Hold the Phones for the Well-Grounded

It’s been a while since I’ve posted. I’ve been busy. And I’ve been thinking so much about so many different things that I haven’t really been able (or, more aptly, willing) to sit down and pick one thought and write.

As I mentioned, I’ve been busy. And while in the car between one busy and the next, I listen to the news. So I go from busy to stressed-about-the-state-of-the-world to busy to stressed-about-the-state-of-the-world to busy…….

And tonight, just for an hour or so, I have some down time. So I was going to relax. The boys are at a jazz rehearsal, my husband is running a couple errands on his way home from work, and all I want to do is watch a couple of sit-com reruns and relax in front of bad acting and a laugh track.

But I can’t figure out how to turn on the f@$king TV. We have about 5 remotes, each with about a thousand buttons, and no combination is just turning on the tube. I don’t want the Blu Ray player. I don’t need it to go through our 30-some-year-old-speaker-system-set-up-by-my-engineer-husband-to-be-surround-sound. I don’t want the PlayStation to turn on. I just want to watch some f@%king TV. And I can’t. I can manage the health of patients with two dozen concurrent medical issues but I can’t figure out how to turn on the damn television.

So I’m writing.

Just one week ago tonight, we took away the cellphones of our two youngest sons for three days. They really pissed us off, so we imposed consequences. They blatantly defied what we had told them to do.

Our kids pretty much never defy us. They’re ridiculously reasonable people with common sense and good heads on their shoulders. So we expected that when we specifically said “come straight home after rehearsal,” that they would do so.

But they didn’t.

Their rehearsal for this particular jazz ensemble occurs about twice a month and is about an hour away. In Ann Arbor. About a mile from our oldest son’s dorm.

And that’s why our younger two defied us. They went to see and hang out and study/do homework for 45 minutes in the student union with our oldest.

They had done so after their few previous other rehearsals out there. And when they had left the house last week as I was telling them to come straight home, they laughed and said “sure, by way of the Union,” and I laughed and said “no, by way of straight home.”

It was a school night. It was late. It was reasonable to ask them to head directly back. They didn’t listen. And my husband and I were angry that they hadn’t done what we told them to do. When we called our youngest’s cellphone to check on their whereabouts around the time we thought they’d be getting home, he told us they were sitting and doing homework with our oldest. We told them to head to the car and drive carefully home.

They did.

And when they walked in the door, we told them to hand over their cellphones.

They did.

And they didn’t utter a word of protest.

My husband and I expressed our displeasure with their choice. We lectured about all the reasons they should not have done what they did.

They didn’t argue.

The next day, our middle son came home from school during lunchtime. I said, “We need to talk.” And he said, “Yep.” And we sat down.

I started. “You know, we let you do an awful lot. We don’t put a lot of restrictions on you. That’s because we trust you. You’ve earned that trust. You’re a good person. You make good decisions. And last night you were not where we expected you to be. It was late, and you had woken up early in the morning and had been up late the night before.”

“I know, Mom,” he replied. “But here’s the thing. We were completely safe the entire time. We went straight from rehearsal to be with an adult member of our family. And we sat and did homework with him. I wasn’t tired – you know that on every car trip we’ve ever taken, when I’ve been tired I haven’t driven – I’ve stopped and asked someone else to take over. I would never drive tired. I know it’s as dangerous as driving drunk, which I also would never do. I knew that I felt awake. I would not have put myself or my little brother in danger by driving tired.”

“That may all very well be true,” I said, “but you defied me. And I thought you were almost home when you were actually 50 miles away.”

“I know, “ he responded, “and I’m sorry about that. And you were perfectly justified in taking my phone. It was worth losing my phone. I was a mile from my brother, and I wasn’t not going to see him.”

There was something in his voice as he said this last sentence. And there was something in his eyes, and in his jaw. I looked at him. “You really miss him,” I said softly. “Yes. Of course I do,” he said.

And there it was. That was the drive – not to rebel against authority, not to eat fast food in the Union’s food court, but to be with an older brother who used to be there every day but now isn’t, who even though we see him regularly doesn’t really live with us anymore.

“I get it,” I told my middle son.

I had a very similar conversation with our youngest when he came home from school.

The motivation was clear. The depth of the urge was significant. The risk was calculated. Their decision was really not surprising when you think about it for even a second.

We still held onto their phones for a couple days. We had a point to make. But tonight we didn’t tell the boys to come straight home. They have their backpacks with them. They will hang out with their brother. They will be their triplet whole and they will laugh with one another as they do homework and insult one another as they hug goodbye.

And somewhat strangely, I’m happy we’ve raised sons who don’t listen to us every single time. They’ve listened to and absorbed the value of family, they love one another, and they’re willing to give up their electronic social lifelines for a face-to-face connection with their brother.

And I’m happy I couldn’t figure out how to turn on the television. It feels good to write.

Baby, It’s Hot Outside. And Inside.

So on Friday evening I was sitting at the computer, minding my own business, when out of nowhere I was hit with a peculiar feeling.

“It’s ridiculously hot in here,” I said to my husband. “Did the A/C just stop working? What is going on?”

“It’s really not hot in here,” he replied. “No, it’s not, Mom,” my 14-year-old son agreed.

They were both obviously wrong. It felt like Death Valley. I was certain the air conditioner had gone haywire and had begun spewing out hot air. Maybe the two of them had fevers and were chilled.

I began flapping my shirt to cool myself off. It helped a little, but not much. So I flapped it harder.

My husband reached out and touched my leg. “You feel cool,” he said. “You’re fine.”

