hunting for zebras

 

When we were studying the art of clinical diagnosis in medical school, we were cautioned not to look for "zebras"--those rare, exotic diseases and conditions we studied but were unlikely ever to encounter in clinical practice. In other words, when a child presents with fever and rash, Fifth Disease or chicken pox should come to mind before you think about less common causes, like Rocky Mountain Spotted Fever or rubella. When a patient comes in with abdominal pain, rule out appendicitis and cholecystitis before you start to worry about Familial Mediterranean Fever. If the problem is dehydration and diarrhea, consider viral gastroenteritis or food poisoning before you think about cholera.

 

"If it looks like a duck,

and walks like a duck,

and sounds like a duck...

chances are it probably is a duck."

~unknown~

 

Not always, though.

 

True stories:

• The patient was a woman in her sixties. She was admitted from the ER directly to the OR with a diagnosis of "acute appendicitis." She'd had increasing pain and tenderness in the right side of her abdomen for two days. As the intern on call that night, it was my job to perform the admission history and physical, and to write orders before the surgeon could begin the operation. The patient was already on the operating table and the OR team was ready to go. "Don't waste time," I was told. So I took a quick history, checked the patient's vital signs, and listened to her heart and lungs. Then I examined her abdomen. She was tender deep in the right lower quadrant directly over McBurney's point--a classic finding in appendicitis--except for one thing. When I pushed in, something throbbed against my fingertips. It was painful for her as expected, but I caught my breath when I felt the pulsating mass and heard the whoosh, whoosh, whoosh of blood coursing through it. I'd seen several cases of appendicitis by that time, and trust me, the appendix does not pulsate. But a dissecting aortic aneurysm does. This was a problem. The OR wasn't prepped for this kind of procedure. The blood bank would need to be alerted, the vascular team assembled, and ICU notified. And time was critical. Zebra #1.

• A twenty-two-year-old man presented with a several week history of fever and malaise. Two weeks earlier, he'd seen a doctor who diagnosed him with a non-specific viral illness. Upon careful examination, he now had a soft (barely audible) diastolic heart murmur and mild enlargement of his spleen, classic findings for subacute bacterial endocarditis. He died two weeks later. Zebra #2.

• A sixteen-year-old presented to his PCP with a two-week history of a cold and sore throat. Everyone in his family had had the same symptoms and had recovered uneventfully. The patient's sore throat, however, persisted and was getting worse. Long story short, what sounded like a straightforward case of pharyngitis or Strep throat in a healthy adolescent, turned out to be gonococcal pharyngitis in a closeted gay teenager. The sexual history is not something most of us routinely obtain when we're seeing a patient for upper respiratory symptoms. Zebra #3.



"Medicine is a science of uncertainty

and an art of probability."

~Sir William Osler~



Today, more than ever before, physicians and other health care providers are under intense pressure to see more patients faster. It's tempting to jump to conclusions. To rush through the patient's history and to gloss over portions of the physical exam in order to save time. Sooner or later, though, you're likely to miss an important detail in the patient's story, or to overlook a subtle finding on examination that points to the diagnosis. 

 

What you think is just another pony over there in the field, may turn out to be a zebra, after all.

 

"The intuitive mind is a sacred gift,

and the rational mind is a faithful servant."

~Albert Einstein~

jan

 

how storytelling reopens the wound

 

If you follow this blog, you probably have some familiarity with, or curiosity about, the concept of storytelling as a healing practice. If you are a health care provider, a therapist in any field, a caregiver—or if you have been sick yourself—an untold story may be wreaking havoc in the back of your mind. Perhaps it reflects a painful, sad, or frightening episode from your past…something you’d rather not resurrect. Maybe there was a time of such joy or relief or healing you can’t imagine putting it into words so you haven’t given it a try. Yet.

This post is dedicated to my brother who, I believe, fits the first of these profiles--the painful one--as the result of a serious childhood illness. At the age of 79, he has started to write his memoir. Cue thunderous applause!

"A writer is someone

for whom writing is more difficult

than it is for most people."

