Wednesday, February 25, 2015

Silver Lining

Chad Williams and I stood outside of his mothers hospital room. Her heavy rhythmic breathing bellowed from the room, like an out of shape runner after a race.
    Chad looked as exhausted as his mother.  "Is my mom dying?" Chad asked as his eyes eyes stared off somewhere else.
I had admitted Ms. Williams for the second time that month for her COPD exacerbation (a slowly worsening breathing problem). I had seen many healthier people not survive episodes like this.
     I took a deep breath to gather myself, "You know, I didn't think your mom would make it the last time I admitted her. She is a fighter, so all bets are off."
It wasn't really the answer he wanted and I knew, so I continued. "Mr. Williams, I know you and your mother have been through this many times. Every time it looks like she wont make it, but she turns around and you go back home. But she looks a lot worse this time."

That much was true. I had never heard Ms. Williams breath sounds so bad. I had never seen her lab values and chest xray look so bad. But yet I had said that before, and had to hedge my bets. So we left it at that. I put her on the appropriate treatments and left for the night. I expected any moment for the nurses to call me notifying me that Ms. Williams was dying.

I never got that call, and the next morning I made my rounds at the hospital. Ms. Williams was my first patient and she was sitting up in bed looking happier than I'd ever seen her. Her breathing and labs were better.

Chad was sitting in the cushioned chair next to her bed. He looked relieved, but exhausted. His eyes were dark and sunken. His blue button down shirt was neatly tucked into his jeans but his unshaven face told me that he had spent the night in the chair next to her bed. I didn't have to update him, he had been through this with his mother enough to know she had turned the corner for the better. I did my exam and let Ms. Williams know the good news.
     I sat on the bed next to Ms. Williams and put my hand on hers,  "Ms. Williams, I think your doing great. But we'll have to keep you here a while longer to make sure you get enough medicine and treatment."

As I walked out of the room Chad followed me out. I expected him to barrage me with questions about his mother, but instead he asked.
     "Dr. Mash, I was wondering. I've got this horrible abscess in my tooth and, well, is there any way you could call in an antibiotic for me?"

I was confused at first. But that was definitely not the first time someone had curbsided me for help outside of the office. Just a couple days before a patient had stopped me at Wal Mart and pulled up their shirt to ask me advice about a rash on their belly.
In those situations, I have to set boundaries, so I said, "Mr.Williams, I'm really not sure, I mean, can't you ask your doctor?"

His eyes looked down at the floor. "I, Uh I don't really have a doctor. You see, I've kind of let my health insurance lapse since I moved out here to take care of mom."

I could tell that was hard for him to admit, and I felt horrible. "I'm so sorry, listen, tonight my free clinic is open. Why don't you come by, I'm sure we'll figure out how to help with your infection and I'm sure you're due for a regular doctor visit. Also, your mom is doing fine here so you won't have to worry about her."

His eyes looked up at me, and he looked excited again. "Sounds great, doc, I'll see you then."

A few years before, I had opened a free clinic in our town. Unfortunately, I don't have a lot of time and I couldn't find any other physician volunteers to help. I really only had time to work there once a week. So, once a week, everyone would line up in front of the clinic until I walked up there after work to open the doors. The nurses and other volunteers would check people in and room the patients and I would see them. That night, I didn't see Mr. Williams as I opened up the clinic. I went about seeing patients and as I opened the door for the last patient, there he was.

We got down to business at first and I got him a prescription for an antibiotic for his tooth infection and referred him to a nearby dentist who did work for low cost. But at that point I was curious. Chad was in his fifties and taking care of his mother. It wasn't often that men were the caregivers for their parents. And I wanted to know what brought him to that path in his life.
      After I handed him his prescription, I asked, "Mr.  Williams, so how did you end up taking care of your mom?"
      Chad smiled "Doc, that is an hour long explanation" he said.
     "Well, you are the last patient. My family has already eaten 'cause its so late. I'm on my way to Subway for a sandwich. Why don't I get you something and you can explain." I answered in reply.

Chad Williams' life was amazing, with twists and turns that made me dizzy. He had left high school without graduating, because he wanted to make a life for himself. Shortly afterward, he met a scientist and helped him invent a cooling material that they marketed for diabetic supplies. He had made his first $10 million before he turned 20. He then worked selling bulk medical supplies to large stores like Wal Mart. His life was perfect. He had a wife and son. But his marriage didn't work out had he divorced his wife. "She took more than half of my money and I got depressed" he said. He then quit his business and lived in Las Vegas. He developed a drug problem and within 5 years had no money left. He had lost millions.

    I was riveted, I felt like I was watching a show on cable TV. As he finished that part of his story, I asked "But none of that explains why you are here taking care of your mom."

