Since

I'm sick (again) and in the middle of a shitstorm at work (again) and my precious assistant just went out on maternity leave (not again, and the baby is adorable, but I am near helpless without her), and I'm working this weekend.

These are my excuses for this short post. I have the needle phobia one half-written, so that'll be out soon.

But today, one really cool thing happened: my son correctly used the word "since" in a sentence. This reminded me of how I once worried that I would be sad to see him leave babyhood behind. When in fact oh my god am I glad to leave his babyhood behind. Babyhood kicked my ass. He was a real HellBaby, but as a toddler, while he's still intense, he's a lot closer to the norm (if the norm encompasses channeling Bono, that is).

Suck It Up and Run

Turns out I’m not the only quack out there who says that you can/should keep running even if it hurts! (Thanks to Elizabeth for noticing the article.)

As I said before: if something hurts and running on it is either too painful to do OR seems to be making it worse, then don’t do it; otherwise, get your butt out there.

Placebo Deficiency

Is the light therapy working?

I do feel less gloomy and more energetic than I did before. And when I think about how long it will be until the sun really starts making a comeback, that seems like a simple fact; I don’t feel it in my bones.

At first I was thinking it might just be a placebo effect. Then I remembered—I have a serious deficiency: I am immune to placebos. I used to be proud of this, thinking it meant I was less gullible than other people, but over time I have come to realize that it just means I don’t feel as good as other people. Because the placebo effect is a marvelous thing.

I always suspected that I was missing out. I get terrible post-viral coughs, and used to drink gallons of dextromethorphan without noticing the slightest decrease in the hacking. (I continued to take it mainly because the people I lived with got terribly annoyed if I didn’t—as if I were destroying their sleep on purpose.) I felt vindicated when I finally saw data that over-the-counter cough remedies are entirely useless aside from their placebo effect—but the knowledge didn’t help me cough any less.

My first attempt at (illegal) mind alteration was a dud. It was a pretty pathetic scene: three of us huddled around a tinfoil-and-tampon-applicator b0ng containing a tiny dried-up lump of h@shish. J, who supplied the stuff, was an anorexic who consumed only Tab and tiny, strictly measured mounds of trail mix. After a few minutes of inhaling hot cotton shreds, J said, “I feel it! I definitely feel it!” My friend S, a 2-pack-a-day smoker who was fluent in three languages, politely said, “Maybe?” And I said, “Nope. Don’t feel a thing. Let’s go get drunk.” (This non-starter led to unfortunate overindulgence much later on, on the suspicion that I just might need a higher dose; the result was not unlike that described by Feral Mom here.)

The real proof came one evening when I was staying at my sister’s house. She and her (first) husband went to a dinner event without me. I got takeout Mexican and happily sat down with a book and a beer. I didn’t much like the beer—some weird German brand I found in their fridge—but I really felt like I needed a drink that evening. Strangely, after I finished the beer, I still felt like I needed a drink. Must be really stressed, I thought, and cracked open another. But after draining that one, I still felt like I needed a drink. Am I becoming an alcoholic? I wondered. It was not until I pulled the third beer out of the fridge that I noticed the fine print on the label: non-alcoholic. I swore a bit, rummaged around and found a real beer, and was perfectly happy after drinking that one (though a bit bloated by that point).

While others are happily enjoying their buzz or being relieved of headaches and such, I’m moping in the corner wondering how I can get my hands on the good stuff.

I’m always a little amused when people get started on antidepressants and after about four or five weeks say, “You know, I’m feeling a lot better, but I don’t know if it’s really the medication—maybe I’m just snapping out of this!” Not that that could never happen, but it’s interesting that it almost always seems to happen right around the time when one would expect an antidepressant to kick in. And here I am, wondering the same thing about the light therapy.

So, I guess it works.

What Would Miss America Say?

I was thumbing through the most recent issue of Glamour (a magazine I usually find sneakily feminist) and I saw a little filler article that made me want to smack approximately 1,750 women upside the head.

They asked 2,156 readers some “Would you rather” questions—for the most part silly things like “Would you rather go to a huge party naked, or never eat your favorite food again?” (66% would give up their favorite food). But two of the questions—or rather, the answers to them—made me dizzy with disbelief. The first one was, “Would you rather achieve world peace but never find a cure for cancer, or cure cancer but never have peace?” The majority (59%) answered that they’d rather cure cancer.

WHAT? What is it with the fear of cancer? Don’t people realize that they have to die of something? Most people don’t die of cancer as it is. And though I don’t like to scare anyone, there are plenty of diseases that are worse than most cancers. Give up the possibility of world peace to eliminate cancer? I know it’s just a silly poll that I’m sure most of the respondents didn’t take seriously, but come on.