~Thomas Mann~

Perhaps you’ve started to write your own story again and again and gotten nowhere with it. It turns into a rambling description of places, persons, and events that fails to capture the emotions that made the experience meaningful to you. That fails to explain why it stalks you so many years later, and still affects your feelings and behaviors.

This is where a good writing prompt can be helpful. That and a supportive reader who knows how hard this is for you and heaps praise upon you just for trying.

If you need a little nudge to get you started, here are a couple of writing prompts for health care providers that might help:

·         Write about “expectations” you’ve embraced (or rejected).

·         Tell us what it feels like to work without sleep, on an empty stomach, when you have to pee, in the middle of the night.

·         What goes through your mind on the way to work in the morning…or on your way home at the end of the day.

If you are the one who was sick, or you cared for someone who was ill, try these:    

•    Write about "waiting."

·         Tell us what you fear the most.

·         Tell us what you do to care for yourself.

When you begin, don’t worry about grammar, spelling, or punctuation. That’s the easy part. It can wait. Instead, write about the first thing that comes to mind.

"When in doubt, tell the truth."

~Mark Twain~

Give yourself 15 minutes or so, then rest. Wait a couple of days and try again. Write until you come up against the piece that is hardest to put into words…a time when you were so sad or scared or angry you still hesitate to commit it to paper…or so comical or comforting or inspiring it leaves you groping for words.

"The most important things are

the hardest to say

because words diminish them."

~Stephen King~

When you write, include details even if they seem insignificant. The missing tile on the ER wall. The overflowing trash can in the visitors’ lounge. The ladybug that made its way into the OR. These familiar images connect the reader to your story. Use the senses to bring the scene to life. The sight of blood pumping out of a tiny artery after the other bleeders were all tied off. The taste of cold, black coffee in the middle of the night…and why you sometimes need it. The smell of stale urine.

"To create something exceptional,

your mindset must be relentlessly focused

on the smallest detail."

~Giorgio Armani~

An untold story can leave us with a vague sense of frustration, anxiety, or confusion that we don’t understand, and can’t dispel until we put it into words...until we set the scene, name the characters, and face the feelings that have festered out of sight for so long.

Storytelling unmasks the wound so healing can begin.

"Nobody cares how much you know,

until they know how much you care."

~Theodore Roosevelt~

jan

opting out

 

Last week I spent a few days with my granddaughter. She's five years old. One day, she invited a friend over to play, and everything seemed to be going well until her friend came to me asking to take her home.

"I don't want to play anymore," she said...and I thought to myself, I completely understand...because I don't want to play anymore, either.

I, too, want to go home, which in my ideal world would be somewhere near where this photo was taken, in the mountains along the Northface Trail near Murren, Switzerland, or in Wengen, or in Lauterbrunen...far, far away from a culture that is self-obsessed, driven by wasteful consumerism, and addicted to power and wealth. Far away from the political nonsense that is fueled by the media. In denial of climate change and its effect on the planet. Far away from the bigotry, cruelty, and abandonment of those in need. Ridden with conspiracy theories, outright lies, and fraud.

Health care providers, in particular, should understand that we are tottering on the brink of disaster at the hands of political appointees who lack the knowledge, experience, and wisdom required to protect both health care delivery and public health policy. 

Our narrative is shifting.

"Suffering by nature or chance

never seems as painful

as suffering inflicted on us

by the arbitrary will of another."

~Arthur Schopenhauer~

I don't know about you, but I get tired of it. I get discouraged. I am fearful. Some days, I just don't want to play anymore. I want to go home, to a place of relative solitude, simplicity, and peace. Of respite and restoration. Of mindfulness and healing...if only for a little while.

"...walk away from situations

that threaten your peace of mind,

self-respect, values, morals, or self-worth."

~marcandangel.com~

Last week, my granddaughter's friend went home for a little while, too...but the next day she was back, full of joy and playfulness, rested and energized, ready to reconnect...

...which is how we should all be. 

So...what do you do when things get to be just too much? What do you do that helps? Where is home for you?

"Whatever is good for your soul...

do that."

