Sunday, June 30, 2013

More on weaving and Harrisville

I wanted to put in some text besides photo captions, but blogger doesn't seem to want me to tonight. 

So, here are pictures:

After one runs 3.4 miles in a hilly terrain when it is 88 degrees, one can make any sort of face one wants for the selfie. In the background is the bed and breakfast I stayed at--The Harrisville Inn. I couldn't get their sign in the background. There are five rooms, they grow their own vegetables and eggs and organize the community garden that is just up the road. The other people who stayed there were very congenial and we sat around in their front room, chatting almost every night. The bed and breakfast put out a bottle of wine and a plate of cookies every night. "Something for everyone" must be their motto.

The general store is in the background. The town owns the building and rents it out. It has a really great grill in it and they make delicious prepared foods. Kale salad, asparagus and mozarella paninis, etc. Also some nice little cakes. The ice cream is subpar and kind of expensive besides. The iced coffee is perfectly acceptable and--a nice touch--you fetch your plastic cup and lid pre-filled with ice out of the cooler.

This is the view back into town from the general store. The buildings sit over the stream which used to power the mills as it lost elevation on its way through town. There is a plan to re-harness the river and produce small scale power again for the 125 (!) residents of town. 

Thursday, June 27, 2013

weaving in a most beautiful place

I've been weaving on ad off for twenty two years or so and except for several moths of lessons at the beginning have been self taught. This is incredibly ironic because I am a big fan of formal education.

Go figure; it never seemed to bubble up to the top of the list of Important Things to take a weaving class. There are plenty of good books on weaving to learn from and I have read many and owned more, including the rug bible, appropriately enough titled "The Techniques of Rug Weaving." The son of the guy who wrote it teaches rug weaving classes every summer which sell out more or less as soon as the hosting institution announces them. This year I managed to sign up for the one in Harrisville in time. I have learned an incredible amount and have been having a very good time.

Harrisville is a very interesting place and is one of the best preserved early industrial villages in the U.S. (so they say). It is gorgeous and incredibly untouristy. In fact, they try very hard to just do their work and go about their business without attracting any attention as they are afraid essentially that any observation will change that which is observed. The guy who owns Harrisville Designs who is also the president of the board of the local historical society gave us a talk today at lunch time about how Harrisville managed to preserve its essential nature and keep from going bankrupt. It involved a large measure of vision and a medium measure of luck. I already told Terry it's a good thing we just bought a house in Exeter or I would be agitating for us to move to Harrisville; it's that charming.

I will post pictures when I get home and am not free-loading off a neighbor of the bed and breakfast who has not password protected his wifi. Thank you, Nathan.

Saturday, June 22, 2013

You didn't do that right

Recently, I had the opportunity to get a warm blanket for an elderly patient. It turns out that there is a skill to giving a patient a warm blanket, not much of a skill, but enough that if you haven't mastered the skill and you perform the task, the patient will know.

Here are the key pieces: patients who ask for blankets are cold. Patients who ask for warm blankets are especially cold. The rate at which two objects tend towards each other's temperature is proportional to the difference in their temperatures, i.e., the warmer the blanket, the faster it cools down.

Here's how to do it ideally. Get your blanket(s) from the warmer. Do not unfold. Put the part of the blanket that has been on the shelf against your front. Wrap the rest up in a non-warmed blanket (only necessary if you have to walk to a different until as I did). Hurry back. Put the blanket down taking care to wrap up the side that had been against you with the loose end of the non-warmed blanket (extra blanket will not be there if the warmer is on your unit). Pull all the blankets off the patient and to the bottom of the bed--below the patient's feet. Be sure that several are untangled so that they can just be pulled straight up when you're ready. Leave a sheet on the patient. Unfold the blanket and put it on the patient, unfold the other blanket and put it on, then pull up the other blankets to insulate the warm blanket from the cold air. These steps must be done quickly or the blanket will lose its heat before it gets to the patient.

This particular patient had never had a skilled practitioner of warm blanket before and really appreciated my efforts.

As I thought about this patient, I realized that there was one nurse in Lebanon that I had who did not know how to do warm blankets. It's such a simple skill that really anyone who is reasonably dexterous can manage it. What she did wrong was unfold the blanket, then pull the old blankets down. This allows most of the heated blanket's heat to escape before it gets to the patient. I even said to her, "don't unfold the blanket until the old ones are off" as I was frantically trying to untangle them and get ready to accept the new one. As predicted, the warmed blanket was cold. I did not ask her for another warm blanket. I didn't ask for two reasons that I can identify: 1. I didn't get a warm blanket so why ask for something they won't give you 2. she did not listen to me when I told her how I like it done so I didn't really want to interact with her anyway. Remember, I speak the same language as the nurse, am articulate, hear well, am a doctor and still chose just to wait for the next shift rather than risk a repeat of that interaction.

