Challenges

In my last blog, I accepted a challenge. At the time, I was overweight, out of shape and had just tried to ride my bike and keep up with Pro cyclist Ted King. I got dropped in the first 10 minutes of the ride. It wasn't pretty.

At that point I had a decision to make. Was I going to continue my current lifestyle, or was I going to accept the challenge and get in shape? I chose to get in shape. Carpe Diem. Seize the day.

That was in April 2012. By July of 2012 I had competed in my first triathlon of the year. By August, my second and by September my third triathlon was done. Finally, in October of 2012 I rode in a charity ride, the 60 mile Krempels King of the Road Challenge. That ride is organized by Ted King to raise money for rehabilitation of people with head injury.

By that point, I had dropped 22 pounds, my blood pressure had reached the normal range from being borderline high, and my symptoms of daily reflux that I was having were completely gone. I had felt so good about my training that for the first time in my life I applied for a cycling license and began racing cyclocross.

But more importantly for me, at the Krempels ride, I was able to ride with Ted King the whole 60 miles and actually found it fairly easy. During that ride, I told Ted about how getting dropped had motivated me to change my life for the better. He told a similar story about how he got dropped from an Exeter Cycles Wednesday night ride when he was younger. He also got motivated from this experience. "Sometimes it takes getting dropped to give you motivation" he said. How true.

We all get dropped in one way or another during our life. In fact we probably get dropped more times than we like to admit. What is really important though is how we chose to react to getting dropped. And we always have the same two choices. Are we going to Carpe Diem? Or, are we going to lie on the couch and forget about it. Motivation or not?

Lately, I have been trying to recognize those decision points in my life where I have choices. It seems that the best choice is always to seize the day. Life doesn't last forever. Why choose complacency?

My Dad was my junior high principal. On the wall of my junior high hallway, he placed a big wooden sign that everyone saw on their way to class. It said "Success usually comes to those who are too busy to be looking for it --Henry David Thoreau.”

Dad and Henry were right, and so was Ted. You will get dropped, and you will have a choice. Carpe Diem.

Carpe Diem

I just fulfilled a lifelong (or nearly so) dream.

Since I was a young teen I have loved cycling. I remember reading everything I could about it in the high school library in rural Ohio in the early eighties. Everything, being maybe two magazine articles. I remember reading about drafting and specifically, about how the pros call it “wheelsucking.” For the non-cyclist, that’s when you ride close to the rider in front of you, allowing them to break the wind for you. The whole idea of riding at high speed with lots of other fit cyclists intrigued me and I could imagine wheelsucking as I raced over cobbled roads, sweaty and in fantastic shape. Unfortunately in rural Ohio in the early eighties, no one else had apparently read those 2 magazine articles, so I rode my bike every day by myself. All-the-while, imagining the glory of pro cycling.

Since that time I have continued to ride my bike with some regularity. I even remember buying a bike one time to the dismay of a steady girlfriend who assumed that my big purchase was going to be a ring. But I digress. I have participated in triathlons since my senior year in high school for the sole reason of being able to race my bike. But, as happens to many cyclists, I fell on a railroad track while training last summer and fractured my collar bone, which required surgery and a plate. Admittedly, since that time, I have let myself go a bit, have gained some weight and generally gotten out of shape. Only recently have I gotten back on the bike, and going across railroad tracks has been a bit scary for me.

Well, this morning I was perusing Twitter and to my surprise, local pro racer Ted King posted that he was starting his training ride at a local bike shop at 9am. That was in 30 minutes. He just finished the Paris-Roubaix race last week with Liquigas Cannondale and is currently training for the Tour of California.

Wait, did I read that right? An open invitation to fulfill my dreams? I could potentially wheelsuck off of the back wheel of a real pro cyclist! Who really rides the big races! He even rides cobblestones!

But wait. I am sorely out of shape and there is no possible way I could keep up.

So I decided to think about it as I got my bike ready. The last time I rode I got a flat and haven’t changed it yet.

So, as I changed my flat tire, I began to think about whether I should give it a go or not. Surely, if Tom Brady was at the local park tossing passes and invited me to catch a few, I would go. Sure I’d drop a few, but who cares. It’s not like he would expect me to catch them all. Or if Michael Phelps was swimming at the rec pool, and wanted me to swim a few laps, I’d join him. Or even if I was out with my daughter and ran into Bruce Jenner and his daughter I’d.... ok forget that example.