The second question that got me riled up was, “Would you rather have a body like Heidi Klum’s but die at 40, or be morbidly obese but live to 100?” A whopping 81% said they’d choose Heidi Klum’s body.

All these women really believe that having a hot body would make their lives so special that it would be worth giving up 60 years of life for? (Or perhaps they’re so afraid of getting fat that they’d rather die? But since the vast majority of women in this country are already significantly bigger than Heidi Klum, I assume it’s mostly the former.) The question didn’t say you’d get her face, or her career, or even Seal; you’d just have her body. Just what do they think they’d do with it?

Even weirder, most of the women who said they’d give up world peace for a cure for cancer must also have said they’d die at 40 for Heidi Klum’s body. I guess they’d be okay with dying young as long as they don’t die from the Big C. Maybe they’d rather step on a land mine in the next world war?

Lessons Learned This Holiday Season

1. It is not enough to bring your toothbrush and medications in your carryon; you should also bring your passport. Because even if you are not flying through, say, Denver, it may happen that of all the flights going out of your airport the Saturday before Christmas, yours could be the one that is cancelled for “maintenance.” (Now, to me, “maintenance” implies routine things like changing oil or rotating tires. Things you would never do on one of the busiest travel days of the year. Couldn’t they just admit that the flight was cancelled because the PLANE BROKE?) On such a busy day, there will be no extra seats on any of the rest of the flights that day, unless you are willing to fly via a complicated connection THROUGH ANOTHER COUNTRY. Hence the need for passports (which TrophyHusband was able to drive home and retrieve in time).
2. You might also want to bring a few changes of clothes in your carryon. Because even if you are checked into a flight three hours early, it may happen that none of your luggage makes it on the plane with you.
3. Don’t pack a suitcase for each person; mix it up a bit. This way, when all of the bags eventually show up except yours (which does not arrive until the night before you are leaving to go back home), you will still have something to wear.
4. My mother really needs to update her wardrobe. Since I had no clothes to wear, I had to borrow hers. She is somewhat shorter and wider than I am, so I couldn’t comfortably wear her things the whole trip. And when I braved the mall wearing her clothes and asked the sales clerk where I might find jeans, she looked me up and down and sniffed, “Well, you wouldn’t want the Juniors department,” and took me to a rack of Mom Jeans. I couldn’t decide whether to slap her or spontaneously combust from embarrassment, so I just slunk away. (I did find an awesome outfit, in the Juniors department, so there, judgmental salesgirl.)
5. It is truly is better to give than receive. You become acutely aware of this when your gifts are stuck in your lost suitcase and you have to unwrap others’ gifts and then say, “Thanks! I hope my gift to you isn’t being sold on a corner in another country!”
6. My husband is a trophy and a mensch. OK, I already knew this one, but he proved it over again. My family has a tradition of giving most gifts as “stocking stuffers,” which creates an absurdly huge stack of gifts to unwrap Christmas morning, but is pretty cool because you never know who gave what; it’s quite freeing. But many of the gifts were stuck in my suitcase (see #5). Then my brother (whose awesome girlfriend recently broke up with him, probably with good reason) announced that he had bought no stocking stuffers at all. I thought it was going to be like Whoville, only without the singing. But my husband, despite being Jewish and finding this whole Christmas thing incomprehensible, had gone out on the sly and bought a heap of cute and thoughtful gifts, and the pile of loot was not appreciably smaller than usual. (HellBoy, when he saw all the presents, said, “It’s Hannukah morning!” which pleased my husband greatly.)
7. If you are very tired and have just eaten a big Christmas dinner, do not lie down with the child while putting him to bed. Because it may happen that you wake up the next morning with fuzzy teeth, and your parents and their guests will be very perplexed as to why the hell you never came back to the table.

Happy New Year, everyone.

If You Don't Think Studying Is Hard, You're Doing It Wrong

A disclaimer: I never said I had a fun or easy way to study, or even a particularly original one. I only said that it worked (for me).

When I decided I was going to try to get into medical school, I’d had thirteen years of grade school, three years of college, and two years of grad school. But the vast majority of this time was spent in classes in the arts, and the art I perfected was that of doing just enough to get an A- in anything. (The trick to that, if you’re interested, is: read the assigned material closely enough to get the gist of the ideas, show up to most of the classes (in particular the first three and the last three), write a paper that is slightly longer than the minimum assigned length, and string together coherent sentences for the midterm and final. So few people (no matter how fancy the school) manage to do all of those things that they’ll feel guilty marking you down much for simple crappiness (and believe me, I was guilty of much crappiness). There were a few classes that I got really into, but it seemed like even when I flayed myself open for a class, the T.A. wouldn’t care for my take on the subject and would give me an A- anyway.)

