7. Thinking Clearly

At 46, M. has a problem list that one would expect at 86: heart failure, liver failure, diabetes, morbid obesity. So she takes seriously the living will that every hospital admit is encouraged to discuss. "If there is a problem with the surgery," she says, referring to a relatively simple excision of an ovarian cyst, "and I don't wake up, then just turn everything off. I don't want to be on all those machines if I'd wake up and not be able to think clearly. But if I'll still be able to think clearly then do everything you can." I like M. Dr. House wouldn't, but I do.

p.s., she did wake up, the cyst was benign, and her thinking is quite clear.

6. ER

24 year old, mother of two and now 16 weeks with a third. Bipolar. Her doctor told her to stop taking her antidepressants (the kind of doctor who would tell her she'd go to hell for drinking a glass of wine during pregnancy). She complied (most of us like to think of ourselves as not needing to take any medications). Depressed moms don't make good moms. Now suicidal and infanticidal, she was seen hitting herself on her abdomen as hard as she could. Tackled by police as she tried to leave the ER. I was consulted regarding the need to hospitalize her against her will to monitor for possible placental abruption. No bleeding, no cramping, normal ultrasound; I said no.

5: HSV or HPV

Remember the 54 yr old matron who was concerned about the appearance of a genital wart and her concern that it was an STD? Well, I biopsied it, and it turns out it was not HPV but HSV: herpes! I've yet to reach her but can offer her some immunity testing that will tell us whether this is a newly acquired herpes or a reactivation. Will she accept or leave well enough alone?

4. The Clock Is Ticking

A's mother died a few months ago after a brief, unexpected illness. Current boyfriend "is the best yet," but they have been arguing lately. So no surprise that her cycles have been off-kilter lately. Helpful friends tell her she may be entering menopause which is frightening because she still wants to have a child--just not now. I reassured her that at age 37, menopause is unlikely but acknowledged that the clock is ticking and she shouldn't wait too long

3. Deadlines

Really needed to leave clinic by 5pm (usually I leave at 5:40 to catch the 5:50 bus). Down to the wire: at 3:30 I'm waiting for an Implanon insertion (subdermal contraceptive), having caught up on everything else. There's a 4:00 new referral and a finally a 4:30 checkback. The 3:30 showed up at 4:00 so I asked that she be rescheduled, something I do about once every 5 years. At 4:15 she's in the waiting room crying, so I said, okay I'll see her, but she has to wait for the others. The 4:00 was late and complicated, 54 yr old with vulvar wart wondering if it is an STD. My reply evasive. I started with the 4:30 at 4:55. She had lots of questions; finally finishing around 5:30. So I finally meet Ms Implanon. She looked like she just came out of a Vermeer painting. How could I have been so mean to her? We talked and decided to go for an IUD instead, which was done by 6:20; one last but important phone call; made the 6:40 bus.

2. Miscarriage

An email from a patient who recently experienced a miscarriage:

"But for now to get over what a failure I am I will have to bury myself in my school work and work as at least these are two things that I am not a failure and do have some type of control over."

1. The Living Fields

Heng is a community call patient, meaning either no insurance or no established relationship with a local specialist. Her employer offers insurance but she didn't understand how to sign up. She is Cambodian and though speaks good English I can understand how such issues would be difficult. But her daughter will help and in a few months she may be able to have her enlarged uterus removed, a uterus responsible for bleeding that has left her with just half the blood volume she's supposed to have, prompting the ER visit an my interview.

 The same daughter who was born in a Cambodian field as Heng and her father fled Vietnamese bombs. As she told the story I could see her reliving the fear of that day. "Run faster," her father pleaded, neither of them understanding that she was in labor. Finally she had to stop, and attended by her father with only a pocket knife, gave birth.