~attribution unknown~

jan

an untapped resource for patients and healers alike

 

If you work in health care as a doctor, or a nurse, or a therapist in any field, it's probably safe to assume you understand how the human body functions. How the heart maintains its steady beat without any effort or awareness on your part. How the lungs manage to deliver just the right percentage of oxygen to your tissues, and how they eliminate the carbon dioxide you exhale. How an open wound closes, or a broken bone heals.

"Your body's ability to heal is greater 

than anyone has permitted you to believe."

~Roger Ford~

If the way the heart and lungs operate is something that amazes you, the way the brain works should mystify you. How it oversees and regulates every bodily function. The way it controls movement, maintains our sense of balance, orchestrates vision and hearing, enables our senses of taste, touch, and smell, and modulates the neuroendocrine system. And on and on...

If you're in health care, you studied human anatomy and physiology for years. You learned about the anatomy, physiology, biochemistry, microbiology, and cellular biology that life, as we know it, depends upon, and illness disrupts. You are familiar with the functions and processes that make healing possible. Except one.

"Your body hears everything 

your mind says."

~Naomi Judd~ 

The one thing we don't study, or dissect, or measure in preparation for patient care, which is our calling, is the nature and essence of thought. We don't examine memory under the microscope, or trace the course of creativity and imagination. We don't fully grasp the location or power of human consciousness, and we don't come close to understanding the function of the unconscious. Because no one understands it.

The hardest thing we can do is to think about our own thoughts.

"Consciousness poses the most baffling problems 

in the science of the mind.

There is nothing that we know more intimately

than conscious experience,

but there is nothing that is harder to explain."

~David Chalmers~

Interestingly, it is not so much the biologists, physiologists, pathologists, or psychiatrists who are making headway in the quest to understand consciousness, but the quantum physicists, contemporary incarnations of the likes of Einstein, Bohr, Planck, Bohm, Heisenberg, John Wheeler, and Paul Levy who are compelled to define reality without any proof of it. To understand consciousness without any image of it.

If, like me, you are in awe of the complexity, precision, and perfect timing that mark the biology and physiology of the human body, you can't help but be mystified by the brain. Sooner or later you will be led to contemplate the role of consciousness in health and disease. The benefits of meditation. The influence of mood and emotion on well being, all of which should amaze you. Humble you. And naturally spiritualize you.

"Attempting to understand consciousness

with your mind

is like trying to illuminate the sun

with a candle."

~Mooji~

I just finished a book about quantum theory. It opened with an introduction, foreword, and preface, and it ended with 896 footnotes. It suggests that there is a precise, elegant, and exact parallel, down to the most minute detail, between the laws of subatomic physics and the workings of the human mind. That would be hard enough to comprehend if we understood the mathematics that proves it. The problem is we don't have a language to express it yet. And, until we do, the nature of consciousness will remain a mystery, and an untapped resource for patients and healers alike.

"If you think you understand

quantum mechanics,

you don't understand quantum mechanics."

~Dr. Richard Feynman~

jan

"this time we are in"

I don't know how you're feeling today, but lately a lot of people I know have been feeling a little, well, let's call it "funky". Tired. Anxious. Discombobulated. No, wait. It's actually a lot worse than that. They are battling a defeating sense of injustice, anger, fear, and helplessness. 

"We are living on this planet

as if we had another one to go to."

~Terri Swearingen~

Maybe it has something to do with the fact that we are witnessing fires and floods the likes of which we never thought possible, a daily reminder that climate change is real. A growing conviction that now is the time to do something about it...before we lose our chance.

Or perhaps it's the fact that we're teetering on the brink of economic chaos, which unlike climate change, is something most of us are helpless to prevent. 

Or perhaps the problem is the reappearance of measles among the unvaccinated, already taking the lives of children who could have been spared.

Maybe it has something to do with the fact that our nuclear codes have been placed under the control of a man who probably shouldn't be trusted to protect his own phone number.

The security we have been working so hard to secure is being squandered by our political and corporate taskmasters. We are confronted with lies and deception every day.

Our concerns are not only global, but personal. Not only political, but existential. Not only secular, but sacred.

