Category: Nonfiction

A Dream.

Post author By Maria Yang, MD
Post date September 19, 2013

A few days before I learned what happened, I had a dream about you. When I awoke, my heart felt like a bird flapping its wings inside the cage of my ribs.

The details had vanished. Only anxiety remained.

I gasped when I learned what happened. I suddenly remembered the little details, the things that never made it into the clinical notes: You liked your coffee black. You read the Wall Street Journal. You missed driving your sports car.

Where did you kill yourself? Did you get a motel room? Were you outside? What time of day was it?

You certainly planned this. When did you make the final decision? Did you waver? Did you want to waver?

They say that there are two kinds of psychiatrists: The kind who have never had a patient commit suicide, and the kind who have had patients kill themselves.

I now belong to the second group. We all join the second group at some point.

I wish you hadn’t killed yourself.

I thank you for what you have taught me, both in life and in death.

I wish you had the peace in life that you thought was only available in death.

May peace be with you now.

Medicine Nonfiction Observations

I Remember.

Post author By Maria Yang, MD
Post date August 6, 2013

I remember when we dragged ourselves to the large lecture hall every morning, backpacks slung over our shoulders and cups of coffee in our hands. Six to eight hours of lectures awaited us.

I remember where we all sat in that lecture hall. I remember the future ophthalmologist who sat behind me and made snarky comments while certain professors gave their lectures facing the chalkboard. I remember students sitting six rows behind me who told me after class, “We saw you falling asleep today. If you sit in the back, it won’t be as obvious.”

I remember the guys throwing around a fluorescent Nerf football between classes. Some of them would take off their shirts (and one would look around to see if women were watching) and relive their days of playing college sports.

I remember when we wore shorts, tee shirts, sandals, tattered jeans, dangling earrings, and tank tops.

I remember going to parties and watching people drink wine and beer out of those red plastic cups.

I remember when we received the short white coats. I remember how stiff they were, how awkward we looked in them, and how annoyed we were that we had to buy “nice clothes” in preparation of training in the hospitals.

I remember that we exchanged ideas of where to find “nice clothes” for “cheap”.

I remember how tired and haggard we looked after we took call. I remember when our scrubs were wrinkled, our hair was unkempt, and our hygiene was suboptimal.

I remember when we wondered how we would ever survive our intern year.

I remember when we contaminated sterile fields and didn’t know what size sterile gloves we needed. I remember certain nurses rolling their eyes and yelling at us for our ignorance. I remember when we would see each other in the hallways and stairwells, holding order sheets for signatures, carrying baskets filled with gauze and tape, and trailing behind the medical team that was into its third hour of rounding.

I remember when we tried not to cry when attending and resident physicians said unkind things. I remember when we shared strategies about how to manage certain doctors. I remember how much we said, “I don’t know.”

I now see current photos of my classmates from medical school and, to my surprise, they actually look like doctors. They have wrinkles around their eyes. The men wear white collared shirts, mild neckties, and dark business jackets. The women wear conservative jewelry and shirts with modest necklines. The long white coats fit their frames. Their smiles radiate confidence.

They look mature.

And old.

Which means I must look that way, too.

Nonfiction Observations

Contrast.

Post author By Maria Yang, MD
Post date July 5, 2013

She was a petite woman. She thrust her shoulders back and her dark hair cascaded down in waves towards her slender waist. Her burgundy and white dress gently bounced with each step she took in her four-inch heels. Her arms and legs had the girths of tree saplings. A designer handbag swayed on her left shoulder and pearl-accented earrings dangled from her ears.

It was crowded at the buffet. With purpose she walked past the glistening hunks of prime rib, the pink slabs of baked salmon, the heaps of bacon, the blobs of scrambled eggs, the bowls of romaine lettuce and spinach, the rounded cubes of honeydew, pineapple, and cantaloupe, the bundles of fried egg rolls, the vats of noodles, the pot of egg drop soup, the bowl of quivering red jello, the trays of walnut brownies, lemon cake, and chocolate mousse pie, the racks of barbecue ribs, the oozing discs of pepperoni pizza, the rows of chocolate chip cookies, and the limp triangles of French toast.

She carried her plate with both hands, her fingers tightly gripping the edges. Her eyes scanned the buffet, but she was not looking at the food. The only item on her plate was one roasted red potato.

Education Medicine Nonfiction Observations

CPR and Informed Consent.

Post author By Maria Yang, MD
Post date January 28, 2013

Radiolab recently aired a show called “The Bitter End” that discusses the end-of-life care preferences of physicians and non-physicians. Physicians are much more likely to decline “heroic” measures, such as CPR, mechanical ventilation, feeding tubes, etc. This comes as a surprise to the hosts and, presumably, to other non-physicians. It’s a good show. I recommend it. (Full disclosure: I like Radiolab.)