     Chad smiled, "well, doc, I was sitting on a couch at a friends house 6 years ago and got a call from my mom. She said she was dying of breast cancer and the doctors had given her 6 months left to live.  I thought, well, I've got no money and made a mess of my life. The least I could do is do something good for my own mom during her last days."

It was true. Ms. Williams had been diagnosed with breast cancer about a year before she called him. Her type of breast cancer was very aggressive. But with surgery and chemotherapy, she was actually cured.
Chad Williams had stayed with her and as she learned she was cured from the breast cancer he made plans to start his life over again. He had a friend at his old company who was willing to let him come back. But his mom got sick again. She had COPD and her breathing problems got worse and worse. She would be admitted to the hospital and get treated then go home. She required many medications and treatments each day and required a portable oxygen device that she had to carry with her at all times. Chad stayed with his mom. Each time she would get admitted to the hospital, the doctors would warn that she could easily die. Many times she had to be placed on a breathing machine to survive. But she would bounce back and go home. It became agonizing for her son to be on such a roller coaster all the time. He had been with her for 6 years and his life was on hold.

"I feel like I've made a lot of mistakes in my life. But this isn't one of them." He said later. "Even though it has been agonizing for both of us, I can't imagine Mom going through this with no one to help. I've got 2 other brothers, and neither would even come out to visit and check in on her during all these years."

For Chad, taking care of his mother was something he thought had to be done. I think that even if he hadn't lost all his fortune, he seems like the kind of person who would stop everything to help. But in the end, he found redemption from the failure he felt before.

A few days later, I sent Ms. Williams home. She and her son had agreed this time, to let her go home with hospice and instead of aggressive medical treatment aimed at curing her, the goal was to make her as comfortable as possible. She died a few weeks later. And I saw Chad at the free clinic after that. He looked rested and happy for the first time in a long time. It was finally time to start his life over again.


Sunday, February 22, 2015

Be Careful What You ask For

One of my least favorite things is treating Chronic Pain. The whole aspect of narcotic pain management for me is in no way gratifying. I don't think I've helped people when I treat their pain and I've had so many patients take advantage of me I always think they have something to hide.
Ruth McCale was a 65 year old grandmother when I first met her. She was wheelchair bound and as we say she was an "old 65" meaning she had lived a hard life. she looked more like 80. she was also a very frail lady. She had many medical problems and I'll be honest I felt so sorry for her.
I'll make a long story short- It turns out she was taking the narcotics I was prescribing and selling them. She was making a killing.
Well I finally figured it out and had to "no narc" her - meaning myself and my partners would no longer prescribe scheduled medications to her. In the year since then she has just fallen apart. She has not taken care of her body, and has been "circling the drain" so to speak. One medical issue after another - I've had to admit her to the hospital about every other month for one issue or another. Sometimes with frail elders - everything is intertwined and if one piece of the puzzle gets taken away then the rest falls apart.

Monday, February 16, 2015

Ethics

I sat on the edge of Mr. Shermer's bed in the nursing home. He was hours or maybe days from his last breath. I had placed him in the Nursing Home because his dying was too difficult for this family to bear at his home. His family had turned up the heat in the room and I was literally sweating. There were 7 relatives in the room. 1 son, one daughter and their spouses, 2 brothers and Mr. Shermer's wife. They were standing around me wondering what I would say next.

Mr. Shermer really looked comfortable. He was asleep, he wasn't groaning and he didn't look short of breath or anxious. I used to work at a hospice during my Geriatrics Fellowship. He was the picture of what I had always tried to make my patients experience. A couple days before he had stopped eating and it was obvious that this was the end. His family and I had agreed that we should make him as comfortable as possible at this stage. I thought we were all on the same page.

I had known Mr. Shermer for 5 years now. Unfortunately he had the end stages of Dementia. So I never really knew what he was like before. But I had spent endless hours with him and his wife and sons during his clinic visits or previous admissions to the hospital. I felt like I knew who he used to be and felt like I knew him as a friend. So this experience was personal for me too.

I was holding his hand in order to see if he felt warm or cold. Sometimes that is a good indicator of how close someone is to dying. I looked up, "I'm so sorry, I can't tell you how much longer he has... hours, days, I just don't know"

They all took a breath, as if stepping back at the same time. I felt some more tension in the room, but I didn't know why. Maybe because they wanted something more definite.

His youngest son spoke, "Dr. Mashaw, we just want him as comfortable as possible. I don't think he's comfortable. I think he's in pain." I felt a little more tension.

I wasn't sure what he meant. I had taken great lengths to make sure I monitored his vital signs (when they're abnormal that is a sign of pain or anxiety), and made sure the nurses told me if he was groaning or fidgity (another sign of discomfort). I had Mr. Shermer on continuous pain and anxiety medications and the nurses had the ability to give him extra pain or anxiety medication if he looked oncomfotable. In short I was doing everything I could to ensure that their loved one was not in pain or discomfort.What else?