But, you get the point. Carpe diem. Seize the day.

I have spent much of my life using that motto. It has allowed me to have some amazing experiences, simply because I have not let opportunities pass me by.

So, tire changed and cycling clothing on (which by the way, fits way too tight for my recent weight gain), I head off for the excruciating 1 block ride to meet up at the bike shop.

And, there he is. Ted King. Or @iamtedking if you twitter. Decked out in full Liquigas kit. (Phil Liggett pronounces it Leaky-gas. Love that.) His bike has crazy spokes, lots of Red parts, and a whole lot of sponsor stuff. As I pull up beside him, I see him check out my bike. Its about 10 years old, decent condition, kind of light but nothing special. I like it, as it has been my training bike forever and even survived when my collar bone didn’t. But, clearly, I have worn Keds to the Olympic 100 meter dash.

Focus I tell myself. You are about to fulfill a dream. Just then, his brother shows up. Yes, another pro cyclist! Oh boy, this is going to be fast. And I’m not talking about the ride. No, I’m talking about how fast I am going to be dropped.

Focus. Carpe Diem.

So a few awkward hey’s and hi’s later, I am told by someone with skinny, shaven legs that my back tire is flat. Again. WE HAVEN’T EVEN STARTED TO RIDE!!! UGH!!!!!

Ok, Chris. You now have to change a tire in front of pro cyclists who can do it faster than you but don’t have to, because they can just wave for the team car. But, no pressure. So, I am not making this up, I somehow pulled off the fastest ever tube change in my life. My NASCAR brother in law would have been proud.

Ok, now time to ride. The Keds are retreaded and ready to go.

We take off from the bike shop at a decent pace. I purposely did not bring a cycling computer because I didn’t want to get psyched out at the mind boggling speeds. Plus, I don’t know how to change mine to Kilometers and that’s probably the only way Ted communicates these days. “Hey lets go 68!” he must say. But in Italian. 

Instantly, we are in a paceline and, I don’t really know how this worked out, but I am in third. THIRD. THIRD!!!! And right in front of me was, you guessed it. Ted King. I was ACTUALLY WHEELSUCKING behind a pro cyclist. My front wheel was inches (I mean centimeters) from his back tire. I was looking straight at his gloriously trained butt, which was decorated in lots of Italian sponsors. I was too out of breath to remember exactly, but it must have said italian words like Go Fast! or Fragile!

And just as fast as I had achieved this crowning moment, reality set in. Though I was not wearing a heart rate monitor, I am fairly sure that the calculation for max heart rate was clearly underestimating what my heart was currently pounding out. And if I, shutter to think, actually touched the wheel of the cyclist in front of me, well, potential for some serious Leaky Gas drama. Tour of Cali gone. Maybe more. 

So, as fast as it started, it ended and I pulled out to let those who have actually been training continue their ride with the pro. I finished my ride through the beautiful New England springtime laughing the whole way home about this series of events.

But also, the rest of my ride was useful to put in perspective a few things. Mainly, I will continue to subscribe to carpe diem. Because without taking the initiative in life, where would we be? And also, for me it was a wake up call. I love cycling and know that in most previous years I would have been able to keep up with these guys, at least for a while. So, its a motivator.

It challenges me to get back in shape, get on my bike, and put in some miles. As it turns out, Ted King will be back in town on Oct 20 for the Krempels King of the Road Challenge (http://www.kingchallenge.org) and I’ll be ready. And though clearly I am not Ted King, I’ll ride with him again. You can bet your leaky gas that I’ll stay with him longer too.

An inspiration.

Sometimes in life we have the opportunity to meet someone special. I met someone special this past weekend. Actually, I had met her about 5 months ago, but this time, it became quite clear how special she is. 

I’d like to introduce you to her. Meet Sadie Desjardins.

Sadie and her favorite pig

Sadie lives in northern Maine, in a town called Ft. Kent. And I mean northern. You can literally see Canada from her house (no you can’t see Russia from there!) Sadie is 13. She lives a pretty normal life of a young teenager. She goes to the local movie theater (1 screen) and enjoys sports and hanging out with friends and family.

But what is really special about Sadie is what she is doing with her summer. You see, one of her hobbies is sewing. She uses her grandma’s sewing machine. Earlier this summer, she decided to design her own stuffed animals. She designed them completely on her own, without a pattern. There was a pig, an elephant, a bear and a cat. Each animal is different. Some have tutu’s some have different colored eyes, and pigs have different colored buttons as noses.