So let’s say I was a tad unprepared for premed classes. I had a heavy load of them, too, since I pretty much hadn’t done anything in college that counted as a science course, with the exception of Physics for Phreaks (where all I remember doing is going on a field trip to walk through a noise-canceling room while some poor grad student babbled about waves). I crammed into a two-semester period almost every required premed course, including labs. I read the books and got the gist; I showed up for class; and when I sat down for my first test—a physics quiz—I wasn’t too worried.

My attitude was rudely adjusted when the quiz came back with a big red “59” written in the top right corner. Thanks to the curve (a lovely device not often used in liberal arts courses), it worked out to something like a C, but holy shit—a 59??? I had blown 41 percent of the questions?? This wasn’t going to get me into med school. And I’d already quit my job.

OK, so it was firmly established that I was no Feynmann. I needed to get serious. Here’s the method I followed:

• Realize that how painful something is to study is directly proportional to how much you need to study it.
• Go to every class—and stay awake.
• Read all of the material, painstakingly slowly, at least three times over.
• The “gist” is useless; memorization is what counts.
• After you think you’ve memorized something, try writing it all down on a blank sheet of paper. Hmm, maybe not as well memorized as you thought?
• When you quiz yourself, which should be often, make sure you get all of the answers right three times in a row.
• Beware the mnemonic. Mnemonics only work in very specific circumstances. For instance, “NAVY” is a handy mnemonic for remembering the order in which one encounters the important structures in the groin: Nerve, Artery, Vein, Ying-Yang. Most mnemonics, no matter how clever or bawdy, just inspire one to invention. Does that I in “PILES of POOP” stand for Ischemic? Infectious? Iatrogenic? Ipsilateral? Italian? Who the hell knows? I found that making up a memorable saying works much better. For instance, if you drink enough alcohol to affect your liver, there is a tell-tale pattern to the increase in the liver enzymes: the AST, aka the SGOT, is usually twice as high as the ALT, aka the SGPT. I remember this by saying “You AST for it, you SGOT it.” (I know it’s stupid. But it works—I remember not only the pattern, but that AST=SGOT.) Corny tricks like the ones for remembering someone’s name (you know, picturing Mr. Heinz as a giant ketchup bottle, for example) work well also.
• You will never be hip again. Obviously.
• Get enough sleep. Cramming all night the day before a test does not work for science classes.
• Study similar things in proximity to each other. Calculus and physics go well together, for instance.
• If studying something is making you fall asleep, take a power nap.
• I said power nap. Do not let yourself sleep longer than 20 minutes.
• Colorful highlighters and tabs and note cards are festive and helpful—up to a point. Past that point, they become time-sucking OCD rituals.

Hey, like I said, it’s not fun. But it worked for me. Despite my pathetic start, I went on to get the highest grade of anyone in that physics class, and I got an A+ average in my premed courses. I realize now that if I had used these kind of techniques in my liberal arts courses, I probably would have rocked them, too. Even when I worked hard, I neglected ever really to learn the material by heart.

In a few years I’m going to have to take my recertification test, so I’ll be hauling out these methods pretty soon. For now, I confess that I’m often getting by on the gist.

Cold-Weather Running for Maggots

• It’s not too cold. From my sitemeter stats, I know that none of you are running where you risk hypothermia from venturing outdoors, provided you are properly attired and do not have a lung disorder. (If you have exercise/cold induced asthma, as I do, your tolerance for extreme cold may be less. Using an inhaler before running helps.)
• Go synthetic. No cotton, ever, on any part of your body, when running in the cold. When you sweat, cotton becomes soggy, and when it becomes soggy, it becomes cold. This is all right while you’re running, but if you stop and walk you’re toast. Iced toast. Ditto for goosedown. (Wool is ok, if you can stand it.)
• Layers. In general, the more, the better; you can always pull things off and tie them around your waist. A polyester turtleneck, a fleece, and a breathable-fabric windbreaker works well. (Non-breathable windbreakers will leave you too wet.) A windbreaker that covers your butt is nice. Two layers is pretty much the max on your legs, or you’ll be waddling. None of these items needs to be running-specific, and they’re usually cheaper if they’re not. I like Campmor for good, reasonably-priced stuff.
  
• Coverage. There are synthetic clothing options for covering up every bit of you, and how far you want to go depends on your cold tolerance. You will likely be sorry if you don’t use a headband or hat and a good neck gaiter (the tall, thin ones are very flexible) at the very least; a balaclava works for some, but isn’t very flexible. Goggles or glasses help keep your eyes from tearing, but wire-frame glasses will transmit the cold. (Using anti-fog spray on your glasses is a good idea.) Gloves are a must, and tucking your hands into your sleeves adds warmth. I’ve never been able to tolerate a face mask; I just use a neck gaiter and keep turning it as it gets too wet from my breath.
• Snot. Your nose will run. Bring tissue, or make sure your gloves are soft and absorbent.
• Reflect. It’s dark in the morning and dark in the night, and you’d be surprised how hard it is for cars and bikes to see you. Make sure you’ve got reflective stuff above and below. I have a nerdy reflective vest.
• Know which way the wind blows. Always run with the wind on your way out and against it on the way back.
• You can run in the snow. Running on packed snow or unshoveled sidewalks isn’t too hard, but you will need to go more slowly. Since you’re going for time, not distance, this shouldn’t matter much.
• You cannot run on ice. You will fall and break your wrist.

