I've been seeing a lot of young patients recently with Hepatitis C. Kids in their 20s who have gotten into IV drug use, and who are now struggling with both sobriety and having Hepatitis C. That's a lot for a kid to deal with. I go in to the room, sit down and look over at them. More often that not, they come in with a parent. I mean, they're kids. They're not fully mentally developed. People who abuse drugs are in a sort of arrested development. They have poor coping skills. Thy have impulsivity issues. They don't do well with mental or physical pain. Babies.

I explain what Hepatitis C is, what the treatment is like, why it's important to try and cure it. I explain that the treatment is difficult, and I talk about the side effects: nausea, fatigue, muscle and joint aches, headaches, depression. I then explain that the most important thing they can do is stay sober. They are so eager to start treatment, that some are disappointed they can't start now. I explain that the treatment can drive them back to their drugs of choice. I explain that unless their depression is under control, the treatment might cause them to become suicidal. Some of them recognize that they are not ready, and they breathe a sigh of relief.

I have them come back in 6 months to talk again. Sometimes I think I'm too eager to start them on treatment as well. I've had 2 patients who have relapsed after starting meds. I feel a little responsible. Maybe I should asked more questions or listened to my gut. It's just hard to hold back treatment and explain how important that gut feeling is. I think I'll need to figure that out, so that I can help get people treated when it's really the right time.

Just Don't Lie to Me

Florence + the Machine has an awesome CD out. I love it. One song on there has a line, "I'm not calling you a liar, just don't lie to me." I find this very apropos to a patient I'm dealing with.

He has an infection in his knee. As I've mentioned here before, working in infectious diseases, I have to ask people a lot of personal questions. Where do you live, what do you eat, what drugs do you do, who do you sleep with, etc. I try to be very open and use nonjudgmental language. During my physical exam, I look at his hands and arms, trying to find other signs of infection. He has track marks on the backs of his hands and in the crooks of his elbows. These are scars from injection drug use. I already asked him about drug use, and he denied any. We don't make eye contact during my discovery, but he must have noticed that I saw them. He mumbled something about donating a lot of blood products in the past.

I sat down at the end of the exam to tell him my plan - antibiotics and such. I said again, "You know, in this job, I have to ask a lot of personal questions, and I'm sorry for that. However it's not to judge anyone or notify any one else. It's simply to help me do my job the best that I can." He said that he understands and that I shouldn't worry about it, ask whatever I want. Again I asked about drug use and told him why this is important. Again he denies it. I tell him that I'd like to test him for HIV and Hepatitis B and C, and he said ok. He doesn't seem concerned. He's been very pleasant through this whole interview, even if I don't very well believe much that he's told me.

I'll wait to get his labs back and make a plan for his treatment. He'll probably need a few weeks of IV antibiotics at home. I'm more than a little concerned that he'll go home with the nice IV we put in place and shoot whatever he'd like into it. I explained to him the dangers of this, and he shook it off and said he'd never do that. I smiled and said ok, as Florence's words rolled through my mind.

"I'm not calling you a liar..."

One Sock

I was asked to consult on a patient this weekend. She is 80+ with severe dementia. She opened her eyes when I said her name, but I'm not sure that it wasn't a coincidence. She doesn't follow commands or even track me with her eyes. Anyway, she had gangrene of her foot. Her family wanted it to be amputated, because they felt it caused her pain. Unbelievably, this is not a post about medical ethics or how we treat the elderly or the quantity vs quality of life. Her other leg had a bone infection, and the doctor wanted an opinion on how to treat it. The surgeon was going to amputate her gangrenous leg above the knee. The family knew that there was a very high likelihood that she wouldn't survive the surgery; they felt that the pain she was having from the leg made that risk one worth taking.

I saw her post-operatively as well. She made it through. I was quite surprised. I went in to see her today, and she wasn't on the board. Turns out she died. Just sort of suddenly, peacefully and completely out of the blue.

I saw a list of her belongings: one neck scarf, one blanket, one winter hat, one sock. One sock. That struck me for some reason. Kind of sad, kind of heartwarming. For some reason, I felt very relieved that her sock made it home.