As soon as she made these, her mom realized how amazing they were and asked her if she wanted to make them for other people. In a split second, Sadie knew what she wanted to do.

She decided to make 50 stuffed animals as a summer project and then personally take them to Boston Children’s Hospital (an 8 hour drive!) and give them to the children there.

That’s a big project! Fortunately, the word got out around her town and one of the locals donated stuffing and material. Even so, her grandmother tells me that she often hears the sewing machine running late into the night and in the early morning hours. Undaunted by the magnitude of the task, she had 30 completed as of last weekend. Then she gave one away to a child she met who had lost her mother to brain cancer.

What is really amazing to me is the spirit that she embodies. She is working her entire summer on a project for other kids that she doesn’t know, just so she can bring a little bit of happiness to their lives. She is such an inspiration to me and I hope, to you too. If we could all have that same spirit of giving, the spirit of caring for others, the empathy for others going through a tough situation, this world would be a much better place,

So, Sadie, thanks for being that inspiration and for sharing your talent and your thoughtfulness.

The Golden Rule

Treat others as you would like others to treat you.

That is a very simple rule. I know I remember learning it from my grandmother. I couldn’t have been very old, probably preschool age. And it was probably in response to fighting with my brother. I’m sure most have you have learned this early in your life too.

I was reminded of the Golden Rule recently when I was talking to my son about how he should be treating his friends at school. As I was giving him examples of how the Golden Rule plays out in everyday life, I was surprised at the number of examples I could give. Unknowingly, I realized that I commonly do things in my daily life based on it.

I hold the door for people. I try to stop for pedestrians trying to cross the street outside the crosswalk. I say hello with a smile to people I see in the hallway. The list could go on. But, I generally try to do these things because I know I would like it if someone did them for me.

The next example I gave my son, was that I treat patients like I would want to be treated. This one, I am conscious about. I will commonly try to put myself in a patient’s position before I go into the room. Doing this helps me to relate better to their particular issue. After interviewing a patient, I may also learn new things that completely change my understanding of their problem. I will then alter a bit the way that I interact based on how I would want my doctor to respond.

For instance*, I was once sent a patient for evaluation of gallbladder disease. The emergency physician had noted a rise in liver enzymes, and a gallbladder that had thickened bile, or sludge as it is called. The patient also had frequent bouts of vomiting. The scenario seemed to make sense on the paperwork that I was sent. So, I went into the room expecting to book the patient for surgery. But the tip off to me was that the patient smelled of alcohol. So, I researched old labs and found that his liver enzymes have been elevated for years. A little more research showed another recent ultrasound that was perfectly normal. So, I began to delve into the alcohol questions.

As it turns out, he only has episodes of vomiting after binge drinking. And he never really has pain in his abdomen, except after vomiting a lot. It was clear now that this wasn’t gallbladder disease.

But, probably more important than the medical facts of this patient are the social ones. He was actually glad that I asked him about his drinking, and what he was doing about it. He was happy for me to encourage calling his sponsor and getting back to an AA meeting. He really knew all along that it wasn’t his gallbladder. He told me that by the end of the conversation. He just wanted me to listen and support him.

That’s how I would want to be treated.

Leave it to George Bernard Shaw to have a problem with the Golden Rule. He famously contorted his own version of the Golden Rule, which honestly, I don’t understand. Suffice it to say that his argument was that not everyone wants to be treated the way that you would want to be treated. I can accept that. Sometimes, the way I would want to be treated isn’t exactly what my patient wants. And in that way, it is good to realize that Shaw wasn’t all wrong in pointing out that subtlety. 

I think the real key is to understand this and try your best to meet the patient’s needs. After all, we all want our needs met. 

Whether we are in the school yard or the doctor’s office, treating others as we would want to be treated really is a Golden Rule.


*As always, the details are changed so as not to indicate a specific patient.

What to ask your surgeon. A List.

Visiting your surgeon to discuss an upcoming operation can be quite stressful. Because of this, if you don't go prepared, you may forget to ask important questions. Also if you don't go with a piece of paper and pen, you might also forget the answers to important questions.