When I think about our patients who won't "participate" but are still insisting on full treatment so doctors and nurses get mad at them and tell them they're not being consistent or making sense and roll our eyes when we're talking about them in the doctor rooms and then it turns out that they won't do PT because they therapist puts their prosthetic leg on in a way that has led to injury in the past and they told the therapist but they didn't listen and the doctor was too busy and the nurse never asked so they just feel like why should they bother trying to explain to us and the next thing you know people are saying what a difficult patient they are. My issue was just a stupid warm blanket, the consequences of a nurse getting it wrong are that I'm colder than I needed to be. Things not going well for some of our fragile patients could mean a non-healing stump wound or falling. I can see why one might become inconsistent and difficult.

My nice elderly woman was very happy with her warm blanket. I told her I couldn't cure her cancer, but I could help her get warm.

I am grateful for the warm blankets in my life, both literal and figurative. I hope I can always be warm.

Thursday, June 13, 2013

last day of the first year

Depending on exactly when you place my diagnosis: June 14 when my labs were abnormal and they said I might have leukemia or June 15 when I had my bone marrow biopsy, they told me I did have leukemia and bundled me up to Lebanon, either today or tomorrow is the last day of my first year of leukemia.
Last year, on June 14, I was at CMC's cancer committee in the morning with the pathologist who made the call on my lab work, the oncologist who did my bone marrow biopsy, etc. This morning, I was at cancer committee again: same players. Making it even more surreal, I had not been to a cancer committee in the interim. Last time I went, I got diagnosed with leukemia. Who knows what they'll diagnose me with this time! Fortunately, it seems nothing.
This morning, in fact, I got pulled out of cancer committee after about fifteen minutes to attend to a patient at the hospice house who was having a very bad day so I did not get the full experience of how weird it all was to be doing one of the activities I most strongly associate with my diagnosis. We only meet quarterly so I'll have to wait until September to have that experience.
Moth eaten hair from a little more than a year ago. I didn't seem to have a picture related to tumor board to post.
I am grateful for all the help I have had this past year. I am hopeful to be able to pass on the favor over the coming years. Thank you.

Wednesday, June 12, 2013

Being an attending physician

This article in the NYT today (free with registration) reminds me of something one of my first patients in Exeter said to me, "If you are going to be my attending physician, the thing you will need to do for me is attend. Don't just do something, stand there." When I started in Exeter, I took over the practice of a beloved physician who had been there for eleven years and left to live closer to her aging parents. A few of her, now my, patients didn't even come in to meet me, just went off and found new doctors right away. A handful (I specifically remember two, but there were probably more) met me once and decided it would not be a good match and went off to other doctors. Many made it clear the first time they met me that they were checking me out and if I didn't meet their expectations, they would go find themselves a new doctor. Most of this group decided pretty quickly that I would do OK. My style and the old doctor's style were fairly similar which helped a lot. The patient above, who was well over ninety when I first met him, was one of the last group. I am not even sure as he left after our first meeting that he had decided he would keep me, but ultimately he did, dying two years later in my care suddenly at his home.
In our time together, he taught me a lot, including much of what I know about advanced care planning. He had thought extensively about what he wanted at the end of his life and was the first person to tell me that he did not want under any circumstances to spend a single day in a nursing home. If he entered the hospital for any reason and I thought he was going to need to be discharged to a nursing home even for a few days of rehab, he did not want any medical support at all; he preferred not to survive if nursing home would be the result. He was very adamant about this. He was worried about having an illness that would weaken him so that he could not be independent, but not take his life. His wife had spent years in a nursing home and he was very afraid of a similar fate. He had had this same conversation with his cardiologist, too. And just in case I had any doubts, he would remind me of this conversation from time to time. Did I mention he was a retired physician?
As I stated above, he died suddenly at home after laughing at a joke. I think of him often, especially his reminder of the true meaning of "attending physician." Just attend.
I attended a football game a long time ago where the sharp eyed will see Emily in the formation.
I am grateful for all the lessons from my patients over the years. I am hopeful that I can continue to pay attention and learn from them.

Tuesday, June 11, 2013

So, what do you think of my thinking?