I told him to touch the back of my neck, which was at this point drenched with sweat.  “Oh my god! What’s wrong with you?” was his kind and empathetic response.

“I don’t know,” I answered, “but I feel like I need to rip all my clothes off, right now!” At which point my 14-year-old said, “That’s just too much information, Mom,” as he turned to leave the room with a look on his face of combined bewilderment, horror, and amusement.

And that’s when I realized what was happening. I turned to my husband – “Dougie, I think I’m having a hot flash.”

“Ohhhhh.” He buried himself in his smart phone for a minute. “Yup. It sounds like it.” As frequently happens when something health-related affects me or my family, my medical knowledge flew out the window. “How long will this last?” I asked him. “Hold on a sec, I’m checking with Dr. Google – it says anywhere from a couple minutes to quite a while.” He picked up a magazine and started fanning me as he took my hand and guided me toward an air conditioning vent (which, apparently, had been blowing full-blast this entire time – not that it did any good).

It was over in about 20 minutes.

And then a half-hour later, it happened again, but this time lasted only about 10 minutes.

And then I was back to normal. Fine the rest of the evening. Fine the next morning. So fine the next morning, in fact, and so full of energy, that I went out with my family to attack our weeds.

It had been a while since we had gone on the garden/lawn offensive. We were out there for hours. Filled six of those yard waste bags. Felt great. Neighborhood property values rebounded to where they should be.

And then on Sunday it hurt every time I moved. Arms hurt. Legs hurt. Shoulders hurt. Back hurt. Husband felt the same way. Kids were completely fine (and yes, they had worked the entire time with us).

So I woke up today and headed in to the clinic to see patients. I had survived the introductory temperature dysregulation of peri-menopause. I had survived the physical consequences of the war with the weeds and was feeling significantly less sore.

I arrived early, ready to start my day, and chatted a bit with one of the medical assistants in the office. She was talking about her son, three years old, and I asked to see a picture. She showed me a photo on her phone. I remarked on the child’s cuteness.

Then the medical assistant asked me if I had any children or grandchildren.

And that was the first time in my life I had been asked if I had grandchildren.

I very, very, very much want grandchildren in my future. And I am in my mid-40s – certainly old enough to be a grandmother. But I’ll let your imagination go where it may on what you think some of the thoughts running through my head might have been in response to that question.

I frequently tell my kids how I love each stage of life that I’ve reached, that life keeps getting richer and better. This is how I feel, deep down inside. I have earned every hot flash (although I’d be happy if they didn’t return), every gray hair, and every wimpy-muscle-that-rebels-after-a-few-hours-ripping-out-weeds. I’ve made peace with the fact that it has been years since I’ve been carded. I’m delighted to be in the no-drama, don’t-take-crap-from-anyone phase of life.

But I would advise people to ask me about my children. And when I do have grandchildren, I would politely ask that you react in surprise to such news and remark on how young I look to be a grandmother. And please turn up the air conditioning.

Scratching the Surface of my Response to the Latest Horror

I’ve been busy. And I had started writing a draft about time management and lines and waiting. But that will, ironically, have to wait.

Because I cannot not write about what just happened in South Carolina.

This despicable act of unfettered evil brings up the worst thoughts in me.

The thought that has not left me since the news broke about the massacre is that I would like the monster that perpetrated this horrific act to be dead.

I wanted him to have been found dead by a self-inflicted bullet wound, or to have been killed in a standoff while being apprehended. But he was not.

He was found and was quietly arrested.

I had not wanted him to be alive. I did not want a being with such disregard for human life to be walking among us. To be breathing the same air that we breathe. To have the opportunity for laughter.

I cannot bring myself to call him human. I find myself regarding him as an animal. A vicious animal.

And I do not like the existence of these thoughts in myself.

I do not like that I can so fully deny someone’s humanity. Or that the sanctity of life is not absolute in my mind.

And I do not like that I also do not have the strength, even when I believe there is pure evil, to be in favor of killing this monster now.

I do believe that there can be times to kill. Had I been there, in that church, with a loaded gun and a clear shot, I would not have had any moral compunction in pulling the trigger. But there is a difference between self-defense (or defense of others) and retribution.

I wish he were dead. But I cannot shake the thought that someone throwing the switch loses some of their own humanity in the process of doing so, and becomes closer to becoming the monster.

And I cannot shake the thought that not throwing the switch takes away some of the humanity of those who must morally answer to the families of the victims.

Once the evil is out there, it cannot be undone. It cannot be erased. There is no fitting retribution. There is no fitting rise above retribution.

Some problems have no fitting solutions.

I am sad. I am angry. I am physically nauseated.

And I am overwhelmed.

Overwhelmed with disgust that there are segments of society which provide a fertile ground for hatred and racism to grow.

And overwhelmed with the suspicion that this evil being could very well have come into existence without a fertile hate-filled growth environment – that there can exist evil by itself, with no explanations or excuses.

Overwhelmed with the failure of humanity, which I deeply believe is overwhelmingly good, to have not come further in vanquishing barbarity and corruption.

Overwhelmed with shame at some of the fundamental history of my country, and overwhelmed by a feeling of incompetence for not knowing how to heal it.

To the families and friends of the victims, my heart goes out to you fully. May you some day find peace.

And please, please, please, may the societal devaluing of life crumble upon itself so that we all can climb upon the ruins of hatred to reach the place we need to be.

Mother’s Day 2015

Today I am reminded, as I frequently am, of my exceedingly good fortune. I both have a remarkable woman as my mother and am mother to three spectacular human beings. As a bonus, I have a fantastic mother-in-law.