I explained these thoughts, and finally looked at them each individually, then ended with "I promise you I will make your father, your husband, your brother as comfortable as possible. If he were my father, this is what I would want." Usually that makes people feel better. But I just wasn't feeling any less tension in the room.

I got a call hours later from the nurses. The sons and even the wife, were coming out every hour sometimes more to tell them how uncomfortable Mr. Shermer looked. They would almost bully the nurse into giving more pain or anxiety medication.

"Do you feel comfortable with the amount of pain meds you've been giving him?" I asked. I wanted to see how his nurse felt. I wanted her to be part of this team.

"Not at all, I know this is weird, but I think they are trying to get me to give him too much pain meds".

And then it hit me. They were trying. A side effect of narcotic pain medication is to decrease your sense of needing to breath. You don't breathe enough, or stop breathing.  People die when they overdose on narcotics for this reason. His family wanted him to die. For whatever reason. They felt that is what we should be doing.

Part of the American Dream is that we are in control of our own destiny. That we can blaze our own path. It is part of our culture and part of who we are as Americans. Self-determination is a fundamental value. It shouldn't be any surprise then that some of us apply that to our final moments. Death is scary and mysterious. It seems to laugh at our attempts to fight it. So this was a way to win. By making sure that his family could say when and how their loved one can go. To control destiny.

I didn't know what to do. I just wasn't comfortable with that line of thinking. Nor was it really legal anyway. Could I lose my license. This poor nurse could too.

It was the last place I wanted to be. The last place in the world. But I had a weird sense that I owed it to Mr. Shermer. I made my way back to his tension filled room. Like walking into a room full of electric ether. I explained how important it was to make him comfortable, but emphasized that we shouldn't give him too much pain or anxiety medications. I was able to make my point clear without actually saying that I wasn't comfortable giving him an overdose of narcotics.

The conversation ended with the youngest son, "Well, we'll have to find another doctor for dad" He was short and definitive. Like I had heard his father, Mr. Shermer was.

I thanked them for their time. But as I drove home I felt deflated. It honestly felt like when I was in high school and the girl I had been trying to go out with dumped me.  I had spent hours and days with this patient and his family and wasn't allowed to see things through. I felt I had known him as a friend. I cared for him, but I wasn't allowed to be a part of his death.

Mr. Shermer did die about 2 days later. If it took that long then I don't think his next doctor was bullied into overdosing his patient -  I didn't really get any details, I guess it's a privacy violation. But I am left with an empty feeling. A sense of incompleteness that I don't think can be filled.

Friday, February 13, 2015

Empathy

Ms. Cantrel sat on the clinic room chair panting, like there was no air left in the room.
“Dr. Mash” she said as if taking her last breath, “If I could just get an oxygen tank to take home I’m sure I’ll be fine”.

I had just taken care of her two weeks previous at the hospital. She was treated there for a pneumonia (an infection in her lungs). At the time I had given her antibiotics in an IV and she did very well. I had sent her home with antibiotic pills and strict instructions (and an appointment) to see me the next week to make sure she was getting better. She was actually feeling so much better that she cancelled her appointment. Unfortunately, she started coughing again and then had fevers. She sat in front of me having developed another pneumonia. After listening to her lungs again I sat carefully down in my chair. I paused to make sure I chose the correct words.
“Ms. Cantrel, I am so sorry but I am sure you have developed another pneumonia and need to be admitted to the hospital again.”
The words sank in and I could tell she had no intention of going back into the hospital. Sadly, Ms. Cantrel had had more than her share of hospital experiences. 4 months ago, I did a colonoscopy on her and found a large mass in part of  her colon. I immediately referred her to a colon surgeon that I respect, and he had to take a large portion of her colon out. She had to stay for about 2 weeks in the hospital recovering.Then only a few weeks later I admitted her to the hospital again to treat her for the pneumonia. The type of antibiotics that I gave her then were more complicated and she needed to take them longer than normal so she stayed again for about 10 days. Finally, she was released home. Only to see me again in the clinic room during this visit, with the news that she had to go back.
I could see the horror in her eyes. Like a gigantic Tsunami about to crash into her.

