Cardiogenic Shock and Microteaching that Cuts like a Knife

Cardiogenic Shock and Microteaching that Cuts like a Knife

Rounds in a teaching hospital take different forms, but in addition to taking care of patients, the purpose is to demonstrate and learn.  Sometimes the experience is enthralling and truly enlightening, and sometimes it’s tedious and awkward.  The balance often depends on the approach of the attending.

After we walked around the hospital to see a few patients, we decided to head to the conference room to finish our rounds.  It hadn’t been a good morning.  Our attending had been critisizing the residents on their note-writing skills, unrealistic differential diagnoses, untimely completion of tasks, etc.  He was upset by a patient who took a downturn, later to find out he suspected it was his order for a beta-blocker that sent her into cardiogenic shock…worsened kidney function, ischemic bowel, respiratory failure, and so on.  I wish I could say this event was the only reason he cut the interns with such belittling precision, carving out descriptors like “apathetic” and “ignorant” across their foreheads, but it wasn’t.  This was his usual game, at least in the early days of each week-long tour on the inpatient service.  Usually by Thursday or Friday, he’d give himself permission to be gracious.

I have a pretty good relationship with this particular attending, at least that’s what he wants to believe.  No matter how much he protests, I’m older and more experienced at acute care internal medicine than him.  I don’t mean that I have all his knowledge (although I have the pharmacy-equivalent of training). I don’t pretend to be an expert in diagnosis or physical findings or significance of subjective evidence, but he pretends to be an expert in pharmacology, and on rare occasions he turns to me to confirm that his micro-teaching is correct.  It’s when he doesn’t defer to me, in those moments when he confuses his arrogance for competence, that he often relays inaccurate information. 

He explains to the team how on another patient because she stopped dialysis a month ago, her serum levels of digoxin increased causing her current bradycardia.  Well, actually, no, that’s not it.  Digoxin is not removed by dialysis.  That part of her history is unconnected.  Or how fentanyl is a partial opioid agonist, and that is the reason it’s not a good sedative in intubated elderly patients.  Sorry, it’s a pure agonist, and one doesn’t have anything to do with the other.

How am I supposed to correct these inaccuracies when it’s very possible that my forehead is next?  I imagine my carvings would be “insubordinate” and “irrelevant.”  Picking my battles and picking the right time is always key.  Today most certainly would not be the day.

Today was, in fact, the day.

While walking across the hospital out of the ICU, he offered his elbow to engage in a little Wizard of Oz reenactment, sans yellow brick road.  We talked. We discussed alternative etiologies to our dying patient.  We bonded a little, as he respected me enough to ask my opinion and consider my responses.  Truth is, he knows my strengths, those beyond the scope of the typical pharmacist, those that come with a love of learning and analyzing.  Training.  And experience.

I took that moment in the hallway, away from the others to engage in what I wanted to be an edifying conversation.  “Did you know that fentanyl is not a partial/mixed agonist?”  I continued, hoping that additional information might knock the misconception loose, “It doesn’t have a ceiling analgesic dose.  Partial agonists do.”

He listened, cocked his head, and murmured, “Why did I think that?  What was I thinking of?  Hmmm…”

Then his phone rang.  And that was the end of our micro-lesson.  

Rounds continued a few minutes later around a table. The brief moments of serenity and humanity in the hallway had dissipated.  The repetitive clicking of his pen as the intern presented a clunky assessment and plan for her patient further revealed the mercurial essence of this man.  He was waiting to wield his cutting words while distracting everyone from the intern’s presentation. At that moment, my heart dropped in disappointment at this display.  I think we were all done learning for the day. 

It’s Barely Legible

It’s Barely Legible

Several years ago, as I set out to grab hold of my pharmacy future, I knew I needed to specialize in some area.  Whether I would end up practicing specifically in that area was up for debate, but to get my foot into academia, I had to choose.  I was never fond of nursing homes as a child when my mom dragged me to visit a great-grandmother, but geriatrics is where I landed.  Several forces were responsible for this direction, but that is a story for another day.  Ironically, geriatrics is not so much a focus as it is a nebulous amusement park of unexpected complications with a do-no-harm mentality.

