Perspective.

Same-day-sick Appointment in the Grady Primary Care Center:


"I can't sleep, doc."

"Really?"

"Yeah. And it ain't like I ain't sleepy, either. I just be sitting there. Just up and bored."

"Tell me about your evenings."

"I get in bed at like eleven. I turn on my television and just watch some TV. You know, Leno and the news."

"Okay."

"My old lady falls asleep and then I just sit there. Wide awake.  After while, I shut off my television and just lay there."

"Hmmm."

"I know . . . .  I ain't supposed to watch TV in bed, but I'm telling you, doc, it ain't that."

"That television can be harder on you than you think. Has it always been hard for you to sleep?"

"No, ma'am. I used to sleep fine. And as for that TV? Naw, it ain't that. I been sleeping with my TV for years."

"What kind of work do you do?"

"I'm run a barber shop so I have some long days. I walk around a lot, spend a lot of time on my feet. So I know I should be good and tired. I just can't fall asleep."

"Hmmm."

"But see, I know just what the problem is."

"What's that?"

"I'm a light sleeper and the noise-- it keep me awake."

I needed more information. "Noise? Does your ladyfriend. . . uhhh. . . snore?"

"Naw!" He chuckled at the very suggestion which made me imagine his better half as a dainty, princess like woman who gently sighed all night. "She sleep quiet as a mouse." I smiled at the image.

"So. . . you mean the TV noise? I'm confused."

"Naw.  Not the TV. This."  He pointed at his chest.

I looked puzzled. Was he some kind of human beatbox that played involuntarily? I didn't get it. He saw the confusion in my face and elaborated.

"This, doc." He pulled down his shirt to show me his midline sternotomy scar from what was obviously some kind of open heart surgery. I narrowed my eyes and tried to get his point.

"I got this mechanical valve put in my heart almost a year ago. And doc, I promise to God, when it get real, real quiet in my house, I can hear it. Loud. I'm for real."

Wow. This was a new one for me. Though surely this was not a new problem under the sun, it was definitely my first time sitting across from a patient who had it as their chief complaint. His chart said, "Can't sleep."  Now that, I could deal with. In fact, I'd grabbed his chart to help move things along in the clinic thinking I could knock this out (and him out) in two seconds flat. In my head,  I was already preparing to launch into my shpiel on "sleep hygiene." Insomnia is such a common issue, and almost always, the patient is doing something that can be easily modified. Like watching television or sitting on their laptop/Kindle/iPad all night sending light to the brain and telling it that it's time to get up and boogie. I thought this guy had me at "television", but never expected this. Dang.

"So. . .what are you hearing?"

"The click. That thang click nonstop. Same thing you hear when you put your thing on my chest to listen, tha's what I hear up in my ear.  Like somebody snapping some metal fingers."

I furrowed my brow and tried to think.

"Messed up, ain't it doc? How anybody 'posed to sleep with that in they ear all night?"

Wow. That was messed up. I had no answer for that question. I really didn't. I leaned my chin into my hand and sighed. A concerned, perplexed, mindsearching sigh.

"Have you. . . . tried a noise machine? You know. . .like one of those ones that has all the soothing sounds?"

"What you mean 'soothing sounds?'"

"Like rain. . and thunder. . .the beach. They have machines that do that. Stuff like that?"

"I think it ain't nothin' I can turn up that will be louder than some metal clicking in my body."

Pretty much, he was right. So I just sat there, staring at him kind of like the way a dog stares at you when you are eating. Alert, but sort of dumb-looking.  I realized that it was like someone trying to drown out their own hum--covering the ears only makes it worse.  I wanted him to get some rest. I really did. But the truth was that I had no answers.  None whatsoever.

***

Today I'm reflecting on the fact that (more often than folks realize) sometimes doctors just don't have an answer to your problem. Or as I once heard a medical student say, "I got nothin'."

The good news is that, since common things are common, this is usually not the norm. Most of the time, we do have a strong idea of what's going on, and with that we can set out on a clear cut plan toward reaching a solution. But sometimes the problem or complaint or ailment is one that, for the life of you, all you can say (under your breath, of course) is, "I got nothin'."

You can't sleep because you are disturbed by the mechanical click of your life-saving artificial heart valve?

Earplugs? You'll still hear it.
White noise? You'll still hear it.
Sleeping medicine? Ability to sleep isn't the issue and you'd  be too groggy to cut hair.

