senses - hearing/sight

I'm on an ENT (ear, nose, and throat) and ophthalmology (eyes) rotation right now, so I've been doing some thinking about the senses we often take for granted when they work well.  That is, I was until this week on night float.  But we have a slower week so far, so hence the nighttime blog posts.  :)

Seeing
One of my favorite things about ophthalmology has been the simple process of seeing people's eyes being illuminated by the light as the ophthalmologist examines them.  The lamp and microscope move in front of their eyes and, at an angle as the ophthalmologist looks at the retina (back of the eye), the light reflects off the whole iris (colored part) in the darkened room, giving the patient these beautifully shining lit-up eyes that reminds me every time of the quote about the eyes being the window to the soul.  I am struck by the scene's beauty all the more for the fact that the patient can't see it.  Here's this beautifully illumined eye in all its unnoticed complexity, and they have no idea.

  http://mychinaconnection.com/wp-content/uploads/2010/12/see-eye-to-eye.jpg

Hearing
Hearing, too, is affected by things we can't see or access.  Even common wax can obstruct one's hearing without the patient knowing what it is that makes them hear less on that side (or both sides).  The inner ear itself, where the tiny middle ear bones transmit sound waves made into vibrations that are picked up by microscopic hair cells, is beyond visualization even for the ENT doctor.  It can be seen somewhat on a head CT in large scale but the hair cells that may not work as well for hearing as one ages or whose disruption with tiny stones (otoliths) can cause lifestyle-handicapping vertigo (dizziness) are beyond what we can easily access. 

                        http://www.webmd.com/brain/picture-of-the-ear

Hearing and Seeing
In a recent conversation, I was asked which sense I would rather lose - sight or hearing?  A difficult question to answer, and one that prompted a quick evaluation of all the taken-for-granted ways these senses affect my life.  The crescendo of a piano piece or the steady patter of raindrops.  A glorious nearly-neon sunset or the color of sunlight through a leaf.  Hearing someone call my name as I walk down the hall.  Seeing the identity of the speaker or identifying them by their voice. 

Sight and hearing are linked in another way.  Both senses require two steps to achieve the appropriate perception of sound/vision.  First, the external stimulus must be perceived - cells in the retina send off signals from the eye; those hair cells from the inner ear do the same after the vibrations reach them from the bones of the middle ear.  Second, the message received in the brain must be processed appropriately for it to give us the right picture or sound.  One needs both steps to actually achieve sight or hearing that is meaningful. 

The Bible understands the importance of both of these steps, too.  God's judgment on his people when he sends them the prophet Isaiah is:  "Be ever hearing, but never understanding; be ever seeing, but never perceiving...Otherwise they might see with their eyes, hear with their ears, understand with their hearts, and turn and be healed" (6:9b-10).  This is picked up in the New Testament in Matthew 13 (as well as parallel passages in Mark 4 and Luke 8) when Jesus understands why he speaks in parables, telling stories to communicate truth to those whose ears are open and whose eyes see clearly and concealing it from those who don't. 

My experiences on ENT and ophtho make me wonder: 
1.)  What sort of unseen blockages keep me from hearing God's voice clearly?  Pride.  Busyness.  Independence.  For many patients with wax in their ears, simple daily administration of a few drops of oil can help keep the wax soft enough to move out.  What similarly mundane practices can help my ears stay open?  Daily prayer.  Meditation.  Time in nature.  Time to listen.  Cultivating the practice of listening in my relationships.  Obedience when I do hear God's direction.
2.)  What overlooked glorious beauty and light is shining around me?  A simple mirror would enable the patients being examined to see the light illuminating their eyes.  How can I be a mirror to others, reflecting the Lord's light to them?  How can I be more attentive to God's presence and work in my own life? 

              http://stevetallamy.com/wp-content/uploads/2011/04/Seeing-Beauty.jpg

pain

 As I move into my second year of residency, I have acquired a number of patients with chronic pain.  This is challenging because of the regular number of prescription refills that then fill my electronic medical record inbasket requesting opiates (narcotics).  These are not medicines I have ever started a patient on on a chronic basis, and I hope to avoid doing so.  These patients, however, have been on these medicines for years in many cases, and it is left to me to try to help them deal with the impact of chronic pain on their lives, including writing prescriptions for medicines on which their bodies are now dependent to stave off the pain that initially debilitated them in various ways. 

