You treat a disease, you win, you lose. You treat a person, I guarantee you’ll win, no matter what the outcome. -Patch Adams

I had a great 24 hour shift. Although it started out busy with several cases, including picking up three new admissions and a complicated hand laceration, it was not busy for the rest of it, which was a little blessing. And I had great conversations with the night nurses.

We had a patient who was brought in by the police, after she had flown in from a village for medical appointments and needed imaging. She ended up going out into town and getting drunk and not showing up to her appointments. She was found walking in the street and brought in.

Sometimes there is a temptation not to treat drunk people or drug users or people who are mean or angry with the same compassion, dignity and respect that we treat others with. They can easily be ignored and looked down on, because at the end of the day “we can’t help them” and “they make their choices.” Sometimes drunks get sent out without hardly being seen. This patient’s medical care was never given because of her substance abuse condition. She also had a history of seizures, and was going to jail. The question becomes, how much do we do here and now in the ER, and how much do we expect the patient to take responsibility for their own healthcare? We ended up coming up with a compromise, taking care of her immediate complaints of chest pain to rule out anything dangerous and letting her go with instructions to return. I don’t know that she will…I don’t know if it was the right thing. Maybe we should have kept her and did more of a work up for the other medical issues that she was sent in for, although that’s hard on a weekend and they weren’t an emergency. I don’t know.

Following this, I had an amazing conversation with the nurses about life and one of the nurses said, “We are all just one misfortune away from being that person, drunk in an ER bed…You might be just one step of burying your daughter from being the person who comes in with thoughts of suicide, or one event of losing your job from being the person who comes in on drugs or drunk or angry.”

And he knows, because he’s been through it. He told his incredible, beautiful story about losing a twin daughter, and then losing his house to a fire, living in a motel room, losing his wife, quitting his job while working in awful conditions, and feeling that he was completely at the bottom, with nothing but desperation and thinking about ending his life. He is probably one of the most insightful, kind, compassionate nurses I have ever met. He talked about how what really matters in life is that you are happy. How so many of us choose things that don’t bring us happiness or make us feel unhappy. And how not only can we choose more things that make us happy, but we can also choose happiness. We can be happy right here, right now, just because we decide we want to.

He talked of kindness and compassion and what he learned as a nurse manager–how patients will never remember what technical medical knowledge that you told them, and they won’t recommend a friend to a hospital based on the stats of the hospital, but that they will always remember how kind you were. How you sat down with them at the end of the bed and placed a comforting hand on their shoulder. How you touched them in a real, true, reassuring, comforting way. How you greeted them with warmth and kindness. How you showed them they are dignified, important and worthwhile human beings. How you recognized that this is probably the most difficult, painful, scary moment of their life, and you eased the discomfort. How you treated them like you would want to be treated. He also talked of the holistic approach to healthcare and how it is just as important to treat the mind, spirit, emotional conditions as it is to treat the physical body. How sometimes it is just as healing (if not more in some cases) to have someone recognize and address your emotional pain as your physical pain.

I am so grateful for this night shift and the good reminders to practice with more compassion and kindness. I am also grateful I went to a medical school where our motto was “We also treat the human spirit.”

Like Patch Adams said, “You treat a disease, you win you lose. You treat a person, I  guarantee you’ll win, no matter what the outcome.”

Patch Adams Patch-Adams-children

The Real Patch Adams, another hero

Sunday ER Shift

This morning I got to deliver a baby! A big, chunky 9lb10oz baby boy! What a great, fresh start to my day!20140720-223429-81269463.jpg

Life is a miracle, and at a birth I get to witness that miracle, all brand new. In that moment when a new life enters the world, her or his lungs fill with air, fresh, sweet, oxygenated air for the first time. And blood flows to their lungs–instead of bypassing from the heart to the body–for the first time. Their little miraculous bodies are adapting, changing, adjusting, waking up outside. The squeezing they endure through the birth canal signals their beings to action, to get ready for the big world, and then they take their first breath. And turn pink, and scream. :) it’s amazing to be the first to hold these little beings for a moment.

I just watched this awesome video about a doctor that sings to each baby he delivers, Dr. Carey Andrew-Jaja. I love his quotes! “It’s a beautiful world we live in. You forget all the crises going on everywhere for a moment when you see that miracle of life in front of you.” I borrowed from his way of celebrating and sang Happy Birthday to my new patient with his mom. :)

Life is a miracle
It’s a miracle every time a mother gives birth
Tell me who can say how much a child is worth
A miracle living on this planet Earth
Rotating to the rhythm of the universe
Life! More precious than the rarest stone
More valuable than silver or gold
Life! The essence is invisible,
To the scientific mind it’s impossible
Like the secret of the seed that grows into a tree
The starry galaxies remain a mystery
Oceans and the seas, the air we breathe
God knows that I believe life is a miracle.