When teaching students about the biologic, physical, and social changes that occur with aging, I admit the information can be dull.  Sure, we all have some idea that as people age, movements and mental processing slows, the kidneys and liver don’t work as well as they used to, opening jars and operating utensils escalates to the impossible, climbing stairs is a privilege granted to the young, hearing and seeing clearly are luxuries of good genes, and the vigor for life wanes.

I demonstrate this with an exercise in futility.

Presbycusis is often referred to as “old man’s hearing.”  I’ve diagnosed myself with this, attributing it to standing too close to the monitors on stage at rock concerts I attended in college.  A common description is “I can hear you talking.  I just can’t understand what you’re saying.”  Words run together and certain consonants sound the same.  The hearer spends half the time interpreting what is being heard and the other half listening.  In effect, about 1 in 3 words is actually understood.  It’s hard to string a line of conversation together with just that information.

I have students plug their ears with cotton balls and have their partner read nonsense drug information to them.  It’s filled with words that together make no sense, but they sound like they’re supposed to: “Take this cube with three dimes every garage door opener.  Your dog may have painful yearning, but the phone will abate after a few cupsful.”   The cotton-balled student must repeat what is heard.  It’s funny, but it proves a point.

Vision impairment is also common with aging.  The common degradation of seeing arrives in middle age in the form of presbyopia.  Bring on the outstretched arms, $12 reading glasses from the drug store, and large print versions of everything.  I have students read a legitimate drug counseling blurb, but it is in 6-point font, in italics, with the letters scrunched together. The students must hold out the page at arm’s length and read it.  It’s a challenge, but these twenty-somethings usually nail it.

Every semester I have our administrative assistant print off several copies of these blurbs, usually with no comment, but this time she took exception.

“Lucy, do you really want me to make copies of this?  It’s barely legible,” commented the 53-year-old Ms. P.

“Ha!  Yes, that’s the point!  It’s a demonstration of how our vision declines when we get older,” I replied, trying to be both light-hearted and informative.  I get a response.

“Oh, okay.”

Not sure that she got the humor of this exchange, but it was kinda perfect.  Of course, I can’t tell this story to any of the students without potentially embarrassing her.  So, I’ll tell it here.  

In the end, I fought my tents a fumigator chains.  I SAID, I HOPE MY SENSE OF HUMOR NEVER FADES, even if my hearing does.

Socrates, Myers-Briggs, and Dog-Training: Languages I Speak

Socrates, Myers-Briggs, and Dog-Training: Languages I Speak

via Daily Prompt: Translate

Over the years I’ve significantly improved my relating abilities.  Whether or not you give credence to the Myers-Briggs Personality Types, it has been my Rosetta stone.  INTP.  Probably one of the more misunderstood personalities, in a woman it has much more brutal implications.  Unfeeling, aloof, blunt, overly analytical, indecisive.  It’s not all that bad, most of the time, and especially since I’ve unlocked the mysteries surrounding my affect and those around me.  After several conversations and with enough information, the four letters of my acquaintance beg me to label them.  I’m not a savant, just a studier.   

When I “rescued” a puppy from the farm several years ago, as a studier I immersed myself in all things Dog.  Puppy training classes, dog parks, clicker commands, Animal Planet, socialization, polite introductions, enzymatic urine cleaner, and so on.  All of this training was actually for me, not my dog.  As a human, I had to learn to interpret and relate to my dog.  To anticipate her behavior in certain situations and to use her psychology to our mutual benefit (“sit”, click, treat) was a skill I didn’t realize I desperately needed.  Even the simplest of gestures and one that makes me most proud as a dog mother (ick, hate that term), is when she goes to the back door when she needs to do her business.  She also goes to the door for about 13 other reasons that infuriate me, but at least she doesn’t relieve herself indoors.  Raising and training my dog, my protector, created a new facet in my comprehension of the world.  It made me more human and bilingual.


Make that trilingual.  I studied Spanish for a few years in high school.  It was enough for me to test out of my college credit requirements.  While most people forget the languages they learn, I think the reason I held on to much of Spanish is because English was always intuitive.  A second language is inherently more difficult and requires logic, at least for me, the INTP.  A few times in my career I’ve attempted some translation at the bedside of a Spanish-speaking patient, but I never advertised.  Completely rusty and insecure in my overall ability to speak it, my attempts are generally feeble.  A resident physician turned to me in a patient room, indicating I spoke Spanish.  I never told him this, so, I really think he jumped to a conclusion in an attempt to deflect attention from him not securing an interpreter before rounds.  “Tiene usted dolor?” I asked.  A confused furrow of the brow and darting eyes from me to the resident confirmed my fear that I should practice more, or at least not try to be the hero anymore.