In honor of Mother’s Day, I will share a tiny bit of what I have learned from my own mother, from my husband’s mother, and from being a mother.

From Mom:

-Always say “please” and “thank you.”

-If your friends don’t treat you well, then find new friends.

-Wounds heal.

-Shit is water soluble.

From Mom-in-Law:

-Significantly different parenting styles and personalities can result in equally successful offspring outcomes.

-For goodness sake, it’s just a spider.

From being a mom:

-When a frisbee gets stuck on top of a high hedge, using a snow shovel to try to scoop it off tends to push it deeper into the shrub. Get a hockey stick and poke it up and out from underneath.

Wishing everyone a happy Mother’s Day. I highly suggest incorporating french toast somewhere into today’s menu.

Pet Parallels in End-of-Life Matters

(Note to my children – do not read this. Other people who are close to me – you probably want to skip it, as well.)

It has taken me almost two years to be able to write this. We said goodbye to our beloved dog in early May of 2013. I grieved for well over a year.

About a month-and-a-half prior to his death, we had a big medical scare with him. I wrote at that time about how dealing with a veterinary emergency can provide us with some insights and practice parallels to dealing with human medical crises (Pet Practice). A veterinary crisis also has definite parallels to human end-of-life issues, and can highlight ethical concerns as well.

He was an older dog – old enough that my husband and I would occasionally mention animals’ life expectancies in front of our kids. The boys were well aware of what we were doing: “Mom, Dad, we know dogs don’t live as long as people, and you’re obviously trying to prepare us, but it’s totally going to suck when it happens, whether or not you remind us of how long dogs live.”

So he was older, slowing down in general, with a seizure disorder which had developed in his later years and was generally kept in check with medications (with one episode of multiple breakthroughs a month or two earlier), but reasonably active and happy overall.

The big scare I mentioned above came on pretty suddenly. He became progressively ill over the course of a day, and I brought him to the vet, who did a thorough exam and extensive lab work. It didn’t look good – obstructive biliary disease – and we were referred to a veterinary specialist for an ultrasound, expecting that it would show cancer.

I filled the family in on the details of what was happening, and I took him in for the imaging study. The ultrasound did not show cancer, but elucidated an issue that would be rapidly fatal if not addressed with emergent surgery.

I called my husband. Our dog was old. We didn’t have spare thousands of dollars lying around. We loved our dog. Our children loved our dog.

We happen to live about an hour-and-a-half away from one of the best veterinary schools in the country. I called them and told them what was happening. They said that we could bring our dog out there, and their estimate on the surgical cost was a bit lower than our local place.

I called my husband back. We talked again. Yes, our dog was on in years, but this was fixable. He could have a couple good years left in him. We would figure out a way to cover the cost. I brought him to the boys so they could give him a hug, and then I took him out to the veterinary school’s emergency clinic.

I brought the ultrasound disk and the lab results with me. They looked at everything, concurred with the diagnosis, and agreed that surgery was a reasonable option. “The other vet did tell you that the mortality rate for this surgery is about 30 to 35%, right?” Uh, no. No, he didn’t. How could I not have asked that?

I wasn’t going to change plans now. The odds were still in his favor, even if not what I had assumed. I gave him a kiss, signed the release forms, and gave the front desk my credit card.

And it worked. The surgery, though complicated, went well. He recovered. Within a few weeks, he was prancing and bounding and chasing rabbits like he did when he was much younger. We were so happy – we knew we had made the right decision. We played joyfully with him over the next few weeks.

And then he started seizing. Not just one breakthrough, but multiple. I brought him in. The vet upped his anti-seizure medications. He lost bladder control with the seizures, so I slept in the kitchen with him for the next two nights. He had more seizures. And his post-ictal (post-seizure) agitation kept increasing. It got worse through the next evening. His vet said there was nothing more he could do, and he sent us to the emergency clinic, which had a veterinary neurologist on staff.

The vet who was on duty that night in the emergency/specialty clinic was very kind. She said that it didn’t look good, but we were not without hope. She assured me they would do what they could overnight, she would keep me posted and I could come back in the morning to speak with the neurologist when he arrived.

So I headed back there the next morning. The neurologist said he recommended an MRI, since his seizure history sounded consistent with a brain tumor. The MRI would cost two thousand dollars. And then if it did show a tumor, and if it looked operable, we would have to decide whether to pay for and put him through brain surgery to remove it. He also said he had one other thing to try with medications.

I talked to our regular vet (a very smart man who had always given us sound guidance and advice), and he said that our dog had been through so much, that the prognosis was grim, and that if it were his dog he would not do surgery or the MRI (which would require anesthesia). I talked to my husband. We decided to give the neurologist’s pharmaceutical idea a try.

It didn’t work. The updates from the veterinary hospital throughout the day were very bad. We knew what had to happen. We told the boys, and we took them with us to the hospital so we could all say goodbye. It was a sad, tear-filled car ride.

They brought our doggie into a room with us. It was awful. He was horribly agitated, and he had lost his sight. He really didn’t show much, if any, sign of recognizing us. After hugging and petting him as much as and as best we could and saying what we needed to say, I told my husband and boys to wait in the waiting room. My husband wouldn’t leave me. The boys (12, 15 and 17 at the time) said they’d be ok and went out of the room together.

And then it was time. The vet gave me euthanasia consent papers to sign. I don’t remember exactly what they said, but I think I recall acknowledging the finality of the decision. And then it was really time. The vet asked if I wanted to stay. I said yes. I told my husband he didn’t have to stay, but he would not let me stay alone.