Beam Me Up

The light box thing came. It’s pretty funky. I got the desk lamp version, partly because it was listed on the sheet my doctor gave me and partly because I thought I might be able to pass it off as, you know, a desk lamp.

Not a chance. This thing looks like it was left behind after an alien visitation. Everyone who’s stopped by my office has skidded to a stop and said, “WHAT is THAT???!!”

Though when I confess it’s a light box, they all say, “Ooooohhhh ... I want one!” So I guess there are more dorks out there than I suspected.

I’ve only had it for two days, which is a little early to expect results. It definitely feels different than a regular lamp. It doesn’t seem all that bright—until you switch it off, at which point the room seems to have been dunked in essence of gloom. So after spending the recommended half hour with it beaming on my face like a Gro-Light on a happy pot plant, I move it way over to the corner of my desk and point it down. I don’t know if this will cause a mania-inducing overdose, but a little hypomania wouldn’t be such a bad thing. This has been a really tough month. I don’t feel depressed, exactly; no hopelessness/helplessness/inability to imagine a better future, etc. I just feel melancholy. And yes, that’s normal, but it’s no fun, and it’s affecting other people. I’m avoiding posting, because I can only think of gloomy topics. I’m like a sullen, disaffected teenager. I seem to see only the sad facets of every situation. For instance, one of my students has a deformed thumb. So what, right? It obviously hasn’t harmed her success in the world thus far. But every time I see her, I find myself mesmerized by it, hardly able to focus on anything else. I’m afraid to comment on others’ blogs, for fear of focusing on the deformed thumb.*

Before I sign off, I do have one piece of happy news. One of my colleagues has been going through infertility treatment for a looong time (during which five different women in the office got pregnant, two in an “oops” manner). She underwent multiple interventions, including seven IVFs. Then she thought that she must be going into early menopause, because she hadn’t had her period in a while. You know where this is going … she’s fifteen weeks pregnant now. So how’d it happen? Did she “just relax”? Nope. She and her husband had a fight, followed by makeup sex, and ta-da! Her RE was like, “You got pregnant by having sex? Eww!” So now I have an irritating story to tell people who are trying. “Just have a fight with your partner! You’ll be pregnant in no time! I know this person …”

*Not to imply that anyone else has deformed thumbs, or deformed blogs.

Rage, Rage Against the Dying of the Light

I went in for my quarterly tune-up with my psychiatrist recently. I think he’s a little bored of me; he hasn’t had to tweak anything for ages. This time, though, when he asked the usual questions about how things were going, I answered, “Fine, I guess, though of course it’s always especially hard after the time change in the fall.”

He perked right up.

“Why does that bother you?” he asked.

“Well, because it gets dark so early,” I answered.

Which is how I found out that it’s not entirely normal to dread the autumnal equinox and to count down the days until the light starts to grow again. I’d never understood how anyone can say fall is their favorite season. I’m used to my mood taking a swan dive in the fall, reaching its nadir about the end of December. It always creeps back up, but the prospect of the weeks and weeks of darkness stretching out ahead of me is tough.

So now I’ve got a light therapy lamp coming in the mail. I will set it up on my desk at work. I am going to look like a complete dork. Rather, I will be revealed to be a complete dork. But, I hope, a cheerful dork.

Scurvy of the Soul

Medical school is full of “That’s how that works?!!” moments. One I remember especially clearly was when I learned about scurvy:

Scurvy is a disease caused by a dietary deficiency of vitamin C (ascorbic acid). The disease has occurred with regular frequency throughout human history and prehistory in populations lacking fresh foods … Deficiency of the vitamin causes a breakdown in the binding function of these tissues, producing a series of characteristic signs and symptoms: weakness, lethargy, irritability, anemia, purple spongy gums which bleed freely, loosening teeth, the reopening of healed scars … and hemorrhaging in the mucous membranes and skin. In severe cases the mortality rate is high.

Up until then, I’d believed that scars were stronger than regular skin. When in fact they're weaker. Maybe this was something most everybody else knew, but it really shook me up. The mantra “What doesn’t kill you makes you stronger” is so satisfying. “What doesn’t kill you leaves a scar that may weaken and rupture again if stressed” is kind of scary.

I got to thinking about this recently when I was doing a computer search to see if a paper I’d had published recently was showing up yet. Only one other person with my last name is published in the medical literature, so it was quickest to type in just my last name to look for my papers.