I spoke quickly this time, “Ms. Cantrel, let me tell you a story. Many years ago I was a resident. I was working 120 hours a week. Once every other month, we would get an entire weekend off. We called it our ‘Golden Weekend’. On one of those, my wife and I decided to celebrate and go snowboarding. that day though I fell and landed on my right side. I had this horrible pain and had to sit for a while. I thought at first that I had knocked the wind out of myself. But the pain slowly got worse. I finished snowboarding and went home. That night I could barely sleep because of the pain. I thought that maybe I had bruised or even broken a rib. The next morning I woke up and rounded on my patients at the hospital. By the end of that morning I could barely walk. The pain was unbearable. So finally agreed to go to the Emergency Room. There the ER doctor ordered a CAT scan and found out that I had a pretty bad Liver Laceration -a tear in my liver causing it to bleed.  It was pretty scary. I had to be admitted to the hospital and monitored to see if it would stop. Every day was agonizing. I was in horrible pain, I was getting blood tests all the time, the bed was unbelievably uncomfortable. Worst of all I could have died from this. I might have needed surgery to stop the bleeding.  It was horrible. Finally after 6 days of agony, my bleeding stopped. I was able to go home. I remember about 3 or 4 days later I was sitting on my couch at home and suddenly I had a terrible pain in my side. I remember when that happened thinking that I might have a bleed again. But what is amazing is that I remember vividly thinking: “I would rather die than go back to the hospital.” I did not want to deal with that experience again”.

I stopped my story to let Ms. Cantrel gather the point. “So Ms. Cantrel, believe me when I tell you that I understand that you don’t want to go back there. But I promise you we have no other choice. I promise I will do everything to make you feel better quickly. “

Ms. Cantrell sat panting. “Okay Dr Mash, I’ll go. Thank you for understanding.”  

Wednesday, February 4, 2015

Triage

I'm sure many of us have been in  the ER when it gets really busy. The waiting room is a hodge podge of various walks of life and various ranges of sick patients with their concerned family members. The job of a triage nurse is to identify how sick patients are and put them in line based on importance. So a sprained ankle will most likely go to the back of the line. There are many patients who know this. They've been around the block. And many frequent flier patients couldn't care less about the good of the whole.
Many times I will help out in the ER when things get really busy. When a patient presents to the ER with specific complaints they are roomed into the ER immediately. I have seen many times when some of the more seasoned patients go up to the triage nurse and say "oh I have the worst chest pain" and then when they've been put in their room ASAP I walk in and they're not bothered looking up at me as they enjoy the TV show in their bed. "Yeah doc, I've got this cold that I can't get rid of. Could I just get some antibiotics and get out of here?"

Sunday, February 1, 2015

Incentives

Private Practice physicians are a dying breed. When I moved to this small town I joined a practice that was owned by our hospital. I just don't have a mind for business and I just don't think I could survive if I had to spend any extra time focusing on non-medical thoughts. But more and more physicians are selling their practices to hospitals. It has just become too overwhelming for all of them.
I get paid based on several factors. I do get a base salary but it is very low. On top of that I get paid based on how many patients I've seen and how complicated they were. For example if I see someone in the office with a cold I get a certain amount for that. If I do a colonoscopy on someone then I get more for that. I used to be very happy with this. There were some frustrations. I feel like I do a lot of good for patients when I can see someone for a Geriatrics Consultation. However, that didn't get paid as much and I spent a lot of time on them.
A new trend has been developing recently in physician reimbursement - I get paid now based on what my patients think of me. Typically a questionnaire gets sent out after a patient is seen and they rate their experience. A certain amount of my salary comes from the results of these. To be honest I am not okay with this. There are a lot of times when patients have their own agenda and it is absolutely unhealthy for them to do it. For example, I had an obese obese patient who had heart problems. She wanted a specific type of diet medicine that can cause heart problems. She was not okay with me saying "no" no matter how much time I spent with her to explain why it would hurt her. Her answer to me was "I can't wait until I get my questionnaire". So I"m thinking to myself - I have 3 patients in the other clinic rooms waiting for me. They are getting frustrated that I'm taking so long. And this patient is mad because she's not getting what she wants. I just cannot win.

Thursday, January 29, 2015

Pendulum

We as physicians have been so bipolar about pain management. I can remember when I was in medical school I was taught to make sure that our patients pain was in control. No matter what. Specifically, even if it made patients dependent on narcotics.
I can specifically remember, that the older physicians before me were made out to be the bad guys. They didn't want to prescribe narcotics because they didn't want their patients to become "addicts" (note that I am using the word dependent and addicted differently here). Anyway, years go by and I'm sure anyone reading this will no that we in the United States are in the middle of a prescription narcotic epidemic. I'm sure it is in no small part due to how doctors like myself have been taught to use narcotics to treat pain.
Now the pendulum is swinging the other way - we are taught to be stingy about narcotic management. And sadly I have to drug test and pill count all my patients being treated with narcotics. In fact, doctors have been so averse to prescribe narcotcis that addicts are turning back to Heroine use.
I am going to keep this post and read it again in about 15-20 years. I am sure we will be handing out narcotcs like candy again.