I was recently asked to come up with a list of questions that patients should keep with them when they make this important visit to their surgeon. In her blog about the importance of making lists for nearly everything in your daily life, The List Producer is managing to help simplify our lives by keeping us organized. Below is the list that I developed along with some extra information on each question. I hope you find this useful in your next trip to your surgeon.

1. What is my diagnosis?

            Surprisingly, this very simple question is not asked very often. In order to truly understand your operation you absolutely need to know your diagnosis. This will help you to explain your problem to your family, friends and any other physicians that you might have.

2. What is the operation you are recommending?

            Again, it is important to know the specific name of the operation. This will be on your consent form as well. Most hospitals will also ask you this question at least once during your interview process on the day of surgery to be sure that you are familiar with what is being planned.

3. How many of these operations have you done?

            If your surgeon has not done a large number of the operation that he or she is planning, it is important to specifically ask if he or she is comfortable with performing the operation. It is also not inappropriate to ask if the operation could be done better by someone more experienced in this particular operation.

4. How long is the in-hospital recovery?

            This is often difficult to predict, especially with bigger operations. Usually the answer will be a range of days to expect inpatient hospitalization. You're operation may also be outpatient which may be same-day surgery or an overnight stay that does not exceed 24 hours. Again, it is important to set your expectations for which of these options will be occurring.

5. How long is the out of hospital recovery?

            Recovery means different things to different people. For some people it means how long until you are pain-free. For others it is how long until you can get back to normal activity. Be specific with your questions and ask these specific things when talking about recovery period

6. Will I need a transitional period with rehab or home nursing?

            For bigger operations this is often necessary. Also for the elderly or for people who start the operation in a debilitated state, a rehabilitation hospital or skilled nursing facility may be an appropriate transitional facility.

7. How long do you expect me to need prescription pain medication?

            Commonly, surgeons will prescribe narcotic pain medication for a limited period after which you may be required to see your primary care physician for further narcotic prescriptions. It is also common to try to transition from narcotic pain medication to anti-inflammatory medication or acetaminophen as quickly as possible after the operation. This will minimize the side effects of narcotic use.

8. How long should I take off of work?

            Again, this can be difficult to predict and is largely dependent on your pain tolerance and your specific job. It is always better to try to anticipate this before the operation and your employer will thank you for an appropriate heads up rather than being surprised when you ask for 2 weeks of sick leave following your operation.

9. What are the risks?

            This is an absolute must-ask question. Most consent forms will indicate that your surgeon has discussed the risks of the surgery with you. Be sure that this has happened. It is often scary to learn the worst case scenario, but it is always best to be well-informed.

10. Are there alternatives to this operation?

            There are often alternatives to an operation. These can be medical alternatives, such as treatment with a specific medication, or there can be alternative operations to treat the same disease. Presumably, your surgeon is recommending a specific operation for a reason instead of the alternative therapies. Find out what they are and what their advantages or disadvantages are.

11. Is it worthwhile to seek a second opinion?

Any good surgeon will never discourage this. For simple operations or straightforward decision-making this may not be necessary. But for complicated issues, or if you just don’t feel comfortable with what you are hearing, a second opinion may be right for you. You can always come back and schedule surgery with your original surgeon after your second opinion.

12. Who will oversee my care while I’m in the hospital?

            Will the surgeon see you, you will you be seen by the Nurse Practitioner or Physician Assistant? Or, will there be residents and interns seeing you? All of these are reasonable options, but it’s nice to know up front what to expect in the hospital.

13. Will there be residents operating on me?

This is fine, but it is good to know beforehand rather than be surprised at the group of 20-somethings at your bedside.

14. What do I need to look for after the operation in terms of infection and wound healing and will I need sutures or staples removed?

            This may be covered at the time of your discharge, but ask just in case. If there will be a wound to take care of, it is good to buy supplies now. You won’t feel like shopping after the operation.

I hope this list helps with preparing for the stress of an upcoming operation. As Louis Pasteur once said, “chance favors the prepared mind.”

List Producer blogs at http://www.listproducer.com/ and is on Twitter @ListProducer

Overcoming impossible situations

Surgery, like life, can have complex problems. Not too long ago I was operating on a patient who we all believed had a ruptured colon cancer. He was quite sick and I was operating on him emergently*. As I explored the abdomen, it began to have the appearance of something different. I honestly had no idea what we were dealing with. 