But it turns out that they’ve been slowly working backward in time to put medical articles into the citation system. Which is why the last time I entered my name into PubMed, two articles written by my father appeared.

My father was a statistician who collaborated with medical researchers, so it’s not surprising that he had some papers published under his name. But he died when I was five, and all I knew about his job is that it had something to do with computers. Seeing his name pop up without warning like that was painful; a reminder that he’s not here, and of how much he has missed. I had never even thought about the fact that we could have talked about my work.

People often say that you never get over a loved one’s death. When I was much younger, I hated to hear this. I spent a long time trying to convince myself that my father’s death didn’t really have an effect on me. It happened when I was so young, after all. But things did sneak up on me. When I was driving down a street one day I caught sight of a little girl learning to ride a bicycle, her father running behind her, his hand on the back of her seat. Suddenly I was so upset I had to pull over to the side of the road. Then I remembered that my father had just started teaching me how to ride a bike the summer he died. After he was gone I had to do it myself: there was a big pothole in our driveway, and if I climbed on the bike at the top of it and rolled down, there was just enough momentum to get me started. I did it over and over again until I had it.

Once glimpsed, the knowledge that a person who loves you and takes care of you can disappear in an instant never goes away. It can teach you to appreciate people, but it also makes you very wary.

The truth about what happens when something wounds you is that first there is pain and bleeding. Then you start to heal, and a scar forms. A scar is vastly better than nothing; at least the acute pain goes away, and you don’t bleed to death. But it’s never the same as it was.

I think that human interaction is like vitamin C for the soul: get too little, and your psychic wounds can reopen.

I guess that’s why I keep blogging.

I Didn't Mean Right NOW

I got a call from the Medical Examiner's office that one of my patients was found dead. It was the woman I saw the other week, the one who couldn't stop drinking, the one I called a drink-yourself-to-a-miserable-death alcoholic. The cause of death was clearly alcohol-related. She was found by her daughter, who had stopped by with her newborn baby. I didn't even know she had a daughter.

I spoke with the daughter on the phone. She talked about how the alcohol was the only thing that mattered to her mother; she only ever called her daughter to scream at her. The daughter seemed incredibly nice.

I haven't got anything profound to say about this. I'm just trying to imagine what it must be like to care more about getting drunk than about your daughter, or your brand-new grandchild, or your own life.

Ghouls and Ghost Stories

Yes, I backdated my post to October. Suzan-Lori Parks may have been able to write a play a day for a year, but I know I’m not up to writing even a decent post a day for a month, so I don’t want to imply that I’m doing so by posting on November 1st.

Yesterday I supervised the residents for outpatient office hours. I mostly enjoy this part of my job; it’s a perfect opportunity to teach the art of medicine. There are all kinds of techniques for giving patients what they need and want AND being efficient. Sitting down when talking to them, asking “What else?” and “What else?” and “What else?” until they can’t think of anything more, asking “What questions do you have?” at the end of the visit instead of “Do you have any questions?” Explaining that something “isn’t dangerous” rather than saying “it’s not serious.” Oh, I’ve got tons of cute tricks up my sleeve.

Yesterday got a little out of control, however. We saw 17 patients between 2 and 5 pm, and most of these patients were not 10 minute visit types. A couple of them were very appropriate for Halloween, and haunted my thoughts all night. (Some details altered to shield identities.)

One was a patient I’ve been following for a couple of years; she got put on the resident schedule because I was out of town last week. This patient is truly horrifying. She’s an alcoholic, but not a flunked-a-couple-CAGE-questions alcoholic; no, she’s an old-school, drink-yourself-to-a-miserable-death alcoholic. She used to have a real job and a real life, but has lost it all. She has developed almost every sequela of alcoholism there is—heart damage, liver damage, brain damage, nerve damage—but most frightening is that she keeps falling down and damaging her flesh and bones. She drags herself into my office about every two months for follow-up from a visit to the ER with another horrifying injury. She fell flat on her face and smashed her nose in. She fell and bit through her lip, almost severing the whole bottom lip off. She’s broken both arms several times. She’s so malnourished at this point that she can’t heal properly. She’s a trembling, emaciated, misshapen wraith. And she’s always furious. Furious that she’s in pain all the time (and that I won’t give her narcotics, though she usually has plenty left over from the ER and the orthopedic surgeons). Furious that everyone is “shitty” to her. Furious that she has no life. And especially furious that everyone keeps “implying” that her problems are due to drinking, because she DOESN’T HAVE A PROBLEM, GODDAMMIT. She cries and shakes and fills the room with the fumes of whatever she had to steady her nerves that morning and licks her scarred lips with her cracked, swollen, vitamin-deficient tongue. And begs for sleeping pills.