At times conversing across disciplines requires overcoming a language barrier as well.  Words typed into a chart may hide true intent, feelings, or conclusions and instead provide only facts and clearly defined outcomes.  Although electronic medical records improve the quantity of communication, I argue that the quality lacks, especially for third parties like me who scour the pages like forensic scientists trying to piece together a mystery.  Adding a complication, pharmacists are precise when it comes to pharmacology, especially when communicating with physicians.  Prophylaxis and prevention on the surface connote similar meanings, but guidelines use them differently in specific scenarios.  Patients admitted to the hospital usually receive some sort of DVT (deep venous thrombosis) prophylaxis, and it’s often enoxaparin or heparin at prophylactic doses, not therapeutic anticoagulation doses.  A patient who’s had a blood clot in the leg (a DVT) in the past may continue on long-term anticoagulation for DVT prevention.  This is not the same as DVT prophylaxis.  A prophylactic dose is much lower and ineffective for anticoagulation.  This is the language of pharmacology that prevents misinterpretation, but not everyone speaks it.  Not everyone realizes the breach exists.  So, when I hear from someone that a patient is on DVT prophylaxis but are taking a therapeutic anticoagulation dose, I first have to translate for myself the intent of treatment so I can then evaluate therapy (and on the down-low, suggest alternative verbiage).

Resting somewhere among the pillars of interpreting behaviors, words, and intent, is the practice of effective teaching.  I lecture pharmacy students in the classroom several times a year, but I mostly teach, instruct, and guide them in a clinical setting during their last year of school.  Real, live patients are the case studies, self-directed research is the lecture, and patient presentations are the exams.  Translating classroom knowledge into clinical practice in the hospital presents some level of difficulty for students.  I question the students to assess foundational knowledge, ability to evaluate known and potential factors affecting pharmacotherapy, and critical thinking.  I explain concepts to reinforce or to correct deficiencies in knowledge.  Sometimes I ask questions that yield left-field answers that I have to admit my students would have to be clairvoyant to answer correctly.  (I’m working on my Socratic method.)  Frustration strikes when a student commits the same errors over and over.  Either I am not conveying information in a way they grasp, or they are drowning in a sea of unfamiliarity.  In the case of the latter, my INTP-lack of compassion kicks in.  (How did they make it to their 4th year of pharmacy school?)  But if it’s my inability to uncover the disconnect, to focus the blurry lens, then I have to find alternative inroads.  I study my students, their behaviors and reactions, to identify the cause and whether the fix should be my responsibility or theirs.  Ultimately, I can’t force a student to learn (clicker-treats are not appropriate in this scenario), but I do my due diligence to bridge the language barrier.

Interestingly, INTPs often become professors…of the absent-minded variety.  I wish.

 

 

Translate I’m not a savant, just a studier

On Food and Dying: Upping the Meatballs

On Food and Dying: Upping the Meatballs

The diet order, whether it’s for the patients to select for themselves or one that is most prudent and forced upon them, is often the smallest afterthought, but it frequently becomes the spark-less plug in the discharge engine.

To eat or not to eat:

  • The patient can’t eat because of a procedure scheduled for tomorrow, but, oh, wait!  They ordered food today and had a patty of sausage.  The surgeon isn’t going to be happy.  Or sometimes the patient is resuming a diet that had been held for whatever reason, but it must start with “clears” to see if they can tolerate it before moving on to soft, mechanical and then regular food.  If the diet progresses too quickly, the patient may choke or get nauseated and the process starts over.

What to eat:

  • The type of diet we’ve learned will lead to a healthier and simpler life.  It may decrease the number of necessary prescriptions or effectively eliminate a disease.  Or in the case of kidney disease, liver disease, diabetes, or hypertension, a diet low in phosphate or protein or carbs or sodium will help prevent further complications and make the management of the disease so much easier.  Frankly, though, these diets are not easy or pleasant, and some patients rather starve than force bland fish down.

Diets are like medications, and they can sometimes do the same job as atorvastatin or metoprolol.  Many people struggle for years adhering to a special diet.  It’s in those last few months of life, however, when benefits bestowed by healthy habits lose their impact.  The cost-to-benefit ratio is high.  To be dying…as all of us are, I think we’d rather go down enjoying ourselves with milkshakes, french fries, and meatballs.

