Friday, July 10, 2009


Forgiveness is good for your health. Really. They've done studies on it. People who are 'forgivers' have lower blood pressure and pulse, fewer physiologic stress responses, and more positive emotions. They also sleep better, are more energetic, have fewer physical symptoms and use fewer medications.

Sounds like a no brainer. Let's all be forgivers. Too bad it isn't as easy as it sounds, eh?

What is forgiveness anyway? What does it mean to forgive someone? Say somebody hurts you in some way. They say, "I'm sorry." You say, "That's okay." Have you forgiven them? What if it really isn't "okay?" What if it will never be "okay" what they did? What are you going to do?

"I forgive you" sounds like it's more about what I do to you than what is going on in my own mind. It even has a slightly haughty, patronizing tone to it, as if I'm anointing you or something. But forgiveness isn't something you do TO someone. In reality, forgiveness has little to do with the other person.

If you forgive someone, that doesn't mean you condone what they did. It doesn't mean you excuse it, or even that you think it was "okay." It doesn't mean you will forget what happened, or even necessarily that you reconcile with them. Forgiveness happens in your own mind, and is a process of letting go of the anger and resentment you have. How do you do that? You make a decision that you will not allow those thoughts to dominate your well being or mess with your peace of mind. We control our own thoughts, after all. You can decide what you will or won't think about or dwell on. Our thoughts create our experience to a huge degree.

Thoughts can open the back door for unwelcome feelings to come in. If you hurt me, I can decide to stew about it. "How dare she? I can't believe what she did! That really hurt me. Ow! She's such a *&^%!" etc etc. If I start thinking like that, anger and resentment will soon be invading and before I know it I'm hogtied in my own kitchen. Who wants that? Not I.

You cannot count on someone who hurt you to apologize, to try to make amends, or even to recognize that they hurt you. If you hold your breath for any of that, well, you'll suffocate, that's what.

Let it go.

Trisomy 18

(I'm bringing this old post back up top because it is one that keeps getting comments as people who struggle with Trisomy 18 search for answers and community)
Warning: In spite of the scientific title, there won't be much science here. However, this is a sad story with gross details, so don't read it if you're squeamish.

Tarik and Caroline were having their second child. Their first was a healthy toddling boy, a lovely combination of their two cultures. Tarik and Caroline were both young, both healthy, responsible professionals on their way up. Naturally, therefore, they got in to the clinic early in the pregnancy. I was the lucky Family Practice resident that "picked them up". I'd get to see Caroline for her prenatal visits, checking her blood pressure, urine, weight and measurements to make sure all was progressing normally. I'd be the one to find the first heartbeat for her, to feel the baby's growth at each visit, to marvel with her as baby rolled and kicked inside her, to advise her about diet and exercise. Routine stuff. We'd meet every month at first, then with increasing frequency near the end. At her 36th week (out of 40 full term pregnancy weeks) I'd turn my pager on 24/7 for her, so that I'd be able to deliver the baby whenever she went into labor.

I loved OB. The miracle of a human baby growing inside another human never failed to fill me with awe. We think we're such hot stuff, such modern, technological super-beings. Our lives are filled with devices, with increasing automation and mechanical sophistication. But when it comes to bearing children, we're animals all the way. What is more bestial, more natural, than growing your young inside you, pushing them out with blood and tears, and nursing them at your teat? We in medicine do our best to technologize this experience with beeping gadgets, powerful medicines and invasive procedures. But at the core, nature is in control, a fact that charges the labor and delivery wards with excitement and fear. Birth can be a miraculous, happy event, and usually is. But it can also be a terrible tragedy, anticipation turning to anguish at the last minute.

Round about Caroline's 15th week, her uterus began to measure bigger than it should. We weren't alarmed at first. Could be mis-measurement. Could be a big kid. Could be twins...twins? There were twins in the family background. Hmmm. Since the large size persisted, we decided to get an ultrasound. Nowadays just about every pregnant woman gets an ultrasound routinely, but back then (a long 17 years ago) we had to have a reason.

By the time she got the scan, she was at 17 weeks. By then, the embryo has become an infant, fully formed but small, with weeks of differentiation behind it and weeks of growth ahead. The scans are highly sensitive, able to discern organs clearly.

There was something wrong with Caroline's infant. The heart didn't look right. There weren't four distinct, regular chambers. Further testing was advised. I met with Caroline and Tarik, gave them what scanty information I had, tried to reassure them or at least postpone panic, and suggested an amniocentesis. We didn't know what the problem was, exactly, or how bad it was. Some congenital heart defects are fixable by the surgeons. Some are not. Some are associated with chromosomal abnormalities, which is why the amnio was recommended. More frightened about the infant's condition than about having an 8" needle stuck in her belly, Caroline agreed.

If you watch crime shows on TV, you probably think that DNA results are available just as soon as the patient gets up off the table. Not so. Caroline and Tarik had to wait two agonizing weeks to discover what they were dreading to know.

The baby had Trisomy 18. An extra chromosome. Three of the #18 chromosome instead of two. Well, so what? Sounds pretty benign. After all, we have what, 46 all together? What's one extra chromosome among friends? Well, it turns out that one little #18 chromosome has more power than all the others put together. It is a tiny tornado, packing a destructive force stronger than life itself.