Silence

I'm sitting up late, in my parents' front room, surrounded by the glow of Christmas lights. They have a remarkable amount of lights, for the size of the room. It can't be more than 15x15 feet. They have 4 little snow villages on the various end tables and shelves. They have lights around 2 different windows, along with the plastic - but tasteful- Christmas tree. My folks are in bed. My little brother is out visiting friends. The other 2 siblings are at their respective homes. It's very quiet.

It's a nice quiet. It's the kind of quiet that I don't get often. I am usually wearing a pager, and even on my days off it seems to chirp any way. My cell phone often distracts me with various chimes and rings. Sometimes the TV is on in the background. Sometimes my fiance is playing is guitar. The train whistles by at least once every night. When I am at my parents' house, it's usually for an event or holiday, so everyone is coming in and out at various times. My niece and nephew are usually here, laughing and begging us to toss them around. Even growing up, with 4 kids in this house, it was not a quiet house.

Tonight, it is. Tonight, I'm waiting for the lights to flip off, when their timer hits midnight. Sometimes it's nice to get recentered, amidst the bustling rush that is Life. To take a minute or 16, and just sit with your thoughts and your heart. Not thinking about the past or wishing about the future. Just sitting in the present. It feels good. I think I'd like to do this more often.

Merry Christmas to All...

This year I am taking a week off, between Christmas and New Years, to spend time with my family. I'm looking forward to spending time with my family, eating some good food, and visiting Chicago to go ice skating. I love hanging out with my family, we have so much fun. I anticipate a lot of laughing til my sides hurt and keeping milk from coming out of my nose. Even as we get older, my siblings are some of my favorite people to hang out with.

I hope everyone out there can find at least one person to enjoy spending some time with this Christmas season. Merry Christmas everyone!

You've Got All Year

One of my New Year's resolution this year was to be able to do a pull-up. All by myself, unassisted, like the big boys. Anyone that knows me knows that I am ultra-organized. In school, if I had a project due in 2 weeks, I had it done in 2 days. I hate procrastinating, I hate having things hang over my head, I want to be able to check it off my list - quickly.

So, when I made this resolution, I was hopeful that I could have it done by March. I rarely pick resolutions that are ongoing, like "be nicer to people." I pick things that I can count and finish. I started the year in pretty good shape, so I thought with some specific training, this would be achievable fairly quickly. I got a few sessions with a personal trainer at the gym, to help me learn how to workout my upper body a little differently.

Every week or so, I'd mosey on up to the pull-up machine and see if I could do it. It's a machine that you can add supporting weight on, so that you aren't lifting your whole body weight up. I couldn't do it alone, I'd need 40lb of help, then 25lb of help, and finally 10lb of help. I couldn't budge from there. I was using the overhand grip, because it uses more of your back muscles, and I figured those were stronger than my puny biceps.

Well, this past weekend, I walked up to the pull-up bar we have at home. I tried the underhand grip this time, and I exhaled. And then I did a pull-up. All by myself, unassisted, like the big girls.

It took me over 10 months to achieve this resolution, and I realized that that's the point of a resolution. You have 12 months to reach that goal. So if anyone else out there is thinking it's too late to check that resolution off your list...Sister, you've got 2 more months to go.

Give me the Med

I have a hepatitis C patient with cirrhosis who recently started treatment. He's doing great, his viral counts went from 3 million to less than 43. It's working! Then I got his blood counts back, and his red blood cells were low. In following the guidelines, I reduced the doses of his medication. His next counts were still low. I tried to prescribe a red blood cell boosting shot, but the insurance company said no. My nurse has been more than 4 hours total this week talking to his insurance company to get it approved. They said no again today. I will have to fill out more paperwork to petition them again, and I will try to get someone on the phone to explain that if they don't choose to cover the medication, he will need to be hospitalized weekly for blood transfusions and all the risks that numerous transfusions entail.

Hopefully I can convince someone. I refuse to stop his hepatitis medication; he is undetectable and if he remains that way his risk for liver cancer and transplant drops substantially. I'll fill out any amount of paperwork it takes to get this approved, it's just sad that I have to try and explain this to people who know nothing about medicine let alone the nuances of hepatitis C treatment.