When Worry is a Terminal Disease

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Considering myself a Dr. Doolittle of sorts, always talking to the animals, I reached out to pet a stray cat sitting quietly outside our barn one evening while doing barn chores.  This is a grayish fluffy cat I see around the barns every few months or so–he doesn’t put in frequent appearances and reminds me of a kitten we raised on this farm a few years back, though his markings are a bit different,  so I know it is not our cat.

We have 6 cats to pet here who claim “us” as their home and family, so there is no lack of fur balls to love.  There are probably that many more who hang out,  now and then,  considering our farm fair game and looking for an occasional free meal.  This cat just seemed to need a reassuring pat at that moment or maybe I needed the reassurance.  Wrong.

I found myself with a cat attached to my wrist by teeth and claws.  It took a bit of an effort to shake him off and he escaped into the night. I then surveyed the damage he inflicted and immediately went to wash my wounds.  They were deep punctures near my wrist joint–not good.  Lucky for me I was up to date on my tetanus booster.

By the next day the wounds were getting inflamed and quite sore.  I know all too well the propensity of cat bites to get badly infected with Pasteurella Multocida, a “bad actor” bacteria that can penetrate deep tissues and bone if not treated with aggressive antibiotics.  After getting 6 opinions from my colleagues at clinic, all of whom stood solemnly shaking their heads at my 12 hour delay in getting medical attention,  I surrendered and called my doctor’s office.  I pleaded for a “no visit” prescription as I was up to my eyeballs in my own patients, and he obliged me.  I picked up the antibiotic prescription during a break, sat in the car ready to swallow the first one and then decided to wait a little longer before starting them, knowing they wallop the gut bacteria and cause pretty nasty side effects.  I wanted to see if my own immune system might just be sufficient.

So the bacterial infection risk was significant and real but I was prepared to deal with it.  For some reason I didn’t really think about the risk of rabies until the middle of the night when all dark and depressing thoughts seem to come real to me.

I don’t know this cat.  I doubt he has an owner and it is highly unlikely he is rabies vaccinated.  My own cats aren’t rabies vaccinated (and neither am I) though if I was a conscientious owner, they would be.  Yes, we have bats in our barns and woods and no, there has not been a rabid bat reported in our area in some time.

But what if this cat were potentially infected with the rabies virus but not yet showing symptoms?  Now my mind started to work overtime as any good neurotic will do.  Last summer a rabid kitten in North Carolina potentially exposed 10 people when it was passed around a softball tournament, no one aware it was ill until it died and was tested.  Lots of people had to have rabies shots as a result.

This cat who had bitten me was long gone–there was no finding him in the vast woods and farmland surrounding us.  He couldn’t be kept in observation for 10 days and watched for symptoms, nor could he be sacrificed to examine his neural tissue for signs of the virus.

I called the health department to ask what their recommendation was in a case like this.  Do they recommend rabies immune globulin injection which should have been done as soon as possible after the bite?   I talked with a nurse who read from a prepared script for neurotic people like me.  Feral cats in our area have not been reported to have rabies nor have skunks or raccoons.  Only local bats have been reported to have rabies but not recently.  This cat would have had to have been bitten by a rabid bat to be rabid.  This was considered a “provoked” attack as I had reached out to pet the cat.  This was not a cat acting unusually other than having wrapped itself around my arm.  No, the Health Dept would not recommend rabies immune globulin in this situation but I was free to contact my own doctor to have it done at my own expense if I wished to have the series of 5 vaccination shots over the next month at a cost of about $3000.   Yes, there would be a degree of uncertainty about this and I’d have to live with that uncertainty but she reassured me this was considered a very low risk incident.

I knew this was exactly what I would be told and I would have counseled any patient with the same words.  Somehow it is always more personal when the risk of being wrong has such dire consequences.  I could see the headlines “Local Doctor Dies From Rabid Cat Bite”.

This is not how I want to be remembered.

Rabies is one of the worst possible ways to die.  The cases I’ve read about are among the most frightening I’ve ever seen in the medical literature. Not only is it painful and horrific but it puts family and care providers at risk as well.  It also has an unpredictable incubation period of a up to a month or two, even being reported as long as a year after an exposure.  What a long time to wait in uncertainty.  It also has a prodrome of several days of very nonspecific symptoms of headache, fever and general malaise, like any other viral infection before the encephalitis and other bad stuff hits.  I was going to think about it any time I had a little headache or chill.  This was assuredly going to be a real test of my dubious ability to stifle my tendency for 4-dimensional worries.

I decided to live with the low risk uncertainty and forego the vaccination series.  It was a pragmatic decision based on the odds.  My wounds slowly healed without needing antibiotics.  For ten days I watched for my attacker cat whenever I went to the barn, but he didn’t put in an appearance.  I put out extra food and hoped to lure him in.  It would have been just be so nice to see his healthy face and not have to think about this gray cloud hanging over me for the next few months, as I wondered about every stray symptom.  No gray kitty to be seen.