In my career I’ve worked in acute care, hospice, outpatient clinics, and even a while in a retail  pharmacy.  As a student intern working in a chain pharmacy, I encountered a patient dying to eat.  Every month this thin man with a long, white beard walked up to the window and silently handed over a prescription for two bottles of viscous lidocaine compounded with some other ingredients.  Sometimes he was by himself and sometimes with his son, but I never heard his voice.  The lidocaine he bought numbed the pain caused by esophageal cancer and its treatment so that he could bear to swallow, whether it be a soft hamburger or a few sips of water.  I can’t remember who stopped going to that pharmacy first, me or him, but I know I never saw him again after that summer.

My first clinical job after residency was at a large hospital with well-trained internal medicine physicians.  One of my attendings was a pathologist turned geriatrician.  She could see both the minute and the broad, the little things that could turn into big things.  On rounds one day, a pleasant gentleman with dementia and no teeth widened his mouth with smiling eyes when we walked into his room.  Our attending spotted a mild abnormality–a dried, white film coating the inside of his mouth.  People with dementia often lose awareness and capability of performing self-care.  Wetting his dry mouth had become someone else’s task.  Our attending took a latex glove and pinched the film beginning at the roof of his mouth and removed it.  I rarely get queasy in the hospital, but this did it, just a touch.  The patient was happy with the result.  He was always happy, it seemed.  The man didn’t eat or drink much, but when he could communicate with family he asked for a McDonald’s vanilla milkshake and fries.  At this point, the hospital’s cardiac diet was doing more damage to this amiable man’s spirit than good for his heart.  “He can have whatever he wants,” declared our attending.  The next day on our visit, a warm, salty, greasy smell hovered as we approached.  He was there, smiling and sitting up in bed, with fries sticking out of his mouth.  What else could he want.

There are occasionally those patients who we think are in denial.  They have a very serious disease, cancer, that has brought them to the hospital.  He had stomach pain and impatience.  His wife sat in the window banquette, unamused by her husband’s grousing.  She audibly hushed him as the team of white coats entered his room.  Earlier before rounds, we discussed this gentleman.  His first meal in two days had been a disaster.  He hadn’t been able to eat before because of several tests we needed to perform.  When he ordered spaghetti, he was disappointed by the  meatballs, specifically the number of meatballs.  There wasn’t much more we could medically do for this patient.  His disease path was set, and intervention would be fruitless.  “Sir, we are going to keep an eye on you today and hopefully send you home in the morning,” the resident stated in a bright manner.  Sensing the annoyed demeanor of the patient, he followed up with, “and we’re going to up the meatballs.  Doctor’s orders.”  That’s all he needed to hear.  Again he was able to live his curtailed life.

Today, the biscuits & gravy and bacon & eggs were on the menu for many.  Patients who were admitted due to small bowel obstructions, electrolyte abnormalities, decreased appetites and depression, from whom we withheld feeding by mouth, were once again hungry and allowed to have a diet.  Our team joked at the irony of fixing the mind and bowels only to wreck their arteries.  Oh well, treating the soul is more important right now.  Sometimes that’s the only treatment that works.

Poop Queen

Poop Queen

I didn’t see it coming , but poop has become a frequent focus in my career…and life.  Gastroenterologists and parents who change poopy diapers probably think the same thing or scoff at my confession, but I’ve unwittingly assumed it as a soapbox matter because there’s a hole in our understanding.

It probably all started back in residency when I rounded with a particular group of young doctors in the hospital.  The physicians in their first and second year of residency created a hazing-type of award called the “Golden Finger”.  A chart drawn on the white board outlined every intern’s name next to a series of columns that denoted certain procedures they regularly performed on patients.  They marked every procedure they squeezed out, but only one column resulted in a trophy, the digital rectal exam (DRE).  Also used for prostate exams, the DRE can be used to manually disimpact the poop chute of a constipated patient.  I doubt it’s pleasant for either patient or doctor.