My poor resident was terrified. I ended up doing most of the talking, because at least I’m used to her. There’s really not much to say; I just agree and express sympathy about the fact that her life is hell, and then decline to write prescriptions for mind-altering substances, explaining that I’m concerned they could make her fall even more often. I’m not sure why she keeps coming back. I don’t know how to help her. So that was the only lesson I could give the resident: sometimes there’s nothing you can do.

The second frightening patient seemed only perplexing at first. He was a new patient, a mild-mannered elderly man. He spoke only Albanian, so everything had to be said through the phone interpreter, and even the interpreter seemed to have difficulty figuring out what he was saying. He came with a “case worker” who knew absolutely nothing about him (and definitely didn’t speak Albanian). He presented with papers from prison stating that he had some medical problems and some psychiatric problems. He’d been released several months ago, and had been able to fill his regular meds, but not his psych ones.

The resident came out of the room and explained all this to me. “Someone has to know the story,” I said. “Talk to the case worker and find a number we can call.” She seemed skeptical, but returned to the room.

Turns out that this patient had been in prison for 25 years after becoming psychotic and strangling his mother. He’d been treated in prison with monthly injections of antipsychotic meds, which apparently worked well enough that he was released to a halfway house. Off his meds. The pharmacy hadn’t filled the prescription for the injection because they didn’t carry it.

We slowly and carefully went back in the room and got on the phone with the Albanian translator again, determined that the patient was not interested in harming anyone at present, and explained that we would be starting him on some new pills that he must take every day. (We also got him an appointment with psychiatry, but in our institution that takes a month or so.)

The last scary patient was frightening in what she had rather than who she was. She’s a sweet little white-haired 85-year-old woman who was recently admitted for a possible stroke. As they often do, the neurologists had sent a test for syphilis as part of her workup. The initial test came back positive, but they assumed it was a false positive, and discharged her with instructions to follow up with me and get the results of the confirmatory test.

Of course, the second test was positive too.

The resident was panicked. “How am I supposed to tell her?” he asked. “Her daughter is in the room!”

So I went in with him. First I asked if the patient understood why she was there.

“For the test results,” she said.

“And do you know what the tests were for?”

No.

So I politely asked the daughter to step out for a minute, then dropped the bomb.

She sat for a moment, her eyes narrowing. Finally she said, “That brings back some bad memories. That no-good son of a bitch. My mother told me I shouldn’t marry him!”

Turns out her husband had cheated on her some forty years ago, and she found out because he’d given her syphilis. She’d been treated, but she didn’t remember how, since she was allergic to penicillin.

“That’s why I kicked him out,” she said. “He’s dead now, and it’s a good thing, because if he weren’t I’d throttle him myself. I thought this was over and done with.”



By the time I got home last night, HellBoy had already gone out trick-or-treating and come home—he’d had enough after just one house. He was having a good time sitting on the stoop with his dad greeting all the other kids.

I didn’t stay out there long. I’d had enough of ghouls and ghost stories for the day.

Are You On Drugs or Something?

In response to my prior post, some people have requested specifics about the medications.

My first was sertraline (Z*l*ft), an SSRI. Started at 25mg daily, then 50, and eventually 100. Worked great. Felt like myself again, except that I didn’t get depressed and I was no longer afraid of spiders. (I still had some trouble talking on the phone—another phobia of mine—but it was a lot better.) Side effects were entirely manageable, not unlike having had an extra cup of coffee … with the exception of that one pesky thing. Libido wasn’t so much the issue. I could open negotiations, I just had a hard time sealing the deal. I enjoyed casting, but I didn’t reel one in very often. I could crank the starter, but the engine didn’t always turn over. The water got hot, but the pot wouldn’t boil. I could paddle the surfboard, but it was hard to catch a wave. I had a nice time mountain climbing, but had to turn back before the summit. If I were Cracklin’ Rosie, even Neil Diamond might have run out of time.

What’s that? Get to the point? I couldn’t, that’s the point.

It didn’t matter too much at first, because I was busy and single. But then I met my future husband, and I began to long for what I was missing. I’d never been a zero-to-60 in four seconds kind of girl to begin with, and we didn’t have that much free time. So, as I described previously, I stopped. But being happy in the sack doesn’t make up for being clinically depressed, as it turns out.

The next medication I went on was buproprion (W*llb*trin), 150mg twice a day. It’s in a completely different class than sertraline. Worked great for the depression, and practically no side effects. Its one drawback is that it doesn’t have any effect on anxiety; SSRIs are really the only ones available that work for that. So spiders started to freak me out again, and it got harder to start conversations with people I didn’t know. But overall a good choice.