Half of all babies born with this condition die in the first week of life. 90% of them have heart defects. Most of them have other defects as well, including spina bifida, cleft palate, deafness, joint contractures, and mental retardation. Only an unlucky few survive beyond a matter of weeks, and those don't last much longer. The term that is branded in my brain from our meeting with the genetic counselors is "incompatible with life". Caroline was carrying a child that was incompatible with life. As soon as it hit the outside air, it would begin to die. She. "It" was a she. They could tell that from the genetic analysis too, of course.
She was doomed.

After listening, reading, thinking, talking and crying together, Caroline and Tarik told me they decided to terminate the pregnancy. They couldn't face the thought of birthing a baby girl only to watch her die in agony. This was the right decision. I had no doubt, and nor did they. I offered to accompany them to the procedure, and they gratefully accepted.

They went to one of the local abortion clinics for this procedure. The doc there was very experienced in terminations at all stages of pregnancy, though of course most were done much earlier. By chance and good luck, there were no protesters outside the clinic that day. I was prepared to give them a piece of my mind if there were any. Caroline was not the typical abortion patient, and did not deserve to be hassled.

Without much delay, we were shown into the procedure room. Tarik was told to wait in the waiting room, per clinic protocol, making us all glad I had come along. The staff was kind and efficient, helping Caroline gently onto the table, talking in soft voices, explaining and reassuring. Caroline tolerated the procedure very well, holding my hand tightly and breathing deeply as the obstetrician dilated her cervix and removed the infant. Caroline didn't cry, not then.

A termination at 21 weeks is very different from one at 7 or 8 weeks, the usual time an "elective abortion" is done. The early abortions are done with suction, and the "products" just look like so much bloody mush. At 21 weeks, there are organs. There are limbs. There are bones. And the procedure is done not by suction, but by "extraction." Fortunately, Caroline and Tarik were forbidden to look at what was left of their defective baby girl. But I, as a medical provider, was invited into the side room to further my medical education. I had to steel myself, calm my heart, open my scientist mind.

Her little blue hand, curled and lifeless on the surgical towel, is forever wrapped around a tender neuron in my brain. As I looked at the pieces of this ruined life, what I felt was not revulsion or nausea, but a deep sorrow. I knew this was the right choice, the right decision for these parents and for the mutant child, for that's what she was. It was the humane, loving choice for all involved. But that didn't make it easy.

Aching in the depths of my heart, I returned to Caroline. She was resting in recovery now, out of the stirrups, and Tarik was with her. I tried my best to push my own feelings down deep, to put on my doctor face and stay calm. But when Caroline opened her arms for a hug, my humanity came crashing in, and my tears fell with hers.

Friday, July 03, 2009

Narcotic Narcissism

What was I just saying about lessons you have to learn over and over?

I'm smacking my head - but gently - this week as I relearn the narcotic lesson. Patients addicted to narcotics will do just about anything to get their drug. It is a powerful poison. Normally nice people will get nasty. Shy people will haul out their inner drama queen and wax poetic. Scrupulous people will lie, cheat and steal. They don't mean any harm by it, honest they don't. They're just trying to get their needs met. And once they get their drugs, they're the picture of contrition.

If it sounds like I'm painting a large group of people with one wide brush stroke, well, I guess it's because I am, in a way. I'd be the first to declare that each of us is an individual, but, that said, I have to assert that narcotic addicts have a lot in common with each other.

Is someone who uses narcotics for legitimate pain an addict? Of course they are. Anyone who takes a narcotic in high enough doses for a long enough time becomes addicted. Physically dependent. Their body needs the drug in order to feel good, and if they don't get it, withdrawal is extremely uncomfortable. Miserable, to the point that they'll do all those things I mentioned above. They'll make raving lunatics or groveling fools out of themselves rather than go without.

As a physician, I struggle with the dueling forces inherent in taking care of a narcotic addict. I don't want anyone to have unnecessary pain. I also don't want to be manipulated. I truly believe the addict has no ill intention toward me when he/she lies or cheats to get drugs that are needed to treat the pain. At the same time, I can't help but feel angry, at the addict for deceiving me, and at myself, for being too gullible, for believing the tales and the tears once again. I also feel an irrational anger at the medical system, at the pharmaceutical companies, at the chemists who don't develop alternative medicines that are as effective and yet less harmful.

My experience with pain patients tells me that not all of us are born addicts. However, some of us are. There's a definite difference in brain chemistry between people that makes some of us far more likely to end up addicted than others. Some of my patients with acute pain, like that from a broken bone, will only take a couple narcotic pills and flush the rest. Others will still be trying for refills long after the bone is healed.

It doesn't seem fair. My lesson patient this week was injured in service to his country. His wounds are as real as his pain, and both are with him for life. Narcotics are the only meds that help. But because we have so few alternatives, he'll be a slave to their destructive seduction the rest of his days.

The Authors of "50 Ways" Interview on KCHF TV

50 Ways to Leave Your 40s TV interview with Phoenix' Pat McMahon