In addition to my discomfort with regularly prescribing (sometimes large) quantities of highly legally controlled medicines, this situation has caused me to examine myself as I see my own reactions to these patients.  My level of frustration and feeling of helplessness surpass what I would expect from the need for frequent appointments, urine tox screens to ensure there is no other drug (ab)use going on, and simple script signing associated with these patients.  I hear the same frustration in other residents as they talk about these patients.  I think it comes from a deeper cause.

When interviewing for medical school, most applicants are asked, "Why do you want to be a doctor?"  The most common answer is, "To help [hurting] people."  I think the key is here.  We go into medicine hoping to help, to cure, to be part of healing.  Most patients with chronic pain cannot be cured or healed by the reach of medicine.  We seek with the pills within our reach to do some small part of helping instead.  And even that is complex.

The medicines used for chronic pain run the gamut from medicines used for regular pain (Advil, Tylenol, Aleve) to medicines used for neuropathic pain (gabapentin, pregabalin) to antidepressants to (sometimes) opiates.  This reminds me of the complicated nature of chronic pain.  It is a case-in-point of the integrated nature of who we are as human beings.  Our emotional, mental, and spiritual status deeply impacts our physical well-being and our subjective experience of our physical illnesses. 

Pain is hard, too, since it is so subjective; with chronic pain patients, often there's nothing there to point to and say, "This hurts" as one can to a broken bone.  Do I believe my patient's report of pain without questioning?  Is their early request for a refill evidence of undertreated pain or of possible abuse, taking more of the medicine more frequently than prescribed?  There's a lot of judgment involved, and it's hard to judge another's complaint of pain.

I think dealing with chronic pain well requires a re-working of how I think about the role of medicine.  It requires seeing a good part of my role as a doctor as that of care rather than cure.  It means seeking to remember the patient is a whole person and reminding them of it, that they are more than the pain that can become so all-consuming and -defining.  It is encouraging their health in the other ways that affect their experience of physical pain - mental, emotional, relational, spiritual.  It requires a steady balance of firmness and boundaries with compassion and connection.  It is challenging, and I'm not sure that I have it worked out; sometimes I think I lean too far with one patient towards leniency and too far with the next towards strictness.  Trying to achieve some level of evenhanded fairness while still feeling with patients' expressed pain and desire for relief that I can provide, even if it means an addictive, abusable medicine, is hard.  I don't want to become jaded or cynical but allowing my patients to manipulate me into giving them what they want if they may be abusing it is not loving to them in the long run, either.  It's a hard road to walk, and I'm still figuring it out.

stories 2

Before I start with the stories (altered, of course to preserve patients' privacy), I want to review the reasons I share them.  First, it gives me an outlet for processing and sharing the patients whose stories stay with me.  Second, it ensures in some way that I will not forget or grow numb in the busy succession of appointments and rounding.  Third, it forces me to stop and remember that each patient I encounter is first a person - a real embodied life whose body has a problem that leads to their encounter with me.  It encourages me to stop and look the person in the face, so to speak, encountering them as a human being as I review their story with you.  May it remind you in whatever your field is to do the same.

I saw my first rape survivor recently in clinic.  A 14 year old who was violated several weeks ago is now sitting withdrawn and quiet in the chair.  So withdrawn and quiet I had trouble feeling that my compassion and regret for her situation could seep in past the shell she had put up.  I felt very helpless, unable to reach her to comfort or support her, the protective barrier she had erected keeping out those intending her good as well as evil.  It is hard not to feel hopeless in these situations as well.  A friend's prayer as I shared my dismay over the whole situation reminded me that I am not ultimately powerless.  I can still pray that God reaches past her brittle shell and embraces her, enabling her to heal and grow past and despite this and not to get mired, stunted, in the pain and vulnerability. 

The next patient snapshot was a 26 year old G4P2012 (4th pregnancy, two living children, one abortion) at 8 weeks by her last period.  She had bleeding yesterday and went to a different ER where an intrauterine pregnancy was visualized.  She now is here for re-evaluation.  Ultrasound shows an empty uterus after she passed clots all day yesterday, and the baby's hormone (beta-hCG) level is dropping quickly.  The intern I am working with asks her after we give her the news, "How are you doing?"  And we watch her face crumple before she covers it with her hands.  Her sister, sitting with her, also tears up but doesn't move to offer comfort, so I move to the bed and put my arm over her shoulders and one hand over her hand on her belly and rock her, praying for her to somehow find peace in the midst of this disappointment as I hold her. 