Enter infertility treatment. Much stress, much anxiety, not much sleep. Then a new job on top of that. I started to feel as if I was overloading the buproprion. I got a new psychiatrist finally (I had been seeing my PCP, who was great, but not, obviously, a specialist in tweaking these meds). And he said, you know, the sexual side effects of SSRIs are dose-related, and you were taking a relatively high dose. How about we leave you on the buproprion, but add a whiff of sertraline back?

Simple but brilliant. I added 25mg of sertraline, with no appreciable effect on my sex life but a definite dampening of the anxiety.

I was, naturally, worried about what to do if I ever did manage to get pregnant. When I broached the subject with my husband, I was relieved to find he had a strong opinion that it was much riskier to go off meds during such a stressful time than to expose a baby to medication that has not been shown to do any real harm. We decided that since the real issue was depression, once/if I actually got pregnant, I’d taper off the sertraline, just to decrease any possible risk. In fact, I upped the sertraline to 50mg during the worst of the IVF treatment and left it there until we’d seen a heartbeat, then tapered off. I continued buproprion during pregnancy and restarted 25mg of sertraline once the baby was born. (Buproprion does get into breastmilk, but again we decided that the benefits clearly outweighed the risks.)

I find it interesting that a lot of people are afraid to try antidepressants, not because they might not work, but because they might. If you start and find out that you feel like a completely different person, what then? Are you stuck forever? It’s hard to explain why this doesn’t really make sense, because you won’t truly understand unless you try it. What I tell my patients is that if the antidepressants work, you will feel—normal. Not a different person, just yourself, the person that you can remember being, though perhaps long ago. As testament to this, most people who are on antidepressants for a long time eventually get to a point where they feel like the meds aren’t working, because they feel utterly normal. And a lot of people can eventually go off while continuing to hold on to their normal self. The reason I can’t is that it is very likely that if I were not to continue antidepressants for the rest of my life, I could expect the episodes of depression to come more frequently and become more intense. Some people have episodes every once in a blue moon and can use antidepressants as needed, but my last depression came with so little warning and so little provocation that I don’t want to risk it.

And as long as I can make the sale, catch some fish, start the car, boil some water, catch a wave, and get to the top of the mountain, I’m good.

The MICU: How I Know Antidepressants Work

A student recently asked me, “When did you get to the point where you weren’t scared about seeing patients?”

That’s an easy one.

By the time a medical trainee gets to the point of making independent decisions about a patient and has the power to carry out these decisions—the first year of residency, or internship year—they have been through four years of medical school training (generally two years in the classroom and two years in a clinical setting). Most interns are reasonably well equipped to assess a patient and make initial management decisions. This is not to say that they are not absolutely terrified. The first month of internship is a heady time, but an anxious one. The first time a nurse pages you in the middle of the night demanding that you assess a patient in trouble, your heart starts to beat like a cornered stoat. I’ll never forget my first such call, that a patient was having “rigors.” As I descended the stairs to her floor, I went over the causes of rigors. Fever? Medication reaction? When I got to the room, however, I realized that the patient was not having rigors; she was simply shaking. I examined her and talked to her, but nothing obvious emerged as a cause. Finally she made the confession that unlocked the mystery: she had panhandled for change in the cafeteria, then called her connection to come to her room, and the two of them had smoked crack in the bathroom.

That explained the shaking, but what to do about it? This is how raw I was: I actually pulled out my little intern’s pocket guide, called something like “How Not to Make A Complete Ass of Yourself on the Medicine Floors,” and tried to look up what to do when your patient has smoked crack in the hospital.

Over the months, as the call nights add up and your experience grows, the initial white-knuckle terror fades, but a sick patient can still give you a little frisson of fear. What if I can’t figure out what’s wrong? What if I do something stupid and kill her?

Then you become a second-year resident and are placed in charge of the MICU (the Medical Intensive Care Unit, pronounced “Mick You”). This is the place for the sickest of the sick. If you train in a large tertiary-care hospital, as I did, it’s the place for the sickest of the sickest of the sickest of the sick, from miles around. And I do mean in charge. Sure, there’s an attending and a fellow who are technically your superiors. But they don’t spend the night. When dinnertime rolls around and your team is on call, everyone drains out of the unit like tepid bathwater and you are left In Charge.

(I should note here that I trained several years ago, when fellows NEVER spent the night in the MICU. They’d paid their dues, now you pay yours, page them if you need them and they might step out of the movie theater to tell you “Sounds like you’re doing all the right things! See you tomorrow!” These days I have reason to believe that this is less common. I dearly hope this is true, in case I ever end up in intensive care.)

Twenty-four beds, stocked with the most amazingly ill people you’ve ever seen in your life. People who shouldn’t be alive. People who really aren’t alive as that term is conventionally understood. People who have been on machines for months, who are yellow, bloated to the point of splitting, and have mold eating away at their noses and ears. Twenty-four beds, two raw interns, and you. (Also a handful of the baddest of the bad-asses, the ICU nurses. In some ways they are the ones In Charge, and the good ones will save your sorry know-nothing ass, but you do not know yet which ones are the good ones and which ones simply enjoy watching helpless doctors squirm. Not to mention the fact that there are many, many brand-new nurses—if you think doctoring can burn a person out, try nursing.)