~Pato Banton

Sealskin Birds and Cultural Discussions about End of Life Care

I got to see one of my favorite patients today. He has severe, end-stage COPD (emphysema) and so I see him frequently to keep him out of the hospital (where he was practically living in the Winter/Spring, because of frequent exacerbations). He is from Little Diomede, and his sweet wife is from Big Diomede (technically Russia).

Their families used to cross over between the two islands, before the International Date Line was constructed, before the US bought Alaska from Russia. They told me stories of how they used to love growing up in Diomede. They reminisced of all the meat, the eggs, and birds and greens and fish they hunted and gathered for subsisting off the land. They told me of their arts and crafts and ivory carving. My patient is an ivory carver. He still carves some when he is not feeling too short of breath or run down.

***
Months ago, when I first met him, I brought up end stage care for COPD. I thought I was doing the right thing medically by explaining what to expect with COPD, and the downward stepping process, and how it is a terminal diagnosis. I asked him what his wishes would be if he were to stop breathing or his heart were to stop beating. If he would want to be resuscitated or a DNR. I remember he got very quiet and looked down at the floor. When he looked up, his eyes were stormy cloudy. But he didn’t say anything. I was not sure if he was scared or upset or just taking it in, or what… I asked him what he was thinking or feeling, but he didn’t say.

A few more appointments I again tried to gently bring it up, explaining that we only wanted to know what his wishes were so we could do what he wanted if that day unexpectedly ever came. One day his eyes flashed and he told me that it is not appropriate to bring up this topic to elders. That to speak to someone about their death or dying is to almost seen as a curse them. I had been wondering if it was this. I asked him if he would prefer if we physicians would just make the decision in a patient’s best interest when that time comes. He said yes. He is not the first elder who has expressed this to me.

I remember learning about this very different medical-cultural decision in residency on my Palliative Care month. There are other countries, in Asia, where to speak to elders about their own death is taboo. The doctors, rather than pressing the unwanted subject, understand that it is in their purview to decide whether and how much a patient would be resuscitated. They are trusted to do the best for the patient and make the right decision about whether a full code would be appropriate or not.

I felt bad to have made him feel so uncomfortable. I explained to him that the general culture in the Lower 48 is to make sure that doctors know and respect the wishes of each patient. He expressed that he kind of understood.

***
The next visit he greeted me in his language, Inupiaq. His wife made these beautiful little birds of sealskin that I bought. She told me she was grateful and now they can buy food  (!) These birds grace my office space with a little reminders of my beloved patients who are teaching me so much. :)

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They are so happy that it is summer and the salmon are running the rivers now I was told by another patient that this year is odd, that all the salmon are running together, instead of in their normal sequence. But there is a lot of fish to catch and dry! When I asked my patient and his wife about it, they said “Everything is changing.” The climate is changing so much.

I have found that the people who are the most acutely aware of climate change are those who are subsistence living.

In any case, they are happy their family is bringing them seal meat and walrus meat! they wanted to leave the appointment quickly and go get food. I prescribed him a Z-pack for his worsening cough, with encouragement to take it so he can stay strong and stay out of the hospital. He said he will try to take it. he does not like Western medicine. When I’ve asked him about it before, he doesn’t say much, but know there is more to the reasons why.

Maybe someday he will tell me more what he really thinks about the pills and the inhalers he is prescribed, just like he did about the end of life discussions. I know he misses the tribal healing that he grew up with. I think he just might benefit from the amazing Tribal Healers that we have at Norton Sound.

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Back-to-back medevacs!

I got to go out to Gambell to pick up a patient in preterm labor! When we landed at about 1:00am, the sun was getting close to setting and it was still broad daylight. Lots of people (including kids) came out to greet us at the plane, and a crowd of people came to the clinic with us. The health aids told me that they were not used to having patients in labor, so they called in a couple of the older, retired health aids who had more experience with deliveries. I love how the village comes together to look out for each other! I went into check the patient, and sure enough her cervix was 6 cm dilated and it was very thin. There are no good resources to deliver a preterm baby out on this remote island. So we quickly put her on the plane to bring her back to Nome.

Half the village came down to say goodbye. As we were getting on the plane, there were so many “Thank yous” “thank you so much for coming!” “We really appreciate you coming out.” I love this strong sense of community–it felt powerful to see everyone came together so supportively, they felt fear and excitement collectively and they were so grateful for help to take this high risk patient. It made me recall when people were sick in the middle of the night in Papua New Guinea and if it was bad, the whole village would come up with the patient to get medical care from my Mom, who was essentially doing what these health aids in the villages are doing!