Almost a month has gone by now and he finally showed up last night.  I could have grabbed him and hugged him but I know better now. No more Dr. Doolittle.

He is perfectly fine and now so am I, cured of a terminal case of worry and hypochondria which is not nearly as deadly as rabies but can be debilitating and life shortening none the less.

From now on, I’ll be contented to just “talk to the animals” like any good Dr. Doolittle.  I don’t need to cuddle them.

 

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photo by Nate Gibson

Take My Waking Slow

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I wake to sleep, and take my waking slow.   
I feel my fate in what I cannot fear.   
I learn by going where I have to go.
We think by feeling. What is there to know?   
I hear my being dance from ear to ear.  
I wake to sleep, and take my waking slow.
Of those so close beside me, which are you?   
God bless the Ground!   I shall walk softly there,   
And learn by going where I have to go.
Light takes the Tree; but who can tell us how?   
The lowly worm climbs up a winding stair;   
I wake to sleep, and take my waking slow.
Great Nature has another thing to do   
To you and me; so take the lively air,   
And, lovely, learn by going where to go.
This shaking keeps me steady. I should know.   
What falls away is always. And is near.   
I wake to sleep, and take my waking slow.   
I learn by going where I have to go.
~Theodore Roetke “TheWaking”

 

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In my rush to get from there to here
I missed some things.  The solitary song
of the chickadee; the play of winter light
on kitchen walls; the smell of fresh-raked leaves;
the summer days of childhood, stretched slow
from dawn to dusk, no need to know the date
or time, only the sound of a silver swung bell
to call me in for supper.

Could I re-learn to navigate by phases
of the moon, the ebb and flow of tides,
the rhodies budding out today before
the fall’s first snow?  Could I re-learn
to take my waking slow?
~Ted McMahon, M.D. “Slow Season”

 

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I took an unscheduled landing while wheelbarrowing hay to our horses in the field yesterday morning.

In my rush to get from there to here I missed some things.

I stumbled on uneven ground and fell hard, badly injuring my elbow.  Finishing chores afterward was a challenge and a necessity, wrapping my broken wing up tight in my jacket, doing what was needed before my husband came home to take me to the ER where good people who know me took great care of me.

Of those so close beside me, which are you?   
God bless the Ground!   I shall walk softly there,   
And learn by going where I have to go.

Even though no bones were broken, it was dislocated, so my elbow (and I) needed to be put back together.  The miracle of “conscious sedation” IV medication let my body “think” I was awake – I was surrounded by a swirling round of voices telling me to take deep breaths and constantly reassuring me–while the ER doctor and nurse put traction on my arm and shoulder, then twisting and turning my elbow back into proper position with a “clunk”.  I was blissfully unaware of the tugging and torque, paying attention only to the swirling sounds in my head, then waking slow to find my arm splinted and wrapped from mid-humerus to fingers — all fixed but now typing is also slow.

This shaking keeps me steady. I should know.   
What falls away is always. And is near.   
I’m walking more carefully now, paying attention to exactly where my feet land and what is around me.
The ground is near yet still can be a hard and abrupt landing;
I celebrate the good clinicians who put broken people back together again.
Great Nature has another thing to do   
To you and me; so take the lively air,   
And, lovely, learn by going where to go.
tammingasunset

 

 

The Mere Exception

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We should always endeavour to wonder at the permanent thing, not at the mere exception. We should be startled by the sun, and not by the eclipse. We should wonder less at the earthquake, and wonder more about the earth.
~ G.K. Chesterton

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As a physician, I’m trained to notice the exceptions – the human body equivalent of
an eclipse or an earthquake,
a wildfire or drought,
a hurricane or flood,
or a simple pothole.

Ordinarily I’m not particularly attentive to everything that is going well with the human body, instead concentrating on what is aberrant, out of control or could be made better.

This is unfortunate; there is much beauty and amazing design to behold in every person I meet, especially those with chronic illness who feel nothing is as it should be and feel despair and frustration at how their mind or body is aging, failing and faltering.

To counter this tendency to just find what’s wrong and needs fixing, I’ve learned over the years to talk out loud as I do physical assessments:
you have no concerning skin lesions,
your eardrums look just as they should,
your eyes react normally,
your tonsils look fine,
your thyroid feels smooth,
your lymph nodes are tiny,
your lungs are clear,
your heart sounds are perfect,
your belly exam is reassuring,
your reflexes are symmetrical,
your emotional response to this stress and your tears are completely understandable.

I also write messages meant to reassure:
your labs are in a typical range
or are getting better
or at least maintaining,
your xray shows no concerns,
or isn’t getting worse,
those medication side effects are to be expected and could go away.

I acknowledge what is working well before attempting to intervene in what is not.

I’m not sure how much difference it makes to my patient.
But it makes a difference to me to wonder first at who this whole patient is before I focus in on what is broken and what is causing such dis-ease.

I just might be astonished.

