Friday, January 28, 2005

Viernes Se Llega! (Friday Arrives!)

In the course of my work, I sometimes feel like one of those circus clowns, running at full speed, dodging the other performers, and juggling numerous fragile plates in the air over my head as I continue to smile. It's a true juggling act of keeping multiple threads woven in my cerebral cortex, trying my best to remember the myriad details that need my attention: this one needs bloodwork; this one has an abnormal CAT scan that needs follow-up; the other needs a referral for the surgeon; and now my beeper is going off and cell phone ringing simultaneously as I'm paged overhead to meet a patient in the waiting room.

The patient in the waiting room has advanced AIDS that's perfectly under control, but his blood pressure is 170/112 today, and he fell yesterday during a dizzy spell and lacerated his shin. I check the wound which looks clean and is covered with steri-strips placed by an ER doc. His narcolepsy seems poorly controlled today as he nods off while on the exam table, and his wife says that they just can't remember to call me for refills of his Ritalin which helps keep him alert. I make a mental note to pay them a home visit soon to look over his meds and see where they've become confused. He failed his Hepatatis C treatment so that's one less thing to worry about in terms of meds, but I remind him that if he doesn't take care of his blood pressure, it will most likely kill him way before the AIDS ever does. (They're not joking about the "silent killer of hypertension".) I remind him of his appointment with the vascular surgeon for his horrible varicose veins, and also for the orthopedic surgeon for his herniated disk. Does he have the MRI films? Yes. Does he know where to go on Tuesday? He thinks so. Will he come in on Monday for a blood pressure check? OK. Keep those steri-strips dry and change the bandage every day, why don'tcha.

Meanwhile, another of my patients has come in to see his primary doctor, unbeknownst to me. The doctor finds me while I walk down the hall, letting me know that our mutual patient couldn't walk on his right leg for three weeks and never bothered to call us or go to the ER. He's feeling somewhat better, but we send him for a stat ultrasound of his leg and it's immediately confirmed that he has a deep vein thrombosis (DVT) from his ankle to his knee (a long clot traveling up a major leg vein). He's very lucky that a piece of the clot didn't break off and travel to his lungs. He would have died within minutes. We send him home with a prescription for Coumadin (blood thinner) and remind him to come in for bloodwork on Tuesday, without fail. By the way, we tell him, call us right away if you start having uncontrollable nosebleeds or your gums bleed while brushing your teeth. And please be careful shaving, OK?

The man with the DVT is followed by two of my favorite patients. A married couple, both infected with AIDS. She "bought in" early on and has fully suppressed virus and no side effects. He played around with his meds and failed a few regimens of AIDS drugs, and then came to me a year ago, desperate to try again, losing weight and wasting away. I had to scare him and tell him he had less than a year to live unless he worked with me closely, with great concentration and attention to detail. He decided to do it, and here we are. With frequent follow-up and a good rapport, they're a success story, with the virus under control for them both, their kids in school, newly approved Section 8 housing, and a sweet relationship. Our visits are peppered with laughter, jokes, and an ease which makes our time together flow smoothly and easily. I prefill his meds in two one-week boxes, give her an injection of Depo Provera, check their weights, and send them on their way. Hasta la proxima!

Papers and charts are piled on the desk. I make a few notes in my Palm Pilot, scribble some Post-It notes to leave on my desk for Monday morning, file my encounter sheets for the day, and turn off the computer for the first time since 9am on Monday.

The chaos and busy movement of the day are winding down, the phones are routed to the answering service, the beepers cease their sound, laughter fills the room, and we bid one another adieu, leaving the clinic to return to our families for the weekend, only one of us burdened with taking urgent calls until Monday morning rolls around again. It's been a job well done. I feel fairly crispy myself, perhaps medium well at this juncture.....

I arrive to the home fires burning in the woodstove, my lovely wife cooking yet another wonderful meal, the dogs wagging their tails, and the feeling of gratitude for a welcoming domestic scene which draws me in with its wholesome and restful embrace. We catch the end of "The Buena Vista Social Club" on the Independent Film Channel, and I cry as the group takes its well-deserved bows, having accomplished so much and brought joy and music to so many. My cup runneth over.

Wednesday, January 26, 2005


Six inches of snow blanketed our region over night and this morning. The dogs seemed to be begging me to stay home and play, but I was a good little worker bee and drove the sloshy roads to work, the first stop being to get gas, shivering in the cold as I pumped fossil remains into my hunk of rolling steel and plastic. Next stop was a bar and hall in a nearby town, where I found my previously mentioned patient, "X", sitting at a table reading the paper as several older gentlemen drank beers at the bar. It was 9:30am. I felt like a visitor from another planet, or at least another era.

We ensconced ourselves in the very clean and well-kempt hall---replete with chandeliers, large tables and a dance floor---and I launched into my "scare-the-shit-out-of-him-with-the-naked-truth-speech". I showed pictures of a healthy liver, a fibrotic liver, a cirrhotic liver, and a cancer-ridden liver, and was very frank that his organ is enlarged, cirrhotic, and predisposed to failure, or possibly carcinoma, and that each drink of alcohol is akin to pouring gasoline on a roaring fire. He looked at me with his very sad (non-jaundiced) eyes and had little to say verbally, but his grave expression told me that I had hit home. That said, whether he can translate that into action and change remains to be seen, the tentacles of addiction being powerful and beseeching friends who will attract the afflicted person like the smell of barbecue will attract a hungry dog.