It was clear that whatever this was, it was involving the colon, the spleen, the stomach and the tail of the pancreas. The entire left upper quadrant of the abdomen was completely cased in hard inflammatory crud. I have no better medical term for it. Every organ was plastered to the adjacent organ.

At this point in the operation, I remembered the words of a sage mentor of mine, Dr. Jeffrey Pelton. “Chris,” he said. “You will, at a few points in your surgical career get into a situation, which at the outset, will seem insurmountable. You will open the abdomen and find a tumor or other problem, which at first, will look like it is completely inoperable. My advise to you is this. Don’t look at the problem like it is one big problem. Take it one step at a time. Use the surgical principle of going from ‘known to unknown’ and start somewhere easy. Go and take down that easy part of the tumor. If you get to a place where you are stuck, go to another part and go until you get stuck. Eventually, this big problem will turn into a series of little problems, which, by the end, you will have solved. It’s like a jigsaw puzzle. Take it a piece at a time and eventually, you will have it solved.”

That is precisely what I did. Start at the colon. Move to the spleen, then the stomach. Finally, tackle the pancreas. Three hours later, it was all cleaned out. All the pieces that needed to be put back together were together. And the tumor, a nasty lymphoma as it turned out, was out. The big problem was taken care of one step at a time. The operation was a success, and the patient has seen me in followup, tumor-free.

As it turns out, Dr. Pelton was right. I have used his advise on many occasions. I have even taught residents the same thing. Take the big problems one step at a time and you will overcome situations that seem impossible.

*as always, details of this patient are changed so as not to indicate any specific patient

The Back Story

In the movie Love and Other Drugs, Jake Gyllenhaal plays a drug rep for Viagra. At one point, he is forced to go to the emergency room after having taken Viagra, because of a rare side effect called priapism, or persistent painful erection. No doubt, this was one of the funnier parts of the movie.

As a physician, the way I would approach this patient would be much different than the way I acted as I watched this movie from my couch. Sure, its tempting to act the same way, laughing about the awkward situation. But, the reality of being a physician is that patients rely on you to be above that. If I was in that position as a patient, I would want a doctor who could see that I was in trouble and treat me like any other patient with an urgent problem.

What helps me to get into that mindset is to figure out what the patient’s story is. I call it the back story. Sure, it may be as simple as the movie’s recreational Viagra use. But maybe not. 

An 80-year-old man presented to the emergency room with priapism. The back story of this man is that he underwent radical prostatectomy for prostate cancer 15 years ago, leaving him with erectile dysfunction. Years went by with only frustrating sexual experiences. Finally, after much discussion with his urologist, he decided to try Levitra. The result, an embarrassing emergency room visit. This is hardly a laughing matter. He is not Jake Gyllenhaal’s character. He is a real human, with a frustrating disease, now suffering an embarrassing complication of his treatment.

Much of being a physician is understanding not just the disease process of the patient but also the setting in which this disease occurs. For example, two patients recently presented with similar abdominal pains. One of the patients had a sister that had recently died of colon cancer. My approach to the work-up of these two patients was similar, but the way that I talked to them was much different. I had to be cognizant of the emotional distress in the patient whose sister had just died. In that patient’s mind, this abdominal pain was surely cancer. And there was nothing that I could say or do to convince her otherwise until I proved that it wasn’t.

Everyone's back story is different. 

As a physician, learning and understanding that back story is part of your job. It helps you to empathize and it helps you to treat the person, not just the disease. As a human, having an appreciation for the back story is imperative for acceptance.

Many times, I have discussed with my children the importance of acceptance because we simply don't know someone's history. For example, my daughter once told me that a girl in her class was weird because when she got frustrated she would hit people or nearby objects. I cautioned her not to label people as weird for the same reason that I cannot laugh at a patient with priapism. You have no idea what someone has been through or what has gotten them to this point. In the case of my daughter’s classmate, I knew that this girl lived in a household where her parents’ frustration would often lead to hitting and physical abuse. The child's behavior made sense. It is what she learned as the “normal” response to frustration. Seeing her back story suddenly made what seemed like weird outbursts understandable. 

This type of open-mindedness is critical to understanding people. Acceptance of people will not occur without it. The same is true with patients. If you approach the patient with the underlying knowledge that there is a back story which explains much of who they are, empathy and good judgment will follow.

Understanding the back story makes people real. Understanding the back story makes you a good physician, not just a person laughing at a movie character. And, with that knowledge, empathy and professionalism will go hand in hand.