It was so very awful. So very, very awful. Our dog was clearly suffering. His agitation was severe – it had not been alleviated by any of the medications. I will skip the full play-by-play of the final actions, but I will describe a bit of what went through my mind.

“I have to be here. I have to stay here. Good pet owners stay until the end. I don’t want my husband to have to see this. I’m the doctor. I should be stronger than this. What am I doing? Why am I doing this? Am I doing the wrong thing? What if this is fixable? How much did money play into this decision? What kind of a monster am I? How can I do this to my family? Did I make this decision to stop him from suffering or did I make it to prevent me from suffering as I watch him? How can I do this? How can I not do this? Oh God, it’s done. What have I done?”

I stayed as long as I could, with my hand on his fur and my husband’s hand holding me. Then I had to get up. I had to go to the door. I kept talking to our sweet puppy dog. The vet still had her stethoscope on him. He had stopped breathing minutes prior but probably still had a few slow heartbeats left, but I just couldn’t stay any longer. I failed him in those last few seconds. He wasn’t alone, but it was someone else’s hand on him at the very end. The vet had no choice – she had to stay.

They handed us the bill at the front desk. We gave them our credit card.

We gathered our boys, held one another, and had a silent, tearful car ride home.

We grieved. And we recovered. But it took me a long time to recover.

This was a dog. Yes, he was our dog, our pet, a “member of our family,” but he was a dog, not a person. Yes, we all tend to anthropomorphize our pets, but I was not grieving his loss as I would grieve a person. We develop strong emotional attachments to our pets, and they symbolize responsibility, loyalty, and innocence. That wasn’t all of it. It was more complicated. It was much worse than when I had grieved dogs in the past as a child and teenager (and those previous times certainly hadn’t been easy).

I’m a doctor. I keep coming back to this. A big part of why I went into medicine was to prevent death. To promote life. To promote good health. To help give quality to life. And, when not possible to do the aforementioned, then to help support patients and their families through the loss of life. I have been with patients and their families numerous times at the very end of a life. It has been at times when my colleagues and I did everything we could to save a person but were not able. It has been at times when someone has chosen not to be resuscitated or to have “extraordinary measures” taken. It has been at times when the choice was to focus only on easing any pain at the end of life. It has been when removing life support. Some of those times were peaceful, and some of those times were frantic. But never, during any of those instances, did I myself do (nor write an order for someone else to do) something with the express purpose of stopping a heart. Even when removing  someone from ventilator support, we were removing a breath-sustaining machine (and therefore a life-sustaining machine), but the person’s respiratory system had already failed on its own – we were not purposefully making a person who was spontaneously breathing stop that breathing.

Almost two years ago, I signed papers authorizing a veterinarian to kill my dog. We use the word “euthanize” (“eu” meaning “good”, “than” meaning death, translating to a word that means “to kill painlessly,” generally to relieve suffering), which sounds much better than “kill,” but it doesn’t change what is done. Our vet told us we had chosen compassionately. In all reality, it probably would have been cruel to allow an animal to continue to suffer indefinitely with no understanding of what was happening, and it is not financially feasibly to put an animal on the comfort measures that we afford people at the end of life – our choice is a much harsher one with our pets. But still, I signed the papers to stop his breathing. What if I was wrong? I did not handle well the thought that I had chosen to end his life and that I could have made the incorrect choice. When I failed him in those final seconds, it was because I had failed myself. I second-guessed my thought process. I questioned my motives. I felt unworthy of him.

Those feelings hung with me heavily. There was an intense, deep feeling of guilt. Honestly, my really wrong decision probably was to have had him go through that surgery when he was so ill that month-and-a-half prior. It would have been a peaceful death if we had opted out of that surgery. There was nothing about the way he ended up dying that was peaceful. If only we had known then what was going to happen six weeks later.

People lament how much money we spend on medical care in people’s last few months of life. Policy experts and politicians look at the numbers and say we are wasting money and resources. People lament how so many people end up dying hooked up to machines in hospitals when they would much rather have died peacefully at home. But the vast majority of time I was working in a hospital, caring for people at the end of their lives, we had not known it would be the end. Surgeons did not usually advise surgery if they thought a patient was not going to live. We did not give people ventilator support with the expectation that they would not recover. And most of our patients did survive and return home, and get to celebrate another holiday or wedding with their families, and see more sunsets, and sing more songs – how many sunsets, how many songs are worth the cost of that care? More than once, even when an outlook was grim and we expected the worst, a person surprised us and recovered well beyond what we would have expected. And sometimes a person who we had expected to do well’s last moments were on a ventilator or with people pushing on her chest during CPR. We spend those resources and efforts at the end because we don’t know it’s the end.

We don’t know everything. And it’s really hard not to know everything. Especially when you’re the person who is supposed to have the answers.

Battling Buffoonery

My career is based on communication and empowerment within the medical world. I educate on the patient/family side and the medical professional side. It takes understanding and empathy from both sides of the stethoscope to optimize communication. It takes communication between both sides to bridge perceived power differentials. It takes work on both sides to change a culture of uneven power dynamics.

I read two Facebook posts within the past few days dealing with a culture issue that needs changing. This is a matter from the “general” as opposed to medical world, but that which is present in society-at-large certainly spills into medical or any other subset of society.

The first was written by a woman in her early forties, discussing the details of recent times (while in retail establishments) she’s received unwanted amorous advances from strangers (including a time when she had her young teenage son with her, and they included her son in the harassing conversation). The second post was by a friend whose 17-year-old daughter, who works weekends at a toy store, has been receiving come-ons from customers while their children play in the store. Both women experienced definite “ick” feelings as they were being harassed.