In the show, Ken Murray argues that physicians decline these “heroic” measures for intellectual reasons. He argues that we know the data, which includes a study that reported that, of people who receive CPR, only 8% are successfully resuscitated. (Of those 8%, only a portion of them return to their full previous function.)

I don’t think physicians decline CPR and other “heroic” measures because of evidence-based, numerical data alone.

The experience of performing CPR and attending to patients who are critically ill contribute to physician preferences against CPR. It’s emotionally taxing. All physicians have seen the trauma we cause with these “heroic” measures. Yes, performing CPR can lead to cracked ribs and punctured lungs. Mechanical ventilation can lead to severe cases of hospital-acquired pneumonia. Intravenous hydration can cause massive tissue swelling. The consequences of heroic measures are often devastating.

Physicians are taught “first, do no harm.” Sometimes, these heroic interventions seem like they cause more harm than good.

Perhaps physicians decline CPR and other “heroic” measures because of anecdotal experiences and emotions. This isn’t randomized, placebo-controlled data. However, anecdotal experiences and emotions are still data.

Furthermore, there is no true “informed consent” with CPR. When patients are able to consent to CPR, they are not truly informed. They cannot fully appreciate and understand what CPR entails because they have never experienced it.

By the time patients are truly informed about CPR—when someone is pushing on their chests, when a second person is manually inflating their lungs, when a third is injecting medications into their blood, when a fourth is trying to stick a breathing tube down their throats—they are unconscious. They cannot offer or withhold consent.

(This is true with many things in medicine: No one can give true informed consent for general anesthesia, surgery, or even medications. We often only know all the information after the fact. Patients often give consent based on hope and faith.)

Physicians see and treat patients who have undergone CPR. Those patients are usually paralyzed, swollen with fluid, and unconscious. Upon witnessing that, physicians might wonder what the differences are between “living” and “existing”.

This could explain why their end-of-life care preferences differ from that of the general public.

Education Nonfiction NYC Observations PPOH

Daily Schedule: Assertive Community Treatment.

Post author By Maria Yang, MD
Post date January 20, 2013

A sample agenda as the consulting psychiatrist with an assertive community treatment (ACT) team:

7:55am. No one is at the office yet. Insert a key into the gate in front of the building. The gate makes grating and squeaking sounds as it rolls up. After entering the building, quickly disable the alarm, lock the door on the way in, and roll the gate back down. From the medication room, pack into a brown paper bag a pair of gloves, two alcohol pads, one band-aid, a pinch of 2×2 gauzes, a portable sharps disposal container, and a pocket-sized bottle of hand sanitizer. Unlock a different cabinet and fish out a small box that contains liquid haloperidol decanoate, a long-acting antipsychotic medication. Drop that into the brown paper bag.

Leave the office, secure the building, and make sure that the gate is rolled completely down before walking away.

8:40am. Arrive at a patient’s[1. All patients described here are composites of people I have seen across time.] apartment uptown. She lives with her mother, grandmother, and her mother’s boyfriend. As usual, she’s still sleeping, even though she knew that this visit would occur around 8:45am. She’s wearing a strappy tank top and baggy pajama pants. She rubs the sleep form her eyes. She walks back into her bedroom. An electronic rose is in the corner next to her mirror. Different colored lipsticks are on the table. There is a desk lamp on the nightstand, as well as several magazines.

She shrugs her shoulders after realizing that her offer of a seat on the unmade bed was politely declined. She’s doing pretty well: She’s re-enrolled in GED classes and is studying to take the test, though she’s finding the math portions difficult. She’s still going to the local bar on weekends, but denies getting drunk. When she also denies smoking marijuana, her response seems honest, though her next visit to the office will include a urine drug screen test. The antipsychotic medication isn’t causing side effects. She asks for advice on how to avoid bad boyfriends.

9:30am. Arrive at the second patient’s apartment after a subway ride further uptown. He lives with his elderly parents. He’s not doing well. He yells at his mother and his father often locks himself in the bedroom so they don’t have to interact.

He begins to share that he is dating a woman, then suddenly comments that he hasn’t drank any alcohol in months. His mother interjects and says that he has come home very late at night smelling of alcohol. The stories from the past week spill from her mouth; she’s watched him cross and re-cross the same street for two consecutive hours. Sometimes he yells about the gods who have failed him. Small items—vases, salt and pepper shakers, silverware—have started to go missing from the apartment.

He says he’s taking his medications, but his mother says that she finds pills in the trash cans. He mumbles under his breath.

No, she hasn’t had to nor wanted to call the police. No, he doesn’t want to go to the hospital. He’s eating the ham and cheese sandwich that she’s made for him. She asks what will happen next.

“If you feel unsafe, call 911 and call the ACT team. Don’t wait. Just call. We’re all worried about him.”

He rolls his eyes and asks the wall why anyone would think he would hurt anyone. He doesn’t seem to remember that the last time he developed symptoms and drank alcohol, he punched his daughter.