So, after having blown off his post-hospitalization follow-up visit, never filling his prescriptions that were given to him upon discharge, and drinking lots of alcohol since getting released, he is faced with an earnest nurse whom he trusts telling him that if he keeps drinking, he will most certainly die, and probably not with the kind assistance of a beautiful prostitute-turned-nurse like Nicholas Cage in "Leaving Las Vegas". He will most likely go into acute liver failure while in his apartment late at night, with various gruesome clinical situations unfolding too quickly for him to call 911---but wait, he doesn't have a phone. If his liver does go into acute failure, he might become extremely confused ("obtunded" is a term we like to use) from the rising level of ammonia (yes, ammonia) in his blood, poisoning his brain and curtailing his ability to think clearly. He might then hemorrhage internally or lapse into a coma, his friend with the spare key finding him stiff with rigor mortis in a day or two. These and other unpleasant scenarios certainly await him if he chooses to continue to walk down that road of addiction.

Will my candor pay off? Will he choose to move towards healing and recovery? I can't say, but I wouldn't hold my breath. I'll keep tossing him a line, offering my hand, but if his hands are busy with the bottle, my offers will go untaken, and I will attend yet another wake some time in the near future, just like the one I attended a few weeks ago. That gentleman was addicted to crack and cocaine, and try as I might, I could not turn him towards proper treatment of his AIDS, and he died of liver failure as well, a victim of his own trauma and loss, lapsing into a seizure and dying a quiet death in a specialized care center in Boston where we had sent him to die.

The saga of X will continue, as will so many other sagas that will go untold, those to which I am witness, and those which occur on the fringes of society where they reach their dramatic denouement with barely a ripple made or notice given. I dance in these lives, or at least on their outskirts, but there are often reluctant partners who refuse my hand and slip into the darkness. May their learning in the next life be less painful; may their souls know peace.

Tuesday, January 25, 2005


It's 11:30pm and I'm exhausted. Mary is in that sweet state between waking and sleeping, and the dogs are on their way to that canine dream-land which we can only imagine. I will join them soon, but my brain is still spinning from the day.

The nature of my work can lend itself to mental, physical, and emotional exhaustion, with current loads of 80-90 patients each, my current roster numbering 83 individuals.

Imagine for a moment that you are a 60-year-old Puerto Rican woman with HIV, diabetes, hypothyroidism, major depression with psychotic features, and asthma. You speak no English and have a 2nd-grade education. Your family members also speak no English. How would you navigate the healthcare system? Or imagine you are a 35-year-old Latina woman with advanced AIDS, Hepatitis C, asthma, a seizure disorder, a history of trauma and physical abuse by your mother who burned your skin with hot oil and water for fun, and this caused you to pursue a life of self-medication with street drugs? How would you manage to take care of yourself and your children? How would you stay clean and do the right thing? How would you stay focused on your health when your history of trauma effects your every waking moment and decision?

These are just snippets to allow you to see the complexity and tragedy of some of the lives of which I am priviledged to be a part, welcomed into homes, confided in, and relied upon. I say it is a priviledge because it actually is an honor to be embraced by these individuals and their families. Yes, we see our share of death, of failure, of self-destruction and chaos, yet we see enough success and self-preserving valor in the face of grim odds that we feel it is worth our time and effort (and at times our mental health, frankly) to work in this community.

Tomorrow I go to visit a white gentleman in his late forties who is an alcoholic. I recently facilitated his admission to the hospital for alcoholic hepatitis. He came to see me and his liver was in such acute distress that his eyes were as yellow as a flourescent highlighter marker, his face a cadaverous pale yellow, and his ankles filled with fluid, almost the size of his thighs. After a 9-day stay in the hospital, delirium tremens (DTs) from alcohol withdrawal, and a general "tune-up", he is now back at home, hanging out at a local bar and drinking again. In his condition, drinking alcohol is like pouring gasoline on a fire. I don't know his whole history, but I imagine it's rife with abuse, abandonment, or worse. How do I convince him to stop drinking? How do I help him to see that he is slowly committing suicide? I guess I will do my best, and then rent "Leaving Las Vegas" and be reminded that some people will choose to self-destruct no matter what kindness is bestowed upon them. My meeting with him tomorrow may lead to little or no change, but I will remind him once again that help is their for the asking, and I will meet him half-way if he reaches out for it.

Consider this quote from Cracked, a book about addiction by Dr. Drew Pinsky: “We define ourselves by the way we relate to other people. We get deep, lasting, and meaningful satisfaction from giving selflessly to, and being present with, others. My patients can’t do that. They’re struggling with the effects of trauma suffered early in life when they were still developing the brain mechanisms that allow them to relate to other people and the world in general. Unable to trust, they grow up without a sense of self. They’re overwhelmed by feelings, unable to cope, always out of control. Their brains tell them to manage pain by getting loaded. Then, when they find their way to us, we ask them to go back and experience that powerlessness, the very thing that sent them off the rails in the first place. No wonder they resist.”

There are so many stories, so many struggles, countless people out there who deserve more, who deserve better, who have been dealt a bad hand either through genetics, poor choices, mental illness, or plain bad luck. If we think we can save them, we're wrong, and sometimes in our earnest efforts to effect change in the lives of those whom we seek to help, we lose sight of our own self-care. Thus, here I sit, just short of midnight on a Tuesday evening, pouring my heart out on this keyboard, with the realization that I will get up tomorrow and do it again. I don't write this out of a need for congratulations, praise, or moral kudos, I write it to share that this reality, this daily vision of the underbelly of urban America, greets my eyes each day and informs my own personal version of reality. I share it here as an exercise, an exorcism, a description, a way to loosen the hold of that troubling reality on my psyche as I prepare for the sweet forgetfulness of sleep which sometimes seems too brief.

Good night.