Adding to my stress was the fact that when I started my second-year rotation in the MICU, I was slogging through the tar pit of a fairly bad depression, one which had come upon me with almost no warning. Some background: episodes of depression since childhood, some worse than others, always lasting months, usually but not always precipitated by a stressful event. Finally started on antidepressants during my last year of medical school while I was not in fact depressed, just not great and trying to extricate myself from a bad relationship. Worked brilliantly, stayed on them through internship year “just in case”and was truly happy that year. Then started going out with my running partner, and given the fact that the pills made getting to my own private Idaho a near-impossibility, I decided to go off of them. Without telling my boyfriend. My sex life improved, and I felt fine! Hey, I don’t need those silly pills! They’re for wusses! Until the morning I woke up and felt like I couldn’t, well, anything. I managed to hide it for a week or two until I couldn’t anymore. At which point my boyfriend made me promise never to go off my meds again without warning him first. (He was absolutely awesome about the whole thing, further cementing my belief that he was My Mensch.) So I got to my doctor, got some slightly different pills, and started on them just as I started in the MICU.

It’s hard for a normal person to stay sane on an ICU rotation. You’re on call every third night, for starters. This means: Arriving early Monday morning, working all day, staying up all or most of the night admitting or managing people who are trying their best to die, working all the next day, and finally going home about 35 hours later. Then you collapse into sleep, wake up, and come in for your one “normal” day. Go home, collapse into sleep, wake up, and come in for your next call day. I counted one week: I worked 108 hours, exactly one of them spent sleeping.

So the situation is tough. In a way, going into it depressed didn’t seem inappropriate. But it did make it harder. And by far the hardest part was getting the calls after everyone had gone home telling me that a patient was being helicoptered in from an outside hospital. This patient was coming to ME. Of all the people in the whole tri-state area, I was supposed to save them. As I got the information, I literally could feel cold sweat trickling down my sides from my armpits. Up till then, I’d thought that was just a figure of speech.

There were two kinds of patients choppered in. The first kind were outrageously well, but something in their test results had freaked out the other hospital so much that they thought the person was about to die. These people were kind of like the full-term infants brought to the NICU for observation: the contrast between them and the truly critically ill folks was surreal. They were also more annoying in some ways, because they could talk and demand sandwiches and want to know why they were there.

The second kind, well. These were the ones that warranted my sweat. They were so sick, so unstable, that it was hard to know where to start first. I once put a central line in a patient’s femoral vein that, when the patient began to develop a blood pressure again, turned out to be in the femoral artery. (And I left it in, because a good arterial line is hard to get.) But the scariest thing of all was: although I could (and was expected to) call the fellow to discuss the case, if I didn’t know what was important enough to tell her—if I didn’t recognize the important physical sign, the critical lab result—I could easily miss something and kill the patient.

After a few weeks of this, a pattern started to emerge. Hey, I’ve admitted scores of sick patients, and I haven’t killed any of them. Some died, sure—the mortality rate was something like 50% overall—but the ones who could be saved, were (along with a few who probably shouldn’t have been). And I got very, very good at looking at a patient and knowing whether they were Sick or Not Sick. It is very hard to kill a Not Sick patient, and there are a limited number of ways to fix a Sick one.

And about three weeks in, I was strolling through the unit one evening humming a little tune.

“You’re in a good mood tonight!” the intern said.

“Yes, I am,” I said. And then I stopped in my tracks. I’m in a good mood. I’m on call in the MICU and I’m IN A GOOD MOOD.

Shit, those drugs work.

I never stopped them again.

And once I left the MICU, I never panicked about any patient ever again, because I’d seen Sick, and the vast majority of patients are Not Sick. As for the rare Sick ones, there are medications that can keep a lump of hamburger alive for a few hours—long enough to get them to … the MICU.

I Would Miss My Water If My Well Ran Dry

A quick word on water.

In my earlier post on the subject, I may not have made it clear that I love water. When I want a non-caffeinated, nonalcoholic beverage, it is my drink of choice. I drink it before and after running. I drink it with lunch. I drink it first thing in the morning upon arising (granted, I need it at that time to swallow my pills, but it tastes good too). Until HellBoy was old enough to snatch at it, I drank it whenever nursing. And it's what I keep in HB's sippy cup.

Please, if you are thirsty, by all means drink water. If you are thirsty, you need it, and it's far better for you than anything else you'll find in the cooler at the 7-11.

My only objection to water is that people keep spreading the myth that you should drink more of it than you're thirsty for.

So drink up! (If you're thirsty.)