10:40am. Arrive at the third patient’s apartment after a bus ride across town. He’s an elderly man who believes that his neighbors have stolen his internal organs and that cannibals will eat him if he leaves the building. These beliefs as well as gait problems keep him in his apartment. This is the person who will receive the haloperidol injection.

The usual conversation about his medication ensues. He’s willing to accept the medication, but wants to discuss again why it is at its current dose. The reasons haven’t changed from last month. He nods in what seems to be understanding, though then asks, “The medication will not make my skin turn blue, right?”

This is a significant improvement from a year ago.

Three large cockroaches skitter across the countertop. Two empty cartons of orange juice sit on the kitchen table. He looks into the living room, which holds his bed. He doesn’t go into the bedroom anymore. He still cries when he thinks about his dead wife.

He rolls up his sleeve and looks at his arm when he receives the injection.

“It never hurts when you do it.” He’s probably just being nice.

11:45am. Arrive back at the office. A patient sits on the curb, smoking a cigarette, while chatting up a cab driver. Everyone says hello to each other.

11:50am. Two of the social workers are in the office. They and the secretary all share events from the morning. One of the ACT patients may leave the hospital tomorrow. One of the social workers will escort him directly from the hospital back to the apartment if the hospital discharges the patient.

“I’ll visit your guy tomorrow morning,” the other social worker says, referring to the second patient who lives with his elderly parents. “We’ll check in with him every day this week.”

12:00pm. Work on documentation from the morning visits. Mindlessly eat lunch.

12:53pm. Fourth patient arrives for his 1pm appointment. He greets everyone with a warm smile.

He recently started volunteering at the library and teaches young children how to read. He rides his bicycle around Central Park to help keep his blood sugars under better control. His daughter is coming to visit for the holiday. He plans to cook salmon for dinner tonight. He’d rather have fried chicken.

“I’m scared to lower my medication, Doc,” he says. “I don’t want to end up at the hospital again. But if you think all this weight gain might be from the medicine, I guess we could try it—you said real slow, right?”

After some more discussion, he concludes, “No, let’s not change the medicine now. Lemme get through the holidays and then we’ll try. Real slow. Real slow.”

His wishes are honored without argument.

2:00pm. The fifth patient hasn’t arrived.

2:10pm. The fifth patient still hasn’t arrived. She’s more organized than people might initially believe, but she’s rarely punctual.

2:17pm. “Heya doc, how you doing, how you doing,” the fifth patient says, flopping down on the seat. She’s chewing on a popsicle stick. She’s tied the two ends of a necktie together and is wearing that around her neck like a necklace. Four other neckties are tied around her neck the same way. Ear phones cover her ears, but they’re not plugged into anything. Her striped socks are pulled over her baggy sweatpants.

“Heya doc, how you doing, how you doing, the vapor’s hot today, so hot. The icicles bring down the vapor, the vapor pulls the magnet and the poles spin, they spin, that’s what makes the Earth spin, the vapor around the Earth spins, too, spins like a record, so cool, so cool….”

She just finished her first week as the filing clerk for the drop-in center. The staff there said that she did good work and that she seems to like it, but she occasionally breaks out into song.

“Do you like your new job?”

“Yes, yes, but I want them to like my new job, too. I like the money, too, I can buy myself some new shoes, new blue shoes, new blue frue true krue shoes, so krue, so cruel, cruel world.”

On the way out, she flings the popsicle stick into the trashcan and belts out, “NEW YOOOOORK… CONCRETE JUNGLES WHERE DREAMS ARE MADE OF….”

3:05pm. Sixth patient arrives. He sits down and looks out the office window into the lobby. Everyone said hi to him as he walked in. He didn’t respond.

He doesn’t say anything in the room. He doesn’t make any eye contact. He examines his nails. He reties his shoelaces. He rolls up his pant legs. He strokes his beard. He fishes a half-smoked cigarette out of his pocket, then puts it back in.

“What’s going on? Is something wrong?”

He sighs and shakes his head. He gets up and doesn’t look up in acknowledgment when he hears entreaties to stay. As he walks out of the office, he finally says, “I’ll be back.”

3:20pm. Ask one of the social workers to follow the Tacit Man out of the building with hopes that they will have a conversation.

3:22pm. Watch from the lobby while the social worker and the Tacit Man talk. They’re actually speaking to each other.

3:25pm. The social worker walks back into the building and the Tacit Man walks across the street.

“Tacit Man is fine, just having a bad day,” the social worker says. “He’ll come back tomorrow to see you, same time.”

“Thank you!”

3:27pm. Call patients to remind them of meetings scheduled for tomorrow. Most of them answer their phones.

3:45pm. Resume documentation with occasional interruptions from other patients wandering into the office to say hello.

4:35pm. Coordinate plans with the social workers for tomorrow. Discuss medication changes, medication deliveries, and which patients need closer monitoring.

4:45pm. Leave the office. That same client who was sitting on the curb and smoking is still sitting on the curb and smoking. He waves hello. I wave back.