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Only Human

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photo by Nate Gibson

                                                                                                                               above photo by Nate Gibson

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They work with herbs
and penicillin.
They work with gentleness
and the scalpel.
They dig out the cancer,
close an incision
and say a prayer
to the poverty of the skin.
They are not Gods
though they would like to be;
they are only human
trying to fix up a human.
Many humans die.
They die like the tender,
palpitating berries
in November.
But all along the doctors remember:
First do no harm.
They would kiss if it would heal.
It would not heal.

If the doctors cure
then the sun sees it.
If the doctors kill
then the earth hides it.
The doctors should fear arrogance
more than cardiac arrest.
If they are too proud,
and some are,
then they leave home on horseback
but God returns them on foot.
~Anne Sexton “Doctors”

 

Decades ago, essayist, journalist and storyteller E.B. White advised, “Be obscure clearly.”

As a physician, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  There is much that is still unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, hardly pristine and clear.

Let’s face the lack of facts of the plethora of shifting, changing facts.  Our conceit about our clinical work is ready to unseat us and plunk us in the dust even on the best of days when everything goes well.  We hope our patients communicate their concerns clearly and comprehensively, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing, advertised by our training as so solid and reliable,  is quicksand much of the time even though our patients trust we are giving them advice based on a foundation of truth learned over years of education and experience.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with constant silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes documentation.   The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.   Lives depend on it.
And maybe we can stay on the horse and out of the dirt a little while longer.

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Prepare for Joy: Repairer and Restorer

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Then your light will break forth like the dawn,
    and your healing will quickly appear;
then your righteousness will go before you,
    and the glory of the Lord will be your rear guard.
Then you will call, and the Lord will answer;
    you will cry for help, and he will say: here am I.

11 The Lord will guide you always;
    he will satisfy your needs in a sun-scorched land
    and will strengthen your frame.
You will be like a well-watered garden,
    like a spring whose waters never fail.
12 Your people will rebuild the ancient ruins
    and will raise up the age-old foundations;
you will be called Repairer of Broken Walls,
    Restorer of Streets with Dwellings.
Isaiah 58: 8-9, 11-12

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Medical science is realizing there is less benefit (and possible potential for harm) in healthy people requesting an “annual physical”  than previously believed.  Too many people hold off on very real problems, hoping they are insignificant, and expect the doctor might discover what’s wrong during a cursory physical exam.

As healers, we are tempted to look too hard for “something wrong” to fix, at the risk of creating illness where there is none, all at a hefty price tag.

Give us the sick and tired and we doctors feel right at home, with problems to solve and a job to do.

Jesus, as the Great Physician, understood there is “something wrong” with each of us needing His unique healing art.  He hangs out His shingle as the place to come, triaging the most troubled and distressed to move first in line.   When we cry out for help, He is on call full time, a certified, licensed and bonded Strengthener, Rebuilder, Restorer and Repairer.

No more waiting for the annual check up.  The time has come to cry out our brokenness, our desperate need of restoration.

It is not the healthy who need a doctor, but those who are ill.
Luke 5: 31

A Recipe For Good Medicine

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A good night sleep, or a ten minute bawl, or a pint of chocolate ice cream, or all three together, is good medicine.
~Ray Bradbury from Dandelion Wine

Most days in clinic we see tears, lots of them.  We keep boxes of tissues strategically placed in the exam and consult rooms,  as well as the waiting room.  Life can seem overwhelming, fear and worry proliferate unchecked and floodgates spillover occurs when just one more thing happens — maybe a failed test, a fight with a family member, a lingering fatigue that just might be some dread disease.

We underestimate how therapeutic a good cry can be, almost as helpful as deep and heart felt laughter.  Stress and tension is dissipated, endorphins are released, muscles relax.  Holding back tears, like trying not to laugh (think Mary Tyler Moore at Chuckles the Clown’s funeral service) is hard work and cab only make things worse.

So I hand out kleenex like candy and tell my patients to just let it go and flow.  I’m an easy crier myself, and will cry at the drop of a hat with very little provocation — a certain hymn in church, a beautiful word picture, a poignant memory, or sometimes in exhaustion and frustration.  Tears are a visible tangible connection with what is happening to us and around us and to others.   They can be more honest than what we say and do.

When the weeping wanes,   I always recommend a good night’s sleep.

And chocolate.

Good medicine without a pharmacist.

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My Own Usefulness

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Like a doctor, I learned to create
from another’s suffering my own usefulness, and once
you know how to do this, you can never refuse.
To every house you enter, you must offer
healing: a chocolate cake you baked yourself,
the blessing of your voice, your chaste touch.
~Julie Kasdorf from “What I Learned From My Mother”
When my clinical responsibilities top out at 14 hours a day and there is still more to do,  when I’m weary and grumbling about work load, I need reminding that my usefulness is completely dependent on others’ suffering.
No illness, no misery, no suffering and I’m out of a job.
If only. What bliss that would be.
If I’d known it could help you, I’d have baked a cake…

Definitely chocolate.