On the other end of the pooping spectrum is diarrhea, and it can be bad.  In hospitals especially, the spread of Clostridium difficile (C. dif) is as feared as the plague or an impending ice storm, although an ice storm would smell better.  As a resident I presented an educational session over lunch to hospital staff about C. dif.  Antibiotics and stomach acid suppressants can sometimes be just as harmful as they are helpful and lead to outbreaks of C. dif colitis.  The poop is watery and it is frequent.  Washing hands with soap and water and bleaching surfaces are the best preventative measures against its spread.  The best treatment?  Fecal transplants.  It’s a thing.

There’s a fluffier side, albeit just as informative.  A little show called Scrubs immortalized the importance of poop in a song.  It’s not just the fact that the bowel moves or not, but it’s the condition and contents of the poop that expose your darkest secrets.

Runners talk a lot about poop.  There are port-a-potties available on running routes for that very reason.  While urination may be the primary goal for some—some runners just let that go—poop can’t be freely and inconspicuously dropped.  One needs privacy and a pot, or at least a hole.  One time I ate fettuccine alfredo the night before a long run.  I thought carb-loading would be beneficial.  What I didn’t count on was the effect of the deliciously creamy fat in my meal.  After my 8 miles the next morning, I almost did not clear the 15-minute drive home to release my belly angst.

Now it seems that much of my job as a clinical pharmacist is to teach the importance, methods, and mechanisms of keeping things flowing.  Here are a words of wisdom I float to young doctors and those wishing to become more proficient in the cathartic arts:

  • Drug-induced constipation is predictable, therefore, mostly preventable or at least manageable (i.e. if you prescribe a med that causes constipation, you should also prescribe a stool softener and/or laxative, lifestyle modifications/exercise, fiber, and water).
  • Constipation is much easier and less expensive to prevent than it is to treat (i.e. once constipation is present, you’ve already lost the battle; time to bring out the big, unpleasant guns).
  • If constipation has been going on for days, the best route to treat is from underneath (i.e. suppository or enema).
  • If you consult a gastroenterologist for constipation, they will almost always choose the most expensive (albeit, sometimes the most effective) treatment (i.e. potential wasted resources).
  • There are no real evidence-based guidelines for constipation. The patient population and causes of constipation are so heterogeneous (i.e. varied) that a one-size-fits-all approach (or saying one type of treatment is “ineffective”) does not work.
  • Common sense and experience go a long way. Start with your least expensive agents first.  Match the cause of the constipation with the mechanism of action of the bowel regimen.  Maximize doses, routes, and frequencies.  Then, move up the cost ladder.  Then, consult gastroenterology.

Many days my recommendations for bowel regimens pass like this:

“Mr. A is on Norco® PRN [as needed], but he’s taking it 3-4 times a day and has nothing ordered for his bowels.  Can we add docusate scheduled once daily at least?  And maybe senna PRN?  If our attending [physician] prefers Miralax, that’s okay, too.  Just need something scheduled.”

“I was checking Ms. B’s recorded bowel movements, and she’s had none for 5 days.  We started her on diltiazem for her a. fib, and that is known to cause constipation.  She’s also been taking TUMs.  Can we add some scheduled docusate and a one-time bisacodyl suppository?”

Although these seem like rather immaterial propositions and for a seemingly an innocuous illness like constipation, you wouldn’t want to wait until the patient gets a small bowel obstruction and has to be decompressed with a nasogastric tube or until we have to give a $150 one-time injection in hopes to get things moving…or better yet, put in for a gastroenterology consult.

Recommending bowel regimens is akin to a mother reminding a child to flush the toilet after use.  It seems like a minor thing in the hospital, especially when a patient is there for severe pneumonia or a myocardial infarction, but it’s a necessary thing.  Bowels don’t shut off just because there are more life-threatening matters at hand.

I have acquiesced to the fact that this will just be part of my job.  I review medications and look for missing pieces, offending pieces, interacting pieces, and so on.  Who better than me to be on the lookout?  They (the young doctors) know it, too, and I have been crowned the Poop Queen.  I will preside over my kingdom from my throne, if I must.

The Personality of a Hospital

The Personality of a Hospital

The first hospital I worked in after residency was an academic medical center.  It was a hospital located just outside the city limits of a major metropolis that held at least 10 large hospitals, ranging from community to research-oriented, teaching and non-teaching, university-affiliated and non-university affiliated.  There were other hospitals, too, small and medium, specialty, for veterans or native people, etc, etc.  The reason I make all of these distinctions?  They all have different feels, different personalities.  
Now, an academic (or university-affiliated) hospital typically employs a lot of teachers, researchers, and learners.  They teem with teams that are about the size of a junior varsity basketball team, many times clogging the hallways outside of patient rooms or crowded around a computer at the nurses’ station.  All are clamoring for understanding and knowledge of not only diseases and medicine but also of approaches and behaviors.  