Which is why I would like to share this piece for a little change in perspective. For a way and a reason to go on. To serve as food for thought:

This Time We Are In

~John G. Bennett~

We must not have any attitude of blame towards people for what is occurring; this is a cosmic event, this is what Gurdjieff called Solioonensius, (in Beelzebub’s Tales) a state of tension when people – all people – become intensely dissatisfied with the situation in which they find themselves and they react to this state of dissatisfaction differently.

Here is what is the right and wrong of it: those who are wise and understand this, know that this force of dissatisfaction that is developed can be converted into dissatisfaction with oneself and a wish to change and to work on oneself, and it is the greatest and most powerful force that one can have. It is the realization that only those who have attained to inner freedom through work can pass safely through this kind of crisis.

As was amply proved during the great revolutions like the Russian Revolution and elsewhere, this is the path of wisdom in front of this. Other people project the causes outside of themselves and then you have this sort of tension between races, between generations, between classes, between people who want to change things one way, people who want to preserve things in another way.

All these tensions result in people blaming others, and when things go wrong this becomes acute and ultimately threatens violence and disaster. This is happening all over the world, but it is most intense in the United States because the United States is the key to the solution of it all. But this does not mean that the people in power in the United States can do something. In fact, it has now become terrifyingly evident that really no one is in power, that events have taken charge. Neither the president, nor the Senate, nor congress, nor big business, nor wise people, nor leaders of this or that movement, none of them is in charge of the situation. They are all reacting to this state of tension.

This does inevitably occur periodically in the life of man, and it is a part of the general condition of the existence of life on the Earth. It is because of this that we have to work especially nowadays, at this time, and one part of our work is as far as possible removing from ourselves, even in our thoughts, criticism and hostility to people whose behavior we may disapprove of; constantly look upon these people as helpless, not as hostile; as machines, not as evil men – really as victims, and not as persecutors. And this is irrespective of what they may be doing.

Even the most dreadful things are really not done intentionally, or from the desire for evil. They are either done through a mistaken hope for good, or simply helplessness. This helplessness of man is something that people cannot bear to face up to. It is much easier, or much more satisfying to our vanity as human beings to think that things go wrong because of bad will, but things go wrong because man is helpless. But there is nothing really to fear or to be ashamed of in this because this is what we have to work ourselves out of.

For those of you who are in America at the present time, this is a very great opportunity, even if the smallest number of people can manage to preserve a constant state of compassion and abstain from criticism. This does not mean putting away one’s critical faculty which is quite a different thing; it does not mean seeing that mistakes are made. All this we have to do. It is to not criticize people for doing what they can’t help doing; not to find fault where people are being carried along by a stream without any possibility of changing the course of events.

If the course of events is to be changed as I believe it will, and I am not a pessimist, not an alarmist about the situation; in fact, I am more optimistic than almost anyone can be because I have complete conviction that there is a higher power working in human life at this time, with far greater wisdom and far greater resources than we have any notion of. But this confidence does not mean that I think that human beings can help and put the situation right. And as I have said over and over again in the past year or two, our task is, to my mind perfectly clear: to do everything we can to make ourselves into instruments for the higher wisdom channels through which this wisdom can flow, putting aside our worn wisdom, putting aside any belief in our own powers, to allow the higher power to work through us. Perhaps very wonderful things will happen.

*

Perhaps...

"Not everything that is faced

can be changed,

but nothing can be changed

until it is faced."

~James Baldwin~

jan

off topic, but worthy of reflection

 

Yesterday, at the point when I'd had enough news and political commentary to last me a lifetime, I decided to unwind with a walk in the woods. 

"Lose yourself in nature

and find peace."

~Ralph Waldo Emerson~

We are on the cusp of spring here in central Pennsylvania. It is cold and windy one day, warm and sunny the next, gloomy and wet the next. But, yesterday was a beautiful day, despite the cruelty and injustice that are suffocating our country right now. Despite the blows to our retirement savings and Social Security accounts. The jobs that have been lost. The looming threats to health care in this country. The violation of our basic human and constitutional rights. Despite all of it, Mother Nature managed to pull off a perfect Spring day, as if to say, "There, there. It will be all right."