Thankfully, the majority of public interactions are not icky. These incidents referred to above are happily the exceptions to the general rule of civilized, respectful behavior. But although they are exceptions, they are not rare exceptions, and they are threatening.

I am close to the 17-year-old young woman. I feel perfectly comfortable offering her advice. And while I would like to tell her to respond to inappropriate comments with something to the effect of, “I cannot figure out why you would think it’s ok to say that to me,” I am hesitant to advise her to engage these people at all. I’m also hesitant to tell her to walk away. The first option places the power with her, while the second seems more like it leaves at least some power with the tasteless cad.

The problem is, it’s difficult to know whether the label “tasteless cad” is sufficient and accurate. If the issue is simply a lack of manners and a poor sense of humor, then perhaps pointing out the rudeness will help prevent the person from creeping out someone else. But what if the demonstrated disrespect reflects a fundamental disregard for the personhood of those harassed, and attests to a sense of entitlement? A challenge to that entitlement could theoretically provoke more of an assertion of power. Tough for a 17-year-old to gauge when it’s even difficult for a forty-something-year-old to do.

There are protections set up in schools and in workplaces (to prevent harassment from bosses or other employees), but there are no systematic protections regarding interactions with the general public. I would certainly report such matters to business management. A good manager will work to provide a safe environment for both employees and customers. Something as simple as placing a prominent sign reminding people to show respect to others can help establish expected conduct. Management can also ask someone to leave.

It’s more difficult when a store owner is the one engaging in the misconduct. If it’s the owner, I’d avoid that establishment and would warn others. A complaint to the Better Business Bureau or to the state Attorney General’s office may in some circumstances be warranted.

And for everyone’s well-being, we need to teach our kids by always modeling respectful speech and behavior – not reducing people to sexual objects, not describing relationships as conquests, and not indicating that it’s ever ok to make suggestive comments to strangers. If we witness inappropriate behavior, we need to show support to the person being hassled, and when possible we need to report the harassment (to management, to administration, etc., depending on where it is occurring). We need to hammer into our kids that it is never ok for others to harass them.

It’s better than it used to be, and we can all work together to keep improving our world. It will never be perfect, but the exceptions to civility should become increasingly rare.

Springing into the Pharmacy

Spring is here (although it may not yet feel like it). The days are getting longer. The temperature is slowly getting warmer. Green stuff will start poking through the ground and popping out on trees. We’ll see more of our neighbors, since they won’t be trying to get from their cars into their houses (and vice versa) as quickly as possible before they freeze.

Pollen allergies will start up again. And grass allergies.

So many people suffer from the watery, itchy eyes, itchy, runny nose, sneezy, general ickiness of seasonal allergies. And there are so many remedies in the aisle of the pharmacy – no prescription needed.

Several years ago, I spent the better part of an afternoon exasperated with our youngest son, who was maybe eight years old at the time. This was quite unusual. Unheard of, actually. Son number three tends not to piss us off. But he was acting really obnoxious. Not listening. Acting unruly. I was getting angrier at his behavior.

Then my husband (an engineer, mind you, not a doctor) said, “Didn’t you give him that anti-histamine a few hours ago?” Riiiiiiiight. He had had a reaction to some mosquito bites, so his pediatrician had told me to give him cetirizine to help quell the itchy welts.

Wonder-Doc over here hadn’t realized that her kid was reacting to a medication that affects the central nervous system.

As soon as my husband pointed out the obvious, my anger disappeared (replaced with a healthy dose of guilt), and I did a much better job of soothing my agitated son. And as soon as the drug was out of his system, he returned to his normal, sweet self.

The fact that something is available over-the-counter does not mean that it is completely safe/benign/without risk. This holds true for allergy meds, cold meds, or any medication for that matter.

Always read the bottle of a medication to see what potential side effects might be. Don’t drive when taking a medication unless you know how that medicine affects you and you are certain you can drive safely. Don’t take more than the recommended amount. Remember that any medication can interact with any other medication and that alcohol can interact with any medication.

Different people react differently to different things. Our middle son had taken that particular anti-histamine without any negative effects. Don’t assume that if a certain medication is fine for one person that it’s fine for another, or that if one person has difficulty with a particular medication that it’s bad for someone else. Talk to your doctor and your pharmacist with any concerns or questions.

A couple weeks ago, I was at the tail end of a cold. Our family was out in the car, and my eyes were itching and running non-stop. I had a post-nasal drip going and I was sneezing every two minutes. It was miserable. I needed an anti-histamine.

So we swung by a CVS and I picked up a small bottle of disolving-tablets-no-water-needed cetirizine. I took one. Within about an hour my eyes were significantly better and my sneezing frequency was cut in half. But for a short while I felt a little drowsy – almost as if I had had a glass of wine.

Available-without-a-prescription does not mean without-potential-consequences. Only take something if you really need it. Read labels. Ask questions. Watch for reactions. Listen to your body.

And enjoy getting back outside!

 

 

Colored Perception

Late last night, I saw a Facebook post with the picture of a dress. The dress was blue and black. The blue was a deep, pretty blue – kind of a dark royal, but maybe a tad purple-y. The black was one of those blacks that could maybe be a really deep brown if you looked at it closely enough, but if you were forced to call it you’d probably say black.