I grew up in a small, rural town (population ~ 10,000) and never really knew if I would leave it, but as I progressed through my education, the collective ambition of my encouragers propelled me to see more than what my small town or state could offer.  Away I went to one of America’s 5 largest cities.  Of course there were cultural, economic, and atmospheric differences, but I was up to the challenge.  What does “up to the challenge” even mean, anyways?  Must one be successful at the challenge or just blissfully ignorant of the difficulties that lie ahead?

Aside from the personality of a city, I was excited for the bustling nature of a self-contained powerhouse that makes up an academic medical center.  I generally expected to be intimidated just by being there—not many people with an education have an inferiority complex, but I did.  I do.  There were commanding people, knowledgeable people, good teachers, condescending professionals, good attitudes, and bad attitudes.  This is everywhere though.  

My naiveté, that I would be embraced and utilized to the very limits of my professional knowledge, training, and expertise was quickly injured.  I didn’t give up, though.  I was told I’d have to prove myself, make myself an asset that they would soon see they could not live without.  The thing about academic medical centers, knowledge and expertise are commonplace.  I was commonplace.  I was disposable.  I was also young and not as experienced.  It showed, I’m sure.  The truth was that what I offered wasn’t appreciated, to put it politely. 

Perhaps I could win on a social level.  I learned and begrudgingly accepted that it’s not really what you know; it’s who you know.  And it’s not what you say, it’s how you say it.  I chose to say it with donut holes.  That worked for the few hours we were in rounds and maybe for a few precious minutes when I had to page the resident later to give a recommendation on a patient, but it was fleeting.

Every day when I ventured across the hospital to a meeting, to the cafeteria for lunch, or to the coffee stand for an afternoon break, I’d cross paths with the physicians I’d rounded with that morning.  My hopeful eyes would search for contact, I’d prepare my smile and turn my head slightly in their direction…but nothing.  No acknowledgement.  We’d be the only two people in the hallway for 40 or 50 feet, and their eyes that were once straight ahead, searched the floor.  I clearly had done something wrong, I hadn’t charmed them, hadn’t impressed them with my expertise.  My clothes weren’t fancy enough, my sense of humor wasn’t funny enough, I wasn’t pretty enough. 

It took me a long time to figure it out.  Some of my colleagues were more successful at crossing the invisible line.  They had traits that were deemed more attractive or at least local.  I was an alien.  I didn’t belong.  I began to accept it.  At some point I became more confident in my professional abilities and started not to care as much.  I had surpassed the limits of knowledge and had gained experience that none of the residents and many of the attending physicians had.  I vacillated between bitterness and graciousness when considering their snubbing of me.      

Alas, the time had come for me to move on.  Things always have a way of working out for me at the right time, after a lesson has been learned or the next situation has been readied.  After a small, but very meaningful pit stop, my home started calling.  A job back in my home state, the only position I would have accepted, came open.  It was time for a new personality.

The new hospital I went to had a simple rule for its employees:  Make eye contact and say ‘hello’.  I was no longer an alien.  Everyone smiles and is helpful.  It’s not a large, academic medical center, but it is a teaching hospital.  I don’t have to bribe people with sugar anymore.  In fact the food I brought in the early days didn’t impress anyone, but I didn’t need it to attain a level of respect and acceptance.  Acceptance both as a professional and as a person came simply because I was there, doing my job.  I won’t discount my earlier job because it did teach me.  It provided me an invaluable experience.      

Comparing and contrasting the two hospitals is a ready-made tale of the golden rule and loving your neighbor.  Both hospitals are affiliated with the same religious order—both have a motto that implores its professionals to heal and to treat others, both their body and spirit, as Jesus did.  I laugh at the torture I endured, tearing myself apart and doubting my abilities, my personality, and my looks, when it wasn’t my personality that needed inspection.  

The personality of a hospital has many influencers–the people, the administration, the culture of the surrounding people.  My personality was influenced by the first hospital, and my life suffered.  I had to learn to be myself again and what God intended for me, and eventually, the right hospital found me.