It’s Wednesday morning, and not even really close to five o’clock yet.  I’m early enough to be the only person yet waiting for the trains.  I woke up this morning quite early‒obviously‒and though I briefly watched part of a lecture on exploring prime numbers and the Fibonacci sequence, I couldn’t really rest, and I’ve felt angry since pretty much when I woke up.  I’m not angry at being awake, though that is irritating.  I’m not even particularly angry at me, though I’m almost always at least a little pissed at myself.  I was angry and thinking about a stupid exchange from my first medical practice after residency, with one of the partners in the practice.

The substance of it isn’t important, it’s just odd that it came into my mind.  I mean, yes, it pissed me off at the time and I think I was not irrational to be pissed off (though I held my tongue), but it was more than twenty years ago.  Why is that making me angry first thing in the morning?  It is fun to imagine things I might have said then, had I been the person I am now.  I take far less shit than I used to take, largely because I have very little left to lose, and much of what I have‒indeed, sometimes all of it‒I frankly want to lose.  At least, I don’t feel that what I have is much worth fighting to keep.

It is quite amazing to think that it’s been more than twenty years since I finished residency and moved to Florida and started in private medical practice.  It’s been about thirty-one and a half years since I got married…and slightly more than half that long since my wife divorced me.  And it’s been about ten years since I’ve seen either of my kids in person or since my son has spoken to me in any way but via a semi-formal E-mail.  A lot has happened in the last 20 years, I guess; I’ve barely hit the highlights here.  But it still has passed rather quickly on the subjective level.

I’m saddled with a good memory, so I recall a lot of the things that have happened in my life, even going back to quite a young age.  I remember the very bad leg aches I used to get as a child, which make my current chronic pain almost feel nostalgic.  I remember really hating the noise of the cannons (and presumably, though to a lesser extent, the muskets) at the musket festival at Greenfield Village, but my memories of that place are otherwise extremely positive.  There were great molasses cookies from the old-fashioned bakery and candy sticks from the general store, and beeswax candles that my sister loved, and of course all the old rebuilt buildings and roads and horse-drawn carriages…it really was (and presumably still is) an excellent place.

 

That’s better stuff on which to dwell than on the sometimes irritating personality of a former senior doctor.  I’ll say this, though:  he took good care of his patients, and he also made them feel well cared for, at an above-average level.  Respect is due.  Those things are not as common as they ought to be.  He was (and presumably still is) a good doctor.

I had a positive moment yesterday, which came at the end of a long, fairly frustrating process.  The details aren’t important, but basically I was trying to do something that in the past has always ended up requiring a few hours on the phone with tech support and with them remotely controlling our computers to do what needed doing.  I was trying to do it on my own without contacting them, and I followed the basic steps‒the good thing about computers and related systems is that they have internal logic that is consistent and explicable.  Still, I hit an impasse, and knew I was missing something that the tech support people had always needed to pull off in the past, sometimes with difficulty, but I hadn’t been able to see it, and it wasn’t part of the standard steps of the whole process.

I tried watching some videos but they were superficial, and I was steeling myself to get in touch with “the IT crowd”, when something clicked, and I thought I realized what to do.  It took about twenty minutes of watching to see if I had succeeded, but turned out that I had.

Such moments are remarkably euphorigenic.  I mean, I know I’m reasonably “smart” about some things.  Certain types of endeavors have always been easier for me than they are for most people, though there are other things that other people do readily that I find all but incomprehensible.

But every now and then one does something that was difficult, and it brings a joy along the lines of having solved a difficult puzzle, but with the added benefit of being useful, and of being something many other people wouldn’t have seen, or not as readily, anyway.  It’s particularly zingy when it happens in a field in which one is not actually an expert, but it can even happen in cases where someone is.

For instance, there was a case in residency in which a code was called for a man in respiratory distress, who was having “Cheyne-Stokes” respirations.  Without intervention he probably would have died, but such situations are run-of-the-mill in a hospital, and he was being intubated before immediate danger of death threatened.  He wasn’t my patient, but it occurred to me that he was a relatively young man to be in that situation, and from group rounds I thought I remembered that he had a drug problem.  So I asked if anyone had tried Narcan*, and they hadn’t.

They got the Narcan out of the crash cart, gave him a shot of it in his IV, and Wow!  He practically exploded to life.  I’m sure it was unpleasant for him, especially since he was already intubated, and abrupt opiate withdrawal is not pleasant for anyone.  But he was alive, and now it was clear that some “friend” had brought this patient‒who had been put in a corner, single room somehow‒a dose of heroin or something similar, and he had overdosed while in the hospital.

I had a slightly different type of feel-good moment as the Senior Medical Resident on a nighttime consultation in the Rehab wing of Jacobi Hospital for a patient who was having palpitations and a very fast heart beat.  A quick EKG revealed a benign kind of supraventricular tachycardia (SVT).  I tried a quick vagal maneuver that didn’t work, and then gave a push of adenosine to the patient and the rhythm broke.  The patient was very happy**, as was the rehab resident, who began almost deferentially calling me “Dr. Elessar” after that, though she was just as much a doctor as I was, and certainly just as expert in her own field.

And once, during an ICU/CCU rotation***, I helped nudge an obviously dead-on-his-feet Cardiology fellow (they have a very rough schedule) by asking if maybe we shouldn’t quickly cardiovert a patient who was intubated but conscious and was now going into ventricular tachycardia****.  He sort of blinked as if he didn’t even know what language I was speaking, then shook his head and said, right, yeah, that’s what we should do.  We did, and it worked.

I can tell you, there’s nothing quite like the facial expression of someone who’s being externally cardioverted at bedside‒this is basically the same as the defibrillation scenes you see in TV and movies, and it uses the same equipment‒while conscious.  It’s not a pleasant thing for a patient to experience.  However, she converted immediately to sinus rhythm, and afterward grabbed my hand and squeezed it before I stepped back, showing her appreciation, so I guess it was worth the moment of extreme discomfort for her.

It’s one thing to know intellectually that one is reasonably intelligent, but these little events that demonstrate competence and success, however inconsequential (or sometimes quite consequential), really do give a person a boost.  The opportunities don’t come as often now as they used to come, so I have to relish them when they do.  I was rather giddy for a few hours at work after my minor success yesterday, and jokingly said to my coworker, paraphrasing Apollo 13, “I…am a steely-eyed missile man.”

It’s silly and unimportant, of course, but I rarely feel good about myself, so I’ll cut myself a bit of slack.  it didn’t help me sleep any better last night, though.  And then I woke up in an angry mood, but I guess it was ego-syntonic anger, in that I wasn’t angry at myself but at the memory of a twenty-year-old, unimportant interaction.  Beggars can’t be choosers, as they say.

---

*For those of you unfamiliar with it, this is a drug that blocks the action of opiates and related compounds, and it does so quickly and strongly.  It’s not fun for the patient, but it can be life-saving and more.

**I don’t recall if we transferred the patient directly to a medical floor or merely continued to consult and ask Cardiology to take a look‒in a public hospital, we didn’t necessarily get to follow up on particular patients long-term.

***I think this was the rotation in which once while on call I literally did not sit down for thirty hours straight, and in which, due to the call schedule, I worked 21-days in a row, had a day off, and then worked another 10 in a row.  It was a busy month, but a hell of a learning experience in many ways.

****Much more acutely dangerous than SVT, especially in a critically ill patient.  It can easily progress to ventricular fibrillation and even of itself can cause cardiac arrest.