Years ago, our oldest son came into the kitchen with a profoundly amazed look on his face. “Mom, Dad – I just thought about something. We might not see the same thing when we look at something. I mean, when we both look at something and say ‘it’s red,’ I don’t know that the color it looks like to me is the same as the color it looks like to you. Your red could be my blue.” This led to some wonderful discussions around the dinner table. We talked about how people can perceive and interpret things differently. How we never know for certain what is in someone else’s head. We looked at all sorts of optical illusions on the computer and in books. We discussed how an outline could be seen as a vase or as two faces in profile. How two lines that were exactly the same length could be made to look different with certain contextual cues.

But with all of this, the one thing we came back to was that everyone could at least be consistent in their labeling, even if their internal interpretations were different. No matter how we perceive blue, we know to label it as blue. The contextual clues to lengths of lines or shades of gray in shadows are pretty much universal. We can all flip the vase view to a face view, and vice versa. There is consistency, and we can see how our minds can be tricked with subtleties.

And then there was the picture of the dress. It wasn’t subtle. The colors were unambiguous. And I read the introduction to the picture that my friend had posted – she said her family was freaking out because all of them saw a black and blue dress, but she was seeing a gold and white dress. I read through the comments of her friends, and there was actually a split – people were either seeing black and blue or gold and white.

I called my husband over to the computer and asked him the colors of the dress. He looked at me strangely, and said “white and yellowish-gold. Why are you asking me?”

This man and I have been married 21 years. We chose dish colors together. We’ve picked car colors, party colors, ties, shirts, dresses – we are consistent in our color labeling.

And yet.

We both thought that the other was teasing. That the other was in on some hoax.

We called in our younger two boys. The youngest came in first. They both saw blue and black.

We then Googled “blue and black or white and gold dress” to see if there was an explanation out there. We found a few articles – something describing different types of cones (the retinal cells which pick up color), something talking about light settings on computer screens, all sorts of hypotheses. This picture had gone viral and everyone was trying to wrap their minds around it.

While looking through these articles, explanations, comments, and hypotheses, something even weirder happened. As I looked at the picture, the blue lightened considerably. The black lightened to a light, golden brown. Before too long, I was seeing a clearly gold and white dress. Our sons were still seeing blue and black.

Today, I still see basically white and gold, but it is a blueish white or light blue, and a darkish gold. Try as I might, I no longer am able to see the deep blue and slightly brownish black I had first perceived. Nor do I see the distinct white and gold I briefly perceived. What I see now is ambiguous.

The hypotheses will need to be tested as to why this dress photo defies our normal understanding of at least labeling consistency (even if not internal perception uniformity). Of the explanations I’ve seen so far, it makes sense that it will turn out to be some sort of contextual interpretation.

But this flips some very basic presumptions on their head. We presume that those of us with intact color vision have consistent labeling of basic colors. We presume that when we see something with our own eyes we know what we’ve seen, or at least our perception is consistent with specific known visual or psychological cues.

This picture obviously hits at the edge of some specific perceptual border. People either fall on one or the other side of that border. Some of us slip over that border and see it from the other side. And I am guessing that I’m not the only one now stuck on the line of ambiguity.

How many other things in this world and in our lives fall on such borders? What other visuals, aside from colors, have such lines of demarcation? What other senses might fall prey to such lines of distinction? What thoughts? What concepts?

This drives home deeply the importance of communication. Of consciously working towards empathy. Of telling people where you’re coming from. Of asking others what they feel, what they see, what they think.

We cannot presume.

 

Bigoted Refusal of Care is Deplorable

First, do no harm.

We don’t all recite the original Hippocratic Oath, but we all pledge to care for our patients. And we pledge first to do no harm.

The news broke this evening of a doctor in my state who refused to take care of a baby because her parents are lesbians.

I am beyond mortified that someone in my profession, and in my country and my state, would do something so hateful, so bigoted, so utterly disgusting.

How dare this woman.

How dare she.

If it were up to me, she would lose her medical license immediately.

I feel physically ill after reading this news report. I expect more from professionals. From doctors. From people who have pledged to care for humanity. From people who have pledged first to do no harm.

Regardless of whatever hateful laws are in place or being pushed into place, we physicians have a moral duty to care for people. We have a moral duty not to discriminate.

I am so disgusted that I have a hard time calling this woman a doctor. She disgraces the profession.

Bigotry is harmful.

There is no place for it in medicine.

That is all.

Vaccine Resistance – This is a long one….

Vaccines. Diseases. Measles. Big Pharma. Anti-vaxxers. Medical Industrial Complex. Individual rights. Herd immunity. Selfishness. Stupidity. Toxins. Chemicals. Autism. Encephalitis. Mercury. Thimerosal. Febrile seizures. Science. Anti-science. Pseudo-science. Alternative. Natural. Money-grubbing. Lying. Evil.

My Facebook feed has been blowing up with posts and memes related to vaccination. The topic cycles through the news and social media regularly and is prominent at the moment in the wake of the recent/current measles outbreak originating at Disneyland in California. People are angry. People are defensive. People are offensive.

I’m pensive.

Over the past several decades, vaccines have prevented millions of deaths. They are effective. There is no question about this. Current vaccines are exceedingly safe. There is no question about this.

Vaccines are not 100% effective. We need a high communal vaccination rate (generally 95% or more) to ensure “herd immunity,” which stops widespread epidemics and protects those who cannot, for medical reasons, be vaccinated, and those for whom the vaccine did not generate adequate immunity. Vaccines are not 100% risk-free, although the risk of a serious reaction is extremely small (for example, about a one-in-a-million chance of an anaphylactic allergic reaction to the Measles/Mumps/Rubella vaccine). Many vaccines have minor side effects, such as soreness at the injection site or a mild fever (the fever actually is a sign that your body is mounting an immune response to the immunization). The diseases the vaccines protect against have significant rates of severe complications (encephalitis – an inflammation of the brain which frequently leads to permanent damage, pneumonia (the most common measles-related cause of death), paralysis, sterility, blindness, deafness, death, etc., depending on the specific disease).