The final patient whose story struck me was a 55 year old woman who cried through most of her visit as she told me of her history of physical, emotional, and verbal abuse in her 30-year marraige.  She shared how she finally left him after being really beat up one time about a year ago and of the ongoing abuse she endured at court appointments to get her support from him after their divorce.  I admire her courage for finally getting out safely (since the most dangerous time for an abuse survivor is when she decides to leave) while simultaneously wondering how she will ever heal from all those years of fear and betrayal.

Sometimes I marvel at all the pain people carry, wishing I had a sponge to sop it all up, leaving these lives I encounter a bit lighter, less weighed down with their wounds and worries.  I am reminded instead of something Stanley Hauerwas writes in his book, God, Medicine, and Suffering, "I cannot promise readers consolation, but only as honest an account as I can give of why we cannot afford to give ourselves explanations for evil when what is required is a community capable of absorbing our grief."  In other words, what we often need is not an answer to our anguished Why? so much as someone willing to comfort and walk alongside us in the silent space of isolation that suffering produces. 

In my words and actions, I seek in small ways to be part of a community capable of absorbing some of the grief I behold (see more on beholding in this blog post more than a year ago).  In my silent prayers for these women, I seek to bring them before a Community truly able to absorb their grief - the Father who can hold them, the Brother who intimately knows what it is to suffer and shares in their pain, the Spirit who groans their hearts' cries with emotion beyond what words can express to the throne of the Lord of the universe when they do not even know how to pray.  As Sarah Lance said in a quote I have across my computer screen daily, "I have the rare opportunity to share the hope of being found, known, loved, celebrated, forgiven and treasured by the God of the universe. This is my only answer for suffering."  May these hurting lives I encounter also have a chance some day to encounter that hope.

held

So I haven't blogged for a while, partly because I feel like I've had a ridiculously busy series of months through the late spring and partly because I haven't felt like I had anything to blog about.  I felt fairly emotionally burnt out for a number of weeks in April and May, and nothing really stood out to me.  I'm feeling better overall, but nothing struck me until I was reading the list of vital signs on pediatrics the other day.

The vitals come in a list with different headings:  blood pressure, heart rate, respiratory rate, pulse ox, etc.  But what caught my eye wasn't one of the numbers or its heading.  It was one of the entries under the heading "position," usually used to indicate sitting/standing/lying.  Since I am on pediatrics, however, this entry read a single word:  Held.

Such a powerful word.  In one syllable, it brings to mind images of a mother tenderly cradling her sleeping infant, a husband embracing his grieving wife at a graveside, a father catching up a child that runs to him to throw her in the air and catch her close.  It evokes the idea of security, of being valued and protected, of love and affection.  It reminds me, too, of the Natalie Grant song "Held" which explores the ways in which God is present for us, holding us, in the midst of life's trials and suffering.

Much of what makes me feel burned out are the things I carry with me - my own insecurities and shortcomings, my friends' or family's struggles or disappointments, my patients' suffering, pain, and resignation to the way their lives are that in so many ways fall short of what God intended (relationships, health, sex, loneliness, etc.).  What if I can find a way to let all I carry - and myself, too - be held by the Father, the weight of it all still there (because it is real) but no longer borne by me, no longer heavy on my shoulders?  If it takes feeling people's pain to learn to recognize his steady embrace, that's a price I'd gladly pay.  Because I do trust that whether or not I feel it, his arms carry me secure.  And maybe then I can invite others and their pain that so moves me into the strong love of the Father where they, too, can know what it is to be held.

stories

25 y/o G2P1 (second pregnancy, one child already delivered) presents to triage at 38 wks with no prenatal care in labor with a baby found to be double footling breech (both feet down instead of head down).  Baby is born by emergency c-section, and mom decides to give him up for adoption.  I talk her through the possibilities of open vs. closed, available agencies.  I hold her hand as she cries over her selfless decision, over the baby she holds and gives away.  I rejoice quietly with her as she picks a family from the profiles the agency showed her, a family with another little boy, a brother for her baby.  I marvel silently at the strength she shows.