Yeah. I got nothin'.


Over the years, I have learned that one of the best things to do in those "I got nothin'" times is something I should be doing all the time anyway: enlisting the patient as my consultant and collaborator on the plan. There's something called the "explanatory model" that we teach medical students to use during the history-taking portion of their patient encounters. The explanatory model is this point where you essentially ask the patient what they think is going on.  Some wise medical educator finally put two and two together and recognized that patients often are spot on when it comes to pinning the diagnosis.

Case in point:

"I have back pain."

"Did you injure yourself? Pull a muscle? Lose weight? Gain weight? Do something new? Do a new exercise? Sleep somewhere unusual?"

"No. No. No. No. No. No. No."

"What were you thinking this could be?"

"I think it's a urinary tract infection, because it's exactly like the last time I had one."

"Aaaah."

Urinalysis comes back ten minutes later:  > 100 white blood cells per high power field--diagnostic of exactly what the patient said.

Aaaahhh.

So, yeah. We often use the explanatory model to assist us with diagnoses, but I've come to lean on it a lot more for treatment plans--especially the ones that don't involve prescriptions or procedures. This day, more than ever, I needed my patient as a consult.

"Sir. . . . I'm going to be honest with you. I am wracking my brain trying to think of what you can do for this. I'm just not sure how to make it where you can't hear that clicking.  How 'bout we put our heads together on this one, okay?"

"That sounds good."

I turned the computer monitor around and started doing a literature search on the noise of mechanical heart valves. "First, I'm looking to see if any experts have any ideas." I punched in a few terms into a search engine. "What kinds of things have you tried?"

"Honest, doc? I tried having on the TV. I tried having a couple drinks, but then I knew that getting myself drunk wasn't gon' be something I could do every night."  We both laughed.

"Yeah, you're probably right about that solution," I said with a playful wink. "Hmmm.  Everything I'm seeing here just talks about the fact that some valves are noisier than others."

"Mine is the St. Jude."

"Yeah. . .that's a noisy one according to this. . . . Let's see what the patients are saying, okay?"

St. Jude Mechanical Valve

"Okay." He closed one eye like he was debating telling me something for a moment. Then he said, "You know what I did try one time that did kinda work, Miss Manning?"

I offered him a quick glance while still skimming a few message board. "What's that?"

"I slept with a pillow over my chest, and my old lady gave me one of them eyeball masks. Something about that mask make you sleep good."

I stopped what I was doing and looked at him. A mask. Hmmm.  I never thought about a mask. Good thought, actually. Closing out light is good for melatonin production which is good for restful sleep. Hmmm.

"I felt so funny with that mask on," he went on with a slightly sheepish grin, "like I was some kind of . . .I don't know. . . what my old lady call it? A diva."

I cocked my head to the side and then giggled. He was anything but. "You are so not a diva, Mr. Jefferson." We shared a smile before I went back to reviewing the comments on one of the patient web sites. "I'm seeing here that one person said they learned to love the click since it reminds them that it's working." I'm not sure why I mentioned that, but something about that suggestion stood out to me.

"That's a good way to think about it."

"Have you worn the mask any more than the one time your ladyfriend gave it to you? I like that option because they really can help you get good sleep even if you can hear the sound."

He sat there for a moment and squinted his eyes.  "You know, what? I can try that. I only wore that thang once or twice and -- real talk-- it did help even though it don't cover my ears. Why don't I try that."

"You cool with that?"

"Yeah, doc. I'm cool with that. Plus I take enough medicines."

I nodded my head and charted our plan into the computer.

"And you know what else I'm thinkin?" he added as I typed into the electronic medical record. I raised my eyebrows and turned in his direction.

"I'm thankin' that I like that part about seeing my click as my reminder that my heart got fixed." I paused again and gave him my full attention.  "I almost died before they changed out my valve, Miss Manning.  It was infected and they said I could almost die. I was in the intensive care and everything."

"Wow."

"Yeah. And I got kids, and even a grandbaby now."

"So I guess it's like every click is another second that you get to be here loving your family."  I let that marinate for a second.

"Kinda like every click got a testimony in it. My testimony."

Wow. 

"That's a beautiful way to look at it, Mr. Jefferson." I thought about his poignant statement and shook my head. "Mmm mmm mmm. Every click is a testimony. I love that."

He looked down at his chest and then up at me. "You know what, doc? I love it, too."