The scientific and medical establishment is in overwhelming agreement that everyone who can be immunized should receive all recommended vaccinations. The benefits far outweigh the risks. The vast majority of people in this country follow these recommendations.

And yet.

And yet we have pockets of people loudly protesting vaccines.

And some people listening to these loud protests and quietly forgoing immunizations for their children.

And this is a problem.

From the community health and welfare standpoint, this is a problem because there are enough people forgoing immunizations to impair our herd immunity. Those who are most vulnerable (people undergoing chemotherapy, people on immunosuppressive medications, babies too young to be immunized, people with immune deficiencies, people who are too frail or ill for their bodies’ immune responses to function properly, etc.) are at risk. And because the vaccines are not 100% effective, even those healthy folks who are fully immunized are at higher risk because of the decrease in herd immunity. So clumps of folks refusing to immunize will affect other people, not just their own families.

And because we are human, even if the herd immunity issue were not in play (although it most definitely is), many who understand the science and the importance of immunizing and the benefits versus the risks to the individual (putting aside, for the moment, the community as a whole) would still be frustrated by the failure of groups of people to vaccinate their children. Because even if (again, ignoring the public health risk for the sake of this argument) we could say to ourselves, “if they don’t want to immunize themselves that’s their problem – they can suffer from and potentially die from preventable diseases if they so choose,” (which I personally have a hard time saying), we still care about the welfare of their children.

And there’s the rub.

Because that is also what motivates the vociferousness of some of the people who loudly oppose vaccines. Not all of them, but some of them.

And understanding motivation is essential to understanding and communicating with people.

What doesn’t motivate people is calling them stupid.

At this time, I will not speak to the few people within the official medical establishment (M.D.s and D.O.s) who speak against, discourage, or otherwise buck the positions of the American Medical Association, American Osteopathic Association, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Academy of Pediatrics, American College of Physicians, etc. My opinion and analysis of these people will be a topic for another day.

I will also not speak at this time to people who have not undergone the rigors of scientific medical training who hold themselves out to the public to be healthcare practitioners and give advice contrary to scientific medical consensus. This will also be a topic for another day.

What I will speak to right now is the vaccine resistance (and vigorous promotion of this resistance) that is found within small proportions of the general population.

The people I am speaking about certainly love their children. They are motivated to protect their children. They are motivated to protect other people’s children. They are motivated by fear. Deep fear.

I understand fear. And I understand fear of vaccines.

Most of our immunizations are done by injection. A needle is stuck into us (or our child) as the vaccine is injected into our muscle. It hurts.

We have evolved to resist being stuck and injected – we reflexively try to avoid bees and wasps. That resistance for most of us is easily overcome with our intellectual understanding of immunization, but we are definitely actively resisting a natural impulse when we allow ourselves to be injected. Sometimes fears can be too strong to overcome with our own intellectualizing and we need a little help.

Frequently, young children will cry when given injections. It’s awful to see your child in pain. Yes, that pain is to protect him from something that would cause much greater discomfort and could cause grave harm or even death, but the injection pain is right here, right now, and real, while that disease potential is not right in our face and we don’t frequently see the awful diseases that we once used to (due mainly to vaccination).

A child will frequently be fussy after vaccinations – her leg or arm hurts where she was poked. She may have a fever for a couple days. She may sleep poorly while she feels icky. And a parent feels awful, because the parent gave permission to someone to do this to her. This ickiness of vaccination is right in front of the parent, while the disease being inoculated against is not in front of the parent.

Although severe vaccine side effects are exceedingly rare, a parent may still worry about the potential.

We look for confirmation. We look for validation. We look for reassurance. We take it where we get it.

While most of us are able to intellectualize and rationalize the extreme benefit of vaccination, some of us have more difficulty overcoming the fears. When we’re having difficulty, the reactions of others can make all the difference in the world.

Who listens to our fears with empathy? Who rolls their eyes? Who sighs with exasperation? Who ridicules our fears? Who explains and educates? Who gives us time?

Although correlation does not imply causation, our tendency is to infer causation from correlation. We are suggestible. Although large scale data gives us significantly more information than a few anecdotes, we tend to remember and hang on to stories. When we are given some information we know to be correct, we are more inclined to believe accompanying information from the same source, whether or not that accompanying information is valid.

These tendencies, coupled with who is responding to a person’s fears (and how they are responding), will influence whether someone who is afraid will go in one direction or the other.

There was a recent study  that looked at information intervention to see how it affected parental attitudes on the MMR vaccine. For this study, parents were given a questionnaire which included questions on how likely they were to have their future children vaccinated with the MMR vaccine, whether they thought certain vaccines caused autism, and how likely they thought it was that someone would suffer serious side effects from the MMR vaccine. They were then randomly assigned to five groups. One group received information (from the CDC) explaining the lack of evidence that the MMR vaccine causes autism. The second group received text from the official Vaccine Information Sheets explaining the dangers of the diseases against which the MMR vaccine protects. The third group received pictures of children with measles, mumps, or rubella. The fourth group received a dramatic story (from the CDC) about an infant who almost died from measles. The fifth group was the control group – they received no vaccine information intervention materials, but were instead given reading on the costs and benefits of bird feeding. The parents were then given a second questionnaire which included the three specific questions mentioned above.