I give them mad props, because this is not an easy job–to be on call 24/7, taking care care of sometimes very scary cases!

The flight was uneventful, but after the patient was brought to Nome, other complications came up in her labor, so after a couple hours of sleep, I got called back in to take her on the medevac down to Anchorage! I got to go with the best flight teams–some of my heroes who work at here in remote Alaska. Some of them have worked here many many years-one even has worked 30 years! He and his wife had gone to Papua New Guinea some years back. They work so hard and work so much. When they’re around I know that my patients are in such good hands.

Luckily we delivered only one patient to Anchorage~ and not two! When we dropped her off I echoed the same heartfelt, relieved “thank yous” to the ANMC Obstetrics team–for taking a high risk patient for us! It is amazing to feel the sense of relief to know that you have brought in a high risk patient, and they did well, and then handing them over to the specialists safely and soundly! I thought about how lucky we are to have this awesome medevac service here in Alaska! As scary as it can sometimes be, we get to provide healthcare with first-world resources and lots of amazing healthcare providers!

We got a quick lunch and ran a few errands in the big city of Anchorage, and then we returned with a patient on our back flight to Nome. I got to sit in the front seat on the return flight (my favorite!) :) I got to learn some flight basics from an awesome pilot!

Someday I will fly one of these!
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Sunset tonight at 1:45am!
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Right out my front door:
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Humbling encouragement

Whewsh!
I finally have a full, real, beautiful day off!!!! It’s been a looonnggg stretch these last few weeks. I had one day off in the last three weeks, and even on that day, I had to come into the hospital to round on patients. Working12+ hour days, 7 days a week in a mentally, emotionally demanding job, starts to take its toll—it’s like being in residency again. I have less reserve…for anything. I feel my reserve of kindness and grace and love start dwindling away, and I start to become short with people. I barely give anything extra. I keep my eyes downcast so I don’t have to make eye contact with anyone, so I don’t have to say hello, or listen to small talk, or hear about their medical problem. I don’t greet people with more than a quick “hello” and I don’t make myself available…to anyone. Normally I don’t mind doing any of these things. Often I enjoy them, and they make the day brighter and help refill the general reserve of goodness in the world.  And usually the blessings are mutual.

But not these last few days. I’m just hanging on till my next day off when I can rejuvenate and refill this reserve so that it can flow out again. I also make more errors, and I have made a few medical mistakes out of sheer tiredness and not being clear-headed. I wish I was better than this. I wish that I could just keep on giving even without enough sleep. I wish I was still kind and thoughtful and smart and joyful. But all of this dwindles. Small things make my cry.

Funny story: I even cried in front of the president of the hospital this week when my car (technically not “my” car, because I am borrowing from Norton Sound Health Corporation) disappeared. As it turns out, a maintenance guy took my car to use it for our awesome patient driver service here, and then he realized it needed some work so he took it to the mechanic…without telling me. So on my 15-minute lunch break I went to look for it, and it was gone. I had a mini panic-attack, then went to the office to ask about it, where it felt like people were being less than helpful (this is the effect that fatigue has). Then the president was walking by and they asked her, and she said she didn’t know and I just broke down crying. I sobbed about how we spend 12 hours a day taking care of patients and we don’t really take care of ourselves, and then when I had 15 minutes for a lunch break, I couldn’t even go, because the hospital took my car.  I realize this was petty, but I am human after all… Anyway, they kindly offered me alternatives, but I had to get back to work.

The good part: later that day, I went down to the port to pick up my new vehicle that just arrived on the barge (purchased and shipped by an amazing human being)! I still didn’t have a proper title, license plates or insurance, but that’s another story…

My new car!!! Fresh off the boat… an Alaska car now. :)20140607-181102-65462573.jpg

Uggh… I snapped at a few nurses when I didn’t think things were getting done as needed. I also snapped at the behavioral health clinician after I had done all the behavioral health work for a few psych patients, and he hadn’t come up with a plan. So I told him the plan, and more or less told him to do his job. Uggghhh… I hate it when I am unkind. Even when things are frustrating or not working out well, and you are tired and exasperated, it never, ever pays to be unkind. Unkindness makes you unapproachable. I want to be approachable. My favorite people in life are always welcoming and approachable.