This is the thing:

The sky was as blue as it has ever been. The sun was warm, and the winds had quieted to little more than a whisper. The cherry blossoms and forsythia were a profusion of color. The forest floor was blanketed with green. The birds were silent, as if lost in thought. The music I enjoyed was just as glorious as it had been the day before, and the day before that...and for years before that. 

None of that has changed, even though it seems like almost everything else has. 

"Keep close to Nature's heart

and break clear away once in a while,

and climb a mountain

or spend a week in the woods.

Wash your spirit clean."

~John Muir~

The point is that, even as the world bows down before the evil forces of greed, cruelty, violence, injustice, and hatred, its foundation remains unshaken. The animals have come out of hiding. Mother Nature has kept her word. Beauty lives on. Kindness and compassion flourish. Wisdom abounds.

"Some believe it is only GREAT POWER

that can hold evil in check...

I have found that it is the small, everyday deeds

of ordinary folk that keep 

the darkness at bay.

Small acts of kindness and love."

~Gandalf~

To that point, as I was walking along one of the isolated back roads nearby, a man on a motorcycle pulled up in front of me, dismounted, and began walking my way. I have to admit, it scared me a bit. But, it turned out that he had mistaken me for a neighbor he had frequently passed there, until the day she got sick. He hadn't seen her out for weeks. 

When he realized his mistake, he apologized. And then he said simply, "Do you pray?"

I replied, "In my own way," and he asked me to pray for his neighbor.

Which is how I think we're going to get through this: each of us in our own way. 

This was an unlikely chance encounter that served to remind me that we are on secure footing. That people are concerned and caring. That simple pleasures surround us if we turn our attention to them. That we have the power to silence the voices of evil if we will listen, instead, to the sound of the wind and rain. If we appreciate laughter and good music. If we share words of friendship, support, respect, and kindness. Each of us in our own way.

"Everybody should be quiet

near a little stream

and listen."

~Maurice Sendak~

jan

your story deserves to be told

I’m pretty sure Mother Earth wobbled on her axis last week when another child died a wholly preventable death from measles, putting the rest of us on alert because you can't tell by looking at a person if they have been vaccinated or not. I imagine the planet careening out of orbit as another helicopter took a nose dive into the Hudson River killing all aboard...including three children who were enjoying a sight-seeing tour of Manhattan.

The urgent and passionate stories that erupt in the aftermath of tragedies like these hold us spellbound…horrified…as fear and sorrow unfold before our eyes. We have witnessed accounts of terror, helplessness, grief, and pain. We've heard stories of courage, strength, compassion, and faith.

I don’t know about you, but those stories silenced me. The worries I harbor, the sadness I feel, the losses I face in my own life pale by comparison. Who, I wonder, would want to hear about them?

"Writing is a struggle

against silence."

~Carlos Fuentes~

For example, I could tell you about a friend whose husband died of complications after a long bout of heart failure. I could tell you what a sweet man he was, how much they loved one another, and how much he is missed. I could tell you about a wonderful man who drowned, alone, in his backyard pool this week, one day shy of his ninetieth birthday. You probably already know how hard it is for friends who have lost their jobs or are bracing to close their businesses given this week's political chaos...all of it matched by the magnitude of the suffering we routinely witness on the news every day.

Perhaps something like this has happened to you. You went mute because your story sounded dull or ordinary or immaterial by comparison. You felt it was unworthy to be heard. Or unnecessary to tell.

"Write what should not be forgotten."

~Isabel Allende~

It doesn’t take a natural disaster or a or a violent uprising to shut storytellers down. We do it to ourselves all the time. We trivialize the course of our own lives, lock away our memories, and dismiss our thoughts, feelings, and convictions because we doubt ourselves. We tell ourselves our stories aren’t important...

"Write hard and clear

about what hurts."

~Ernest Hemingway~

...when, in fact, everyone’s story deserves to be told. To be heard. Storytelling is not a contest to see whose narrative is the scariest or saddest or most horrifying. Rather, it’s the pathway to truth as each of us experiences it. 

"You can't make this stuff up."

~Lee Gutkind~

jan