21 y/o G1P1 seen in clinic for routine gyn care.  Oh, by the way, my last period was more than a month ago, a bit late now, unusual for me.  We chat around the Pap and pelvic exam about the Gardasil vaccine and contraceptive options, her life living with her mother to save money to stay at home with her two-year-old, her questions about this or that health-related topic.  Near the end before signing the orders for some vaccines and prescribing her birth control choice, I check a pregnancy test just to be sure.  Positive.  I go back in to tell her, and she bursts into tears.  I sit back down, wondering inside at the irony that there are people who would cry tears of joy for this positive test that only brings pain and chaos to my patient and her life.  We chat about options, me recalling my last difficult conversation with a patient in a similar situation who I now see for regular prenatal care since she never went for that abortion she had initially planned.  I give this patient information about resources related with all her options - parenting, adoption, abortion - advising her of the support available for her should she choose to parent or form an adoption plan.  I wish again that I had easy answers about my role in this counseling, my patient's decision, or at least an easy spiel of what to say and how to say it instead of the ambivalent wading through beliefs and values, situations and specifics, reactions logical and emotional.  We agree to meet up again in two weeks to talk about her final decision.

 55 y/o woman with known history of alcohol abuse comes in with alcoholic hepatitis.  She is then intubated for hepatic encephalopathy with failing liver and eventually kidneys, too, as she develops hepatorenal syndrome.  Unexpectedly, she survives her extubation planned for when her family can be there and moves slowly towards comfort measures as she is now alert enough to make her own health care decisions.  I visit her the weekend before she moves to inpatient hospice to check on how she is feeling and end up sitting at her bedside giving her sips of the dozen or two juice bottles beside her bed and spoonfuls of cool sherbet that make her dry mouth less uncomfortable as her failing liver's inability to make protein to keep the fluid in her blood vessels slowly allows her to become more swollen otherwise and more dry inside the vessels.  I lotion her dry, jaundiced hands and arms, recalling the elderly nursing home residents for whom I did this routinely for five summers through college.  I wonder about how she must feel, relatively young and knowing that her drinking caused this poisoned liver, the dry itchy skin, the slow dying.  Vicarious regrets fill me, and I mourn for what her life could have been.

27 y/o woman with family history of blood clots comes in with chest pain and shortness of breath.  She is mildly anxious (never having been to the ER as a patient before), tachycardic (fast heart rate), tachypnic (fast respiratory rate), but pulse ox is normal.  She tells the ER physician of her family history and risk factors for blood clots - the birth control pills she started herself on for acne, the long trip out to Indiana and Minnesota to see friends and family on her one-week vacation from residency a week and a half ago.  She is found to have a pulmonary embolism (blood clot) in her lungs and is placed on blood thinners for the next six months.  After the blood thinner level comes up appropriately and her pain is controlled, she goes home to stay with her parents for a few days to recuperate.

A routine case - one I have seen two or three times already this year in various transmutations - except that this time six weeks ago the patient was me.  It has been frustrating and educational to be on this side of medicine for a change, getting regular blood work, waiting for phone calls from my own doctor for dosage changes on medications based on the labs, filling prescriptions at the pharmacy and bemoaning how expensive medications are (and I have good insurance!).  I also identify more now with the fear of being in pain before the diagnosis is made, the lack of control over a body that no longer acts as it normally does (short of breath with walking, pain when lying down flat to sleep - now all resolved, thank God).  And I am grateful for the family and friends (despite being in this place for only seven months) that support me during the time when I felt sick as well as now when I now feel normal but still have to do the follow up things (blood work, making up the week of work I missed, occasional checkups).

trafficking, shame, and freedom

Human trafficking is an issue that has come up recently in efforts to raise awareness - yes, even here in rural southeastern Pennsylvania.  A quick search of related websites indicates probably 27-30 million people under modern-day slavery, forced to work or be a child soldier or a prostitute often in a place where they don't speak the language.  It's an ugly issue, one nearly overwhelming with the myriad of stories of abuse and rape and shattered lives.  And yet it is one where I as a person in medicine have the possibility of playing an important role in recognizing victims.  Look beneath the surface, the presenters urge.  Look for the signs that might indicate a powerless person with no control over their employment, income, place to stay.  And the corollary:  Be willing to help.

It reminds me somewhat of child abuse.  Physicians are always obligated to report suspected child abuse, even if they are not sure.  The investigation is out of our hands, but the error must always be on the side of protecting a helpless victim.  This feels similar - the obligation to help, to know what resources are available - with the added complication that this is sometimes an adult, so how do I offer help in a recognizable form to someone used to betrayal?

Perhaps the most important step starts with the step illustrated by this Ten Shekel Shirt song, "Fragile:" http://tenshekelshirt.com/.  "It's Not Your Fault."  The people who came and spoke at my church about their work among former victims of trafficking told stories of seeing new life come when women began to find forgiveness for themselves.  Often their own way of seeing themselves kept them in captivity.  But they have found a way out of that crippling shame through Jesus, and it transforms their lives.