Life has a funny way of restoring things. There were a few days when I was trying to get to the DMV to get a proper title and registration for my vehicle, and of course these days were the days when patients came late, had multiple complicated problems, and needed way more than a 15 or 30-minute appointment could accommodate. But each time when I went in already frustrated, stretched thin, determined to just quickly meet their basic need and get them out, everything changed.

Somehow they opened up to let me see their deepest needs, their stories, the reason why they have these needs, and all of a sudden the DMV didn’t seem that important, anyway. I started writing up these stories, and what I’ve learned, which I will post eventually.

Heart-softening encouragement
Particularly yesterday I had an amazing visit with an elderly woman from Gambell, who blessed me so much. She had 15 or 20 medications she wanted me to address for her 8+ medical problems, and she had odd pills in her pill box that we couldn’t identify, and was just recovering from breast cancer and felt like her mastectomy scar was so ugly, part of me was trying to figure out how I could rush through this appointment, since I was already behind and trying to get out early (to go to the DMV again). Then she told me the most amazing thing:

She said, “I can tell your parents raised you right. I don’t know you at all, but I can tell that you care so much about your community and people around you, and that must be from the way your parents raised you. I thank you for taking such good care of me.” All of my haste and impatience and stress dissolved in that instant.
*This* is why I am doing this.
She reminded me.
I smiled and told her that my parents raised me in a little village in the middle of nowhere, and that my mom did basically the same thing as what the health aids do in the villages here in Alaska. And that they lived their lives to love and serve…and yes, they were amazing people who instilled these values into their kids. And that is why I came here. She said, “Oh really? That is wonderful!” She gave me a big hug. And thanked me.
I thanked her for her encouragement, and I told her I needed to hear just that today.

I later saw her in the hallway and we exchanged another big smile and hug. Another RN (one who I was a little bit snappy with earlier) told me how much she appreciates me and sees me starting to get burnt out and encouraged me. And others gave me sweet thoughtful offerings of encouragement.

Kind treats from the secretary. My breakfast and lunch to keep me going. 20140607-181412-65652147.jpg

Encouragement from the least expected places…the DMV!?!

Then I actually made it to the DMV, which incidentally is only open a few hours a week!!!!! (Shocking after the way the day seemed like it was going). Finally, 2.5 hours later, I got to the counter and actually, finally got my proper vehicle title and license plates! Then the DMV woman looked at my name and asked, “Are you Dr. Theobald?!” I shyly said yes—I really don’t like to be recognized as a doctor in public, because that’s when people in the DMV start showing their rashes and telling you their medical history. :) (most of the time I don’t mind it, really). But then she said, “I heard you are such a good doctor. A lot of people have been recommending you as a doctor.” Really?! I felt surprised, and deeply humbled, especially for the way I’ve been feeling this week. My heart softened again, and I felt my reserve fill up a little more.

I got my license plates…now I can drive this car (legally)!20140607-181101-65461773.jpg

Fresh thoughts…after 12 hours of sleep
Today, after waking up at 1pm and feeling refreshed, I was thinking more about it. My amazing parents work at least as hard as I do, in their blue collar jobs, for a lot less pay. I am so incredibly proud of them and honored to have them as my parents. Because I do get paid extra for the extra weekends that I work.  My mom just broke her hip, and I would love to be able to go down and visit her and help take care of her. If I could get time off, I just might. But more importantly, I get a chance to give back to my family who gave me so much. There are so many rewards of this job, and sometimes I lose sight of them, when I am become so exhausted. It is true that we need sleep, we need time to rejuvenate and be filled up again, and to take care of ourselves—and the above events sparked some conversations with the President, the Vice President and fellow doctors of ways to improve the system! But at the end of the day, I am here to serve and take care of people, and I am so lucky and so blessed to get to do what I do. And I don’t want to lose sight of that, even when the days are long.

My TB patient showed me some eggs that were gathered and brought to him. The spotted egg is a seagull egg, and the blue egg is from  a different bird… I totally forget what he said. He is leaving for treatment and he encouraged me to keep loving and serving and told me to not get burnt out. :)20140607-181413-65653195.jpg

Midnight sun–the view from my bedroom window at 12:00 midnight. Glowing midnight blossoms and rusted tin roofs. Summer nights in Nome.20140607-181415-65655191.jpg

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My Friday night entertainment. Love Nome kids!20140607-181414-65654246.jpg

Moose right outside the ER!20140607-181413-65653772.jpg

 

Sometimes the night was beautiful, sometimes the sky was so far away. Sometimes it seemed to stoop so close, you could touch it but your heart would break.
Sometimes the morning came too soon, sometimes the day would be so hot. There was so much work left to do, but there was so much you’d already done.
-Rich Mullins