I've talked a lot about the personal meaning I make from the whole leukemia experience involving in part that I am going to be a much better doctor because of it. Here's a concrete example of how.

I've used this particular little talk twice with patients. Once it made no difference at all and once it really made a difference for the patient. It's a talk for people who are a little delerious and who may not want to take their meds for it because they don't trust anyone. Here it is verbatim so you have to imagine my voice and the way I talk while you read it.

So, I don't usually tell patients this, but I think it might be helpful. I don't know if you know, but I had cancer last summer (aside: one of the patients was so paranoid that I showed him my port scar to prove it which really helped). It came out OK; I'm in remission and stuff (aside: this part of the talk feels a little off and I try to gloss over the I'm in remission part b/c the person I'm talking with hasn't been), but the worst part of all of it: the pain, the nausea, the chemo, whatever the part that was worst, was the part where my husband told me I wasn't thinking very well. I mean, there's nothing you can say to that that doesn't make it worse and it's such a horrible and scary thing to have someone say. I'm not sure, but I wonder if the cancer might be trying to wreck your thinking up. Just a little bit, but it's such lousy sneaky stuff that it might be trying really hard to. Can I tell you what I was thinking? (segue to part of the talk where I explain what I think might help)

The first time I said this to a patient, it was not helpful, but the second time, it felt kind of miraculous. The patient was willing to give a try to a med he had been unwilling to try before (sadly, it didn't work, but it felt really important to everyone to try to make Plan A work and this particular med was necessary for Plan A). His behavior dropped down a couple of notches from almost impossible to manage to just tough and right after agreeing to this he had the nicest interaction he had had with a family member in weeks (maybe not related, but maybe). I really think this worked to reach this particular patient at that particular moment and it was something I could not have done or even understood without the leukemia experience. I just really did not understand what the experience of not thinking well might be like.

As an aside, a nurse and I were discussing a delerious patient and I told her that when Terry (and Tommie, too!) told me I was not thinking very well that that was really the low point of the whole experience for me and she said, "Even for you, Mary? with all you know about this stuff?" Ah, if only cognition ruled it all, huh?

Not related to cognition. Maggie in the Exeter River two summers ago.
I am grateful to have come out on the other side of the leukemia. I am hopeful for no return trips.

Sunday, June 9, 2013

Come here often?

Clearly, I don't. I really haven't had anything to say for a while, but the synchronicity of life has urged me back here so here I am. And you are, too. Thank you.

So, to catch you up on the factual news in my life; it's all good. The leukemia is still in remission; we bought a beautiful new house and the clinic has seen one patient so far.

The clinic patient seemed to be a success. Her care givers seemed happy with the intervention. We helped and have a plan to help more. There are potentially two patients to see next week and we are not even officially open yet. The computer tail seems to be wagging the dog here and we cannot open until the electronic medical record is ready for us to open. We don't have a department according to the electronic medical record so we can't actually see patients. The one we've seen, and now two more we hope to see, are seen as internal medicine patients officially and billed as internal medicine patients, get internal medicine notes, etc although they get the full palliative care treatment. Arg! it's a good thing we have computers to make our lives easier. The real news here, however, is that I think the clinic is going to be a success and that I am going to know what to do. I had my doubts at times on all fronts. I mean, I know how to do hospital palliative care consults and I know how to do internal medicine office consults, but I was worried that I wouldn't know how to take the knowledge base of palliative care and translate that to an office. I was also worried that I wouldn't have enough to offer patients and their families so we would not get referrals. Additionally I was worried that I would be an interpersonal clodhopper and it wouldn't matter how effective I was with patients, no doctor would want to deal with me so we wouldn't get referrals. I am starting to see that I can do OK with referring docs and am starting to see the value of what I do in the hospital even when I cannot get the desired result within twenty minutes of seeing the patient. These things make me feel more confident. Additionally, I am (slowly, o so slowly) catching on to the beauty of the fact that it's a team sport and even if I don't have something useful to offer, the nurse or social worker will and as part of the team I get credit for their work just as they get credit for mine. Ah! I can relax a bit now because I have a good team.
My friend, Barbara's dog team. The shadow in the left part of the picture is my dog, Maggie. Her protege is the fluffly little white dog next to her and Maggie learned everything she knows from the yellow dog in the middle of the picture.
I am suddenly feeling that I have a lot to say here and expect tomorrow to be tapping away again. I am grateful for this blog, for your patience and persistence in checking here even though I've been stewing silently for almost a month. I am hopeful that we will have many conversations.