Shame is not limited to victims of human trafficking, however.  It is found as well in the physician addict who secretly shoots up opiates scavenged from the ER sharps box.  It is found in the young man with hallucinations who can't seem to escape the clamor of voices inside his head.  It is found in the survivor of domestic violence who goes back once again to the abuser, hoping against hope that this time will be different.  It is found in my own heart with my struggles and failures.

I read a book once that spoke of shame, saying, "Shame enters in and makes its crippling home deep within our hearts.  Shame is what makes us look away, so we avoid eye contact with strangers and friends…  We know we are not all that we long to be, all that God longs for us to be, but instead of coming up for grace-filled air and asking God what he thinks of us, shame keeps us pinned down and gasping, believing that we deserve to suffocate... Shame causes us to hide.  We are afraid of being truly seen, and so we hide our truest selves and offer only what we believe is wanted."

I think of that image often as I interact with the hurting people that cross my path, their regrets and disappointments combining nearly to suffocate them.  I think of it today, Ash Wednesday, as I think about the vast heart difference between shame and repentance (which is the season of preparation for Easter that Ash Wednesday initiates).  One leads to that crippling sense of suffocation; the other leads to walking head up and eyes on Him in freedom and life.  As the Anglican liturgy says, 

"Praise to you, O Christ, King of eternal glory.

The Lord is a great God, O that today you would listen to his voice.

Harden not your hearts." cf. Psalm 95.3, 8 

"Remember that you are dust, and to dust you shall return.  Turn away from sin and be faithful to Christ," the priest reminds as he puts the black powder of the ashes of last year's Palm Sunday fronds on our foreheads.  It is a reminder of our fragility and our mortality, a truth I see daily in my work.  But more, it is a reminder that out of death we, like all in slavery - physical or spiritual, are called to life, out of binding shame to joy overflowing, out of sin through repentance to holiness and wholeness.  Harden not your hearts...

trusting the process?

12/23/10 (the thoughts started then, but I am finishing the actual writing much later)

I am completing my second rotation on obstetrics, and the idea of trusting the process keeps coming up.  It comes up related to residency most of all, as I anticipate completing my intern-year coverage of OB and have to trust that I will learn all that I need to know as an upper-year by the end of these four short weeks.  Will I make wise decisions without someone farther ahead off of whom to bounce ideas for evaluation and management of our patients' different complaints?  Will my fingers learn the tasks of the examinations needed, the suturing, the positioning of a baby's head?  Trust that those who have gone before you and learned what they need to know through this training process know what they're doing when they tell you that you, too, will learn what you need to know, I hear again and again in different words related to different topics.

I think about trusting the process for labor itself.  Most patients don't know the different stages of labor (latent, active) let alone the cardinal movements a baby's head makes just before it's born.  They can't read the fetal monitoring strips we look over every time we enter the room, and they don't know how many contractions in ten minutes constitutes "adequate" labor.  They are forced to trust that their bodies know what they're doing, that the pain they endure will be worth it in the end, that their baby is slowly moving towards entering the world long before they can see or feel anything but the tightening of contractions.  It takes a marvelous amount of trust in something we in medicine still don't even entirely understand.  We don't know what hormone or protein makes labor start or where that stimulus comes from.  We don't know why labor starts when it does, sometimes weeks before and other times days or a week after the due date.  But this is how little human beings have been entering the world for thousands of years, and somehow it does work much of the time without any help from medicines or monitors.

The season, too, reminds me to trust the process as we move into and through Advent.  We who believe trust that the One who came as a helpless baby will one day come again as One to reign and set things right.  We can't see that day approaching.  The Old Testament prophets and New Testament writers thought it would be much more immediate than it has been over the hundreds of years since that first Coming.  But we remember that fact that He came and trust this process of labor and birth as well, trust that sight unseen He is making His way towards Coming Again.

In my own individual life, too, I must trust the process.  Am I becoming someone I want to be?  Am I in fact growing as a human being - in character, in strength, in faith?  Moving in a direction towards God?  Or am I becoming stagnant?  Is the Spirit still invested enough in my life to be spurring preparation for new branches and buds?  I am called to trust as I surrender myself, seeking God's way for me to live my life, at peace with the work He is doing at His pace.  I am called to trust in the One "who began a good work" in me and "will carry it on to completion until the day of Christ Jesus," as Paul wrote to the Philippians (1:6b).  That's a process where it is worth seeing the end, and it gives me hope for these other places where I trust that God is also at work, bringing new life, helping me grow as a doctor, preparing for his Return.