On Staying Present

It's hard these days not to be thinking steps ahead of where I currently am.  It occurs on both a large and small scale.  We're here in Atlanta for 5 more months, but already I'm planning for life in Seattle. I'm currently on an ambulatory rotation this month and I'm already thinking ahead to the next two months of ward medicine. When I drop off Sam, I rush because I'm often late to work and when I'm leaving work, I wish I was already with Sam. While eating dinner tonight, I was thinking about what I've planned for tomorrow night's dinner.

It's hard to just stay in the moment. Or within 10 minutes of the moment. But a patient today reminded me of the importance of staying present.

He was a 67 year old veteran, walking into the primary care clinic today complaining of 3 months of intermittent cough and cold symptoms. (In medical speak that's: 67 yo AAM bib self to clinic c/o URI sx x 3 mo.) I don't remember how it came up, but he mentioned he was getting divorced and I asked, "Is that a good thing or a bad thing?" My question seemed to open him up and soon he was talking about moving out of his house of 15 years and how he didn't want to return to work anymore. Finally he said, "I just feel like I need a vacation from people. I need to get away from everyone."

I was just about to examine his lungs, the source of his complaint. I had my mental list of possible diagnoses shuffling around in my head and I was eager to listen to his lungs (Will I hear the wet crackling sound of heart failure? Or the dry crackles of pneumonia? Will I hear the wheeze of asthma or possibly the silence of an upper respiratory tract infection?) but something made me put my hand on his shoulder and ask, "Are you thinking about hurting yourself?"

"Well, I do have guns in my house and I know how to use them. First I was in Vietnam, then I was a cop. They've made a monster out of me. I've seen things that you'd never want to see. But no... I wouldn't be a coward and use a gun... I'd probably take a bunch of pills or jump off a bridge."

Suicidal Ideation (SI) is a term used frequently in medicine to indicate thoughts of suicide without attempt. It can range from thinking about it to having a detailed plan.  When a patient shows signs of depression, we HAVE to ask about suicidal and even homicidal ideation and then we assess their level of planning.

It turns out this patient said he was less likely to harm himself than someone else.
He again begs me to give him a work excuse because "I just can't go back there. I might snap."
His job?
A school bus driver.

So I end up walking him over to the psychiatric emergency department. He was willing to go-- even a bit relieved it seemed, though I would have called security if he had resisted. I wonder if he will be admitted to the psych unit tonight. I wonder if he really would have harmed anyone... or if he ever will. He seemed like a nice enough guy.

In the clinic there's a lot of pressure to see as many patients as possible and to see them all in a timely manner. Many of the docs there arrive at 7 or 8 and want to be out the door with their coat on by 4. At my level of training, I can evaluate a patient for one problem in 15 minutes, but I have to ignore everything else that's wrong with them. How can I do that without worrying that I've missed something?

This gentleman was my last patient of the day and yes, I was already thinking about getting out the door and picking up Sam. But in the exam room, I stayed focused on him, on his case and I picked up on something that I might otherwise have missed. I may have been a little later getting home than usual because of it, but at least I'll sleep better tonight knowing that staying thoroughly in the moment made me a better doctor.