L. M. Bryski

Bedside Manners

June 5, 2015


Some of the best doctors I know have the ability to look at a patient and immediately know whether the person is okay or truly sick. It's a skill that takes practice, and even then, it may not come easily, or at all. It seems like magic to the junior staff. A patient with a story that may not fit typically in the ill category, lab work that looks benign, and yet the Senior Doctor pauses as he/she examines the patient, and says "We need to look closer. I think this person is sick."

Sure, there are things that make this pronouncement easy. An abnormal ECG or Xray. Blood work that is trending the wrong way. A fever or fast heart rate. These are the no-brainers (forgive the expression as doctors truly are humbled to be part of patient care).

It's in the difficult diagnoses that the skill to divine who is sick becomes seemingly clairvoyant. People have tried to figure what cues doctors use to zero in on the sick ones. Is it the sight, smell, sound of the patient? Is there a hormone of impending doom that's released into the air that the skilled clinician can instantly recognize, despite not having the words or evidence to state why they believe in what they do. Maybe it's even just a look the patient has, a grimace or stoicism in midst of internal disruption, an extreme inner focus while the world of action goes on about the patient. Maybe it's a mix of everything. The soup of information that the clinician sips at as he/she stands at the bedside and examines the patient solidifies into that gleaning moment of "This person is sick".

Doctors love Evidence Based Medicine. It helps categorize the probability of who is sick and needs a further workup. The template of likelihood of illness presentation types and trustworthy treatments makes it less likely that a sick one will be left behind. And no doctor wants to leave someone behind, unacknowledged illness, missed chance for possible improvement or cure.

However, this same method of evidence based scrutiny of patterns has so far been very limited in describing the hidden clinical skill that has long been suspected as playing a role in patient examination. A nebulous clinical factor that to some may or may not exist has even hazier ways to define it using traditional methods of study and testing.

The article below from the British Medical Journal perks some interest. It has an intriguing take on the possibility of defining the imprecise and uncanny method that may be employed by some doctors as a part of their sleuthing for the sick, the hidden layer of physician reasoning. Although it is not the strongest of studies, low numbers being one of a few reasons, it's fascinating as it dares touch on something that some doctors suspect truly exists.

The focus of this article is facial expressions, or the lack of them when a person is ill. One of our humanly ways of passing information to each other is through facial expressions and microexpressions, smiles and frowns, smirks and trembling lips, direct eye contact and avoidance. We are so fascinated with all the different variations of facial imagery that this interest even permeates most of the magazines we can buy as we stand in line at the grocery checkout. Facial expressions may be clues to how family knows that it's time to take someone to the doctor. "He just didn't look himself," you'll often hear. Something that the family picked up on that sounded the alarms.

Whatever the case may be, it's an area of research, although difficult to define, that holds importance if it can be pinned down, examined, categorized and taught. It would help both doctors and patients. Especially the patients.

Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting 

http://emj.bmj.com/content/32/1/3.full.pdf+html


With warm words,

LMB


Keep going.

June 3, 2015

I think at some point, we each have a pothole to deal with in our lives. Whether it's our first face smack in the carpet at two months old as we're trying to elevate our head, or when we feel mired in a lonely moment, holding a phone or letter, burned and burning by the sad or bad news that our own brain is trying to reject. Or even a moment in a crowd when everyone is cheering the winning candidate (not us), and we're trying to clap along.

Doubt. Humiliation. A hard head bang against a limitation, real or imagined. Even pain, mental or physical, can feel isolating.

Sometimes it even comes in the quiet moment before we lift our coffee and take a sip. That momentary pause where we reassess the coffee. Is it too strong? Too sweet? Too hot? And our life... is it too weak, too bitter, too cold?

We stutter to a pause as the world keeps turning. And we feel alone. We look up the road we had been walking jauntily along, and it's suddenly daunting. How will we bridge the gaping breaks when we're just one person. Alone.

It's such a human moment to feel loneliness in disappointment or doubt that we forget to count how many times it occurs, for others around us as well as ourselves. Numerous times. More than the stars and sands are those moments. More than all the twitters, tweets and texts put all together and shaken until the letters explode into tiny glittering particles and phrases.

We can't be alone in our setback, our questioning of path, the hazy grey future blurring the stones at the foot breath of our persona. We can't be, we just can't. However we feel it. I know It's sad to think of all the questioning, the pauses of doubt and reflection. And yet, it can be hopeful.

The irony of loneliness is that you're not alone in it. We... are not alone in it.