The results of this study showed that none of the interventions increased a parent’s likelihood of having a future child immunized with the MMR vaccine. The autism-vaccine corrective information did decrease the respondents’ beliefs that there was a link between vaccines and autism, but it also decreased the respondents’ future likelihood to vaccinate (mostly in the group of parents who originally held the least favorable view of vaccines). The dramatic story of the infant with measles increased the perception that the MMR vaccine has serious side effects. The pictures of ill children increased the parents’ likelihood of saying that some vaccines cause autism.

I don’t find the above results surprising, nor do I find them particularly discouraging, although headlines in response to its publication were generally along the lines of “You Can’t Change an Anti-vaxxer’s Mind” (that one was from the Mother Jones blog). The above study looked at four different “spot” information interventions. It did not look at comprehensive education, communication techniques, nor empathy of information providers – it simply provided limited, unifocal written materials. It is not fair to say, from the results of this study, that people scared of immunization cannot be reached.

If I had been a parent in this study given a story to read of a sick child, or had been given alarming pictures of children with measles, mumps, and rubella, I might then go to my computer and do a quick search on those diseases. While doing so, I would very likely come across websites promulgating false information about dangers of the MMR vaccine or quoting the (fully discredited) study linking the MMR vaccine to autism. I also might have thought, “Why are they trying to scare me about these diseases? Maybe they think they need to scare me because the vaccine is dangerous.” I wasn’t given information on the safety of the vaccines. I wasn’t told details about potential side effects. I wasn’t given an opportunity to ask questions.

Communication is critical. Comprehensive communication is critical. Empathy is critical.

The costs would likely be prohibitive, but it would be nice to set up a study (with the same questions looked at in the above study) where people with negative attitudes towards immunization were identified, where they were randomized to an intervention group where a doctor listened to their fears, addressed their concerns, quantified the risks and benefits of vaccination versus the diseases themselves, provided trustworthy further sources, and explained which sources were not scientifically trustworthy and why, all while maintaining an empathetic demeanor; a group where the above was done in an arrogant/ridiculing manner; and a control group where a doctor discussed the benefits of wearing a bicycle helmet. How might people respond then?

The anti-immunization community (both physical and internet) provides empathy. They tend to be comprehensive in their information (albeit false). They define the enemy (enemies). They pull people into their fold, making them feel a part of a valued and cared-for community.

Calling people names will not pull people back from a group that’s making them feel welcome and supported.

Again, the majority in this country understands the science behind immunizations, trusts the medical and science establishments, and immunizes their children against dangerous communicable diseases. People who are wary of immunizations are not trusting the overwhelming consensus of physicians. If they are already pulling away in some thoughts from the medical world, why would anyone think that insulting them would help pull them back?

A piecemeal approach of a written form here, a scary story there, or some random disease photo is also not likely to pull anyone back, nor is an internet meme with a snarky comment or comparison.

Memes make points or sum up arguments with a picture and just a few words, frequently with an element of humor. I frequently appreciate the humor and the analogies made when the memes are pro-vaccine. But when I look at those of the anti-vaccination type, it hammers home just how lacking a meme is. It may pack punch, but it lacks depth. It lacks nuance. It lacks explanation that addresses questions or concerns.

This is not to say that the memes are useless. They generally serve to support/confirm/validate what people on one side or the other already understand or believe. They also, by serving as an indicator of what someone posting the meme thinks, contribute to defining norms. So it is helpful for Facebook to have a preponderance of pro-vaccine posts, since it helps cement immunization as the acceptable/preferable thing to do, and it is possible to do this with humor, with analogies, and with respect. It is helpful for people to respond to/refute anti-vaccine posts in a respectful, empathetic, honest, respectful, non-condescending manner.

Here is my official, as-a-doctor stance on vaccination:

Vaccines save lives. Vaccines are not perfect, but the ones that we have now have been proven overall safe and effective. We’ve come a long way since the first documented attempts to immunize. Variolation for smallpox – rubbing material from smallpox sores into people’s skin to induce a cutaneous case of the disease which was milder than the normal variant and conferred immunity to the more severe infection – has evidence of being performed in China 1000 (yes, one thousand) years ago, and was practiced in Asia, Africa and Europe from the 1600s through the 1700s (see historyofvaccines.org). Our vaccines and their manufacturing process have been refined and improved remarkably over the past two centuries. All of our present-day science overwhelmingly indicates that the benefits of our current vaccines vastly outweigh the risks. This does not mean that the risks of vaccination are zero, but they are ever so much lower than the risks of not vaccinating.

Choosing not to vaccinate has risks not only to those who refuse to vaccinate but to others in the community as well. Doctors and medical researchers read studies, discuss findings, analyze quality of research, and continually ask questions to direct further lines of inquiry. As new information becomes available and as better methods evolve, we update recommendations and practices accordingly. All of our best available current information leads me to recommend immunization.

Immunize yourselves. Immunize your kids. And if you still have concerns or questions about vaccines, ask them of your physician. If you feel you are not being answered respectfully by your doctor, calmly and respectfully point this out, and ask again.

If you are a doctor and there seem to be multiple patients in your practice with similar vaccine concerns, hold a few group talks to openly address the concerns and share your knowledge with multiple people at once. Make a video addressing common concerns, make it comprehensive, include analogies, show appreciation for concerns as you discuss them, and put it on your website. No matter how exasperated you may be with the whole anti-vaccination issue, show empathy, kindness, and compassion to those with fears. Teach your patients, and don’t chase them away with outward manifestations of your frustrations.

Let’s live beyond the memes.