The Art of Medicine — Do you believe in magic?

In pediatric practice a sleight of hand might produce unintended consequences. more»

Interested readers can now access my latest Art of Medicine column — Do you believe in magic? — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

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The worst day of your life

“I suppose you’re going to tell me that this will be the worst day of my life?”

Coming from the mouth of a 10-year-old girl whose mother had just succumbed to an opiate overdose, the child’s words carried unspoken impact.

The priest who was telling me this story said he wasn’t sure how to respond.

This was back in the day when one of his duties was to serve as chaplain for the city fire department. The firemen would call him in on those sorts of impossible cases where no one had any idea what to do; cases like this one: a 10-year-old girl unexpectedly orphaned on the spot with no apparent next-of-kin.

By the time he arrived at the sparse apartment, other tenants in the public housing complex had started to filter in, each attempting in his or her own inept way to offer condolences and comfort.

“It was like something out of a Tennessee Williams play,” the priest said. “Everyone was concerned. No one knew what to do.”

“What did you say to her?” I asked.

Momentarily, the priest’s eyes regarded an infinite point in the distance; then he collected himself.

“I thought of all the bad things that this little girl would be facing in the coming hours, days, and weeks ahead. I thought of all the not-so-good things she might be facing for the remainder of her formative years, maybe even for the rest of her adult life.”

He lapsed into silence. Then the words came again. “Suddenly, I remembered that I had just lost my own mother. I knew how it felt. It felt like the worst day of my life. That gave me the courage to tell her: yes, this would be the worst day of her life; but there was always hope that somehow things would work out for the better.”

The hint of a tear glistened in the corner of his eye.

“Those are the ones that you always remember,” I said.

“Yes,” he said. “They are.”

Sometimes in our struggle to care for others, we must first learn how to care for ourselves, how to lay down our own burdens. In facing our own suffering and accepting our own wounds, we learn how to help others heal.

The patient-centered medical home (ain’t what it used to be)

Advocates of the patient-centered medical home tout the desirability of having all of this information in a central repository, readily accessible, complete. Supposedly, such a system will drastically reduce duplication of services, reduce the likelihood of medical error, and subsequently cut the cost of medical care. Conceptually, it all sounds so good—too good, as the adage goes, to be true. more»

Read more in my latest entry on the Musings blog of the JAAPA Editorial Board here.

JAAPA is the official publication of the American Academy of Physician Assistants.

Long day’s journey of the Saturday

At the beginning of this Easter weekend, I will leave my readers the thoughts of George Steiner from the concluding chapter of his book, Real Presences:

“There is one particular day in Western history about which neither historical record nor myth nor Scripture make report. It is a Saturday. And it has become the longest of days. We know of the Good Friday which Christianity holds to have been that of the Cross. But the non-Christian, the atheist, knows of it as well. This is to say that he knows of the injustice, of the interminable suffering, of the waste, of the brute enigma of ending, which so largely make up not only the historical dimension of the human condition, but the everyday fabric of our personal lives. We know, ineluctably, of the pain, of the failure of love, of the solitude which are our history and private fate. We know also about Sunday. To the Christian, the day signifies an intimation, both assured and precarious, both evident and beyond comprehension, of resurrection, of a justice and a love that have conquered death. If we are non-Christians or non-believers, we know of that Sunday in precisely analogous terms. We conceive of it as the day of liberation from inhumanity and servitude. We look to resolutions, be they therapeutic or political, be they social or messianic. The lineaments of that Sunday carry the name of hope (there is no word less deconstructible).

“But ours is the long day’s journey of the Saturday. Between suffering, aloneness, unutterable waste on the one hand and the dream of liberation, of rebirth on the other. In the face of the torture of a child, of the death of love which is Friday, even the greatest art and poetry are almost helpless. In the Utopia of the Sunday, the aesthetic will, presumably, no longer have logic or necessity. The apprehensions and figurations in the play of metaphysical imagining, in the poem and the music, which tell of pain and of hope, of the flesh which is said to taste of ash and of the spirit which is said to have the savour of fire, are always Sabbatarian. They have risen out of an immensity of waiting which is that of man. Without them, how could we be patient?”

The Art of Medicine — A slice of life

“Can I see your first patient of the morning with you?” the new student asks. “It’s a laceration, here to be glued.”

An interesting way to present a patient, I think to myself as I escort the student into the examination room. more»

Interested readers can now access my latest Art of Medicine column — A slice of life — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

The Art of Medicine — Father wounds: Dealing with loss

“This 17-year-old boy is here for a physical exam,” the nurse says, handing me the chart. “He hasn’t been in for 2 years. He needs his meningitis vaccine to start college this fall. His mother’s out in the waiting room. Oh, and there’s a sticky note posted inside: looks like his father died this past spring.” more»

Interested readers can now access my latest Art of Medicine column — Father wounds: Dealing with loss — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

Dinner break

“I’m heading down to the cafeteria for dinner,” I said.

The charge nurse looked up from the central desk. “Go ahead. We’re good for now.”

I padded down the hallway to the end of the ward, touched the square steel plate on the wall, walked through the open doors and caught the elevator to the ground floor.

The serving line was still open. I picked up a tray, made my selections, paid the cashier and sat down at one of the empty tables along the far wall. There were plenty of vacant seats to choose from.

Methodically, I began to eat. It had been a long afternoon, looking in on the patients on the ward, talking with concerned parents, answering pages from the ED, reviewing labs and x-rays in radiology on the third floor. I was glad for my dinner break, glad for a few moments of down time, glad for the chance to put something in my stomach.

“Mind if I join you?” I looked up at the bald-headed bearded face and motioned for him to sit down. He slid his tray onto the table and pulled out the chair. “You on for the duration?” he asked, reaching for his napkin.

“Until tomorrow morning,” I said. “Twenty-four hour shift.”

“Sometimes Sundays are quiet,” he said.

“You never know,” I smiled.

“You never do,” he said.

We ate in silence. Then he said, “You’re covering pediatrics?” I nodded. “I thought I saw you earlier in the ED.”

“I’ve been around the block a few times since the morning.”

“Haven’t we all,” he said. I noticed the name embroidered in red over the breast pocket on his white coat. “Had a gunshot wound come in mid afternoon,” he said. “Self inflicted.”

I pushed the mashed potatoes around on the plate with my fork. “Did he make it?”

“If you want to call it that,” he said. He held his fork suspended by his side and raised the index finger of his left hand to the side of his head. “Amateurs,” he said. “They don’t know anatomy.”

I lifted a forkful of food to my mouth and chewed slowly.

“The bullet entered the cranium at a shallow angle,” he said. “Spun around the inside of his head like a marble on a roulette wheel. Homogenized his grey matter like whipped jelly. Left the brainstem intact. Not much to do for that.”

I swallowed the potatoes and waited.

“I expect he’s gone by now,” the bald-headed bearded man said. “At least, I hope so.”

Suddenly, the quiet was broken: my pager went off. I pushed the button to silence the noise, read the extension and rose from the table. “Gotta go,” I said.

He raised a silent hand, as though he were offering a blessing. “Hope the rest of your night is quiet,” he said.

For some inexplicable reason, it was.