Look beside you. There's your friend. There's another one. And another. And look over there. There are even the people you think have it all together. Look at them pausing and assessing, feeling the air to see if what they dream to have and to hold will still be there after they get back from the bathroom. They are just as worried as you are. 

There are others standing right there at your shoulders, looking up the path with the same puzzled look. The same query of will it be all right? Will things work out as I hoped and planned? Will there be a future full of golden sun and joy, dancing and twirling, and ice cream and hot and cold beverages?

The answer for some is yes. The answer for others is unfortunately no. I'm sorry. It's a hard truth. Sometimes, it just won't happen, no matter how we try.

However, remember in your moment, you are not alone. We are not alone. We keep talking about the journey, reminding ourselves it's not the end point but how we get there. It's also true of setbacks, of rejection, of the empty spaces devoid of words for reflecting. They aren't the endpoint, but part of the journey. And everybody has them (You're not alone in that, just to reiterate the point). The journey is about the travel, and we have travelling companions.

So, square up your shoulders and grab the hand beside you. Link up your chain when you feel the blue shades wash over you. Reach out. Keep going. Keep going with friends, family, coworkers, mentors and even scheduled support if that's the help needed. In any of those choices, you still aren't alone.

Take another lonely-feeling step after reading this, if you have to, just to see if what I'm saying fits with your path, your determination, but please remember.

We're all here, too. We're all going down the same path, the future. We're all unsure at times.

Keep going. You're not alone.

LB
(Blame the strawberry moon for this post)

My best (worst) behaviour


I've heard it said that if you want to write a good book, you have to write it as the best of you writing about the worst of you.

Everyone has two extremes; two opposite poles of being. The grey zone in between covers most of our waking hours, but we are capable of reaching very wide ranges of operation. For some people, often in the same day. There are those of us who are extremely temperate in their behaviour, and spend their time almost exclusively in the warmer climate of niceness; avoiding the chill of ill-mannered overtures to other human beings. I do know and admire these people. Greatly. They are considerate people. Not pushovers, mind you. There is firmness in their qualities as well. At least in the ones I've encountered.

On the other side of the human metronome, there are the baddies. The fumes of toxicity seems to spill over with each wafting step they take. Again, I have come across a few. And have liked most of them still. Kept my distance when I smelled the chemicals, but liked them anyways. It's occasionally kinda fun, admittedly, until the badness is focused on you.

I lie somewhere in the middle ground. Nice, mostly. Considerate, mostly. But I have my moments. And unfortunately, sometimes those moments make good copy.

I can feel it about to happen. It's as if I'm watching a play and can predict the next line. It sneaks out as an off the cuff sentence that grinds a conversation to a brief stutter and pause. Maybe, if I'm lucky, a barking laugh. A regroup, then moving back to higher grounds where the air flow is easier again. Less noxious, or as the case may be, less obnoxious breathing. I'm not quite certain that others in my circle cause this phenomenon as well, but I'm suspicious. Mostly, I think it's me, as I quite believe that I've picked extremely well, and have surrounded myself in a circle of good; Strong, smart, funny people. But still good. I watch for it anyways because, as I said before, it makes good copy.

I recently read an article talking about how to recognize toxic behaviours in the relationships of one's life. While reading it, I realized that it was a laundry list of the bad behaviour in the book I am writing. And I was certain that I had enacted or come across these behaviours at some point, if not currently, in my life.

The list was quite extensive. Envy, cruelty, martyr behaviour, obsessive negative thinking, taking things too personally, hoarding pain and loss, lack of self-control, superficial judgments, cheating, hiding one's truth, perfectionism. It was interesting to check off which behaviours matched with different characters of my current book draft. It was not interesting to match some with myself.

It caused me to look at the characters in my book with different eyes. Why were they acting as they did? Why the toxic behaviours; both the actions and reactions?

A lot of my characters spoke up, defending themselves and their actions; let me peek behind the curtain a little farther into their rooms. Made me realize that often toxic behaviours start with toxic situations. Toxic behaviours repeat themselves in anticipation of or in reaction to further real or imagined danger to self. The behaviours are mind and body armour. Much like a skunk (a beautiful creature) releases its perfume when it perceives a threat. Doesn't matter if it really is a threat to anyone else. It's a threat if the skunk sees it that way.

It was food for thought for my book. Food for thought for me, my relationships, my surroundings. Still, I didn't make any great leap forward in my own life. I am still guilty of the occasional loose comment full of obnoxious fumes.

But maybe I'm indulging in obsessive negative thinking, making a superficial judgment and just taking things too personally.

LB

May 21, 2015