Sunday, September 28, 2014

You Just Don't Get It

I have a patient who is blind. I diagnosed her recently with a blood clot in her leg. The basic way we can treat patients with this diagnosis is to treat with a oral medication called Coumadin. The medication is very inexpensive but it takes several days (sometimes a week) for it to work correctly. So until then there are a few medications that can be administered that work within minutes. There is a shot that can be given once or twice a day until the Coumadin is working. Or there is a new pill that you can take once a day that can be taken instead.
The whole process does not even need to take place in the hospital - you can do it at home. The problem with my patient was that her insurance would only pay for the shot that the patient could take once or twice a day. The other problem was that I and the nurses couldn't figure out how to teach my blind patient with arthritis in her hands how to give the correct dosage of the shot. She couldn't physically do it. She also didn't have family or friends who could drive her daily to the hospital for shots. I called her insurance and argued with them to pay for the new pill. But nothing worked. In the end I had to admit her to the hospital and have the nurses give her the shots until the Coumadin was working to treat the blood clot.
Can you believe it? I estimate the week of the new medication to be about $300 - compare that to the $10,000 her insurance paid for her hospital stay that week.

Monday, September 22, 2014

What Are You Trying To Accomplish

I have a relative who called me for advice the other day. By the way I have to save this idea for a future blog - when you become a doctor you get calls from family members about medical advice ALL the time. Anyway, their father is living in a nursing home in a "big city". He is 93 year old and sadly declining in health. He is obviously in his last year of life. About a month ago he was admitted to the hospital and while there was very confused. He had an MRI of his brain to see if the cause might have been a stroke. The MRI was normal for his age. then about a week ago while he was at the nursing home, my relative got a call that the doctor had ordered another MRI - basically to see why he was a little weaker recently. The family member didn't think the study was necessary - he knows his father is declining and that expensive studies or procedures are what their father would want at this stage of his life.
I have to wonder why in the world the doctor felt it was necessary to put a patient through such an aggressive workup. What was he trying to accomplish? I think at that stage of someones life (if that is what they would want) should have basic testing done but how is another MRI going to change their overall course? 

Sunday, September 14, 2014

First Patient

When I set out to become a doctor, I thought that my goal would be to prevent death. After all, isn’t that what we are taught when we are watching episodes of “House” or “ER”? So it seemed ironic that my first patient was already dead. In medical school, we are provided a cadaver to dissect, and learn all the mysteries that lie beneath the skin. This cadaver is known as our first patient. We spend countless hours with it, learning the structure and function of the human body.

For some, it is an honor to donate one's body in order for others to learn. Although I never met him in life, the person who donated his body to me and to my gross anatomy partners became someone that I spent more time with and learned more from than any other patient or teacher during medical school. All I know today about anatomy can be traced to that man. I know nothing about his life, but I know more about him and the cause of his death than he ever could have.
I prepared for my first anatomy class as well as I could. I studied as many texts as possible. I read our manual multiple times. Still, anxiety about my first class bit at my stomach the night before, like a ravenous shark tearing at its prey. I believe I could have studied for years, but I cannot think of anything that would have prepared me for seeing that dead body. Of learning how each vessel and muscle and bone fit together in that complicated work of art.
It was the first day of medical school. My classmates and I all met in the hallway minutes before class. We each had our own expectations of what lay ahead. Not just in the gross anatomy lab, but in our careers as doctors. It would all begin with our first patient, our first cadaver.
We entered through the doors of the giant anatomy lab. The air of the cooled lab room hit us like a breeze on an early morning jog.
Ahead of us lay 28 dead bodies, all underneath white plastic covers. The room smelled of the embalming mixture used on all of the bodies to preserve them for as many weeks as we had to dissect every part of them. It was a strange smell, like a sour fruit that had been left in my refrigerator far too long, a smell that I cannot mistake to this day. Standing at the doorway, each body lay on top of silver metal tables as shiny as new kitchen appliances. Each table was aligned in a neat row, and each row, in a parallel column. All gave an initial impression of sterility that I soon learned was just a fa├žade.
We assembled around our assigned cadavers in teams of four. As we unzipped the crackling, plastic cover of the cadaver, we were opening a world that I never really imagined existed, but here it was. Our cadaver then lay before us, beckoning us to open him up and learn from his insides. This man, this dead human was lying there so still that it seemed as though he was actually concentrating on being dead. I almost expected that he would suddenly sit up and laugh out loud. All of us stood silently looking at the body. It was in prone position, meaning that it was lying on its chest, with its face flattened on the dissection table and its nose bent to the left. Later, when we were finished “learning” from his back, we turned him over and his nose stayed bent, like silly putty, until we dissected it too. We knew exactly what we were supposed to do. Our manual read:
“Reflect the skin and superficial fascia by making the following incisions;
1. A longitudinal incision from the external occipital protuberance to the sacrum.
2. A transverse incision from the external occipital protuberance laterally along the superior nuchal line to the mastoid process.
3. A transverse incision from the spine of the seventh cervical vertebra to the acromion.
4. A transverse incision from the sacrum along the iliac crest to the iliac tubercle.
Reflect the skin and superficial facia laterally to the midaxillary line.”
I remember having to look up every single one of those words prior to that dissection in order to figure out what it meant. Basically we were creating four square shaped incisions into the back like a book to open up the back and reveal the lifeless muscles.
But it didn’t say anything about how to make an incision, or how to get up the guts to make the first cut. The strange thing is that at all of the 28 other tables this same silence
was taking place. Like the instant after a tragedy when the enormity of the situation comes to pass in the minds of those still alive.
Thousands of thoughts flew through my mind, and the flash of a thought about being a leader came to me. After all aren’t all doctors leaders? Isn’t that why I was trying to be a doctor? But how did one become a leader? I had no idea. Up to that point in my life I had never been a leader: Happy to follow like the wave of infantry before a battle. But I knew we couldn’t all stand there… not all 112 of us! As if a switch turned on I stopped looking at the cadaver and looked up at my partners.
“ Could I make the first incision?” I asked hesitantly.
A waterfall of relief fell over their faces and in unison they all agreed “of course” said one, “yeah!” said another relieved. The third quickly and happily handed me the scalpel. I was then left with the task of actually cutting. All of the books I read and movies of surgeries I’d ever seen looked like you would just lightly touch the surface of the skin and the anatomy would just open up like a book. They didn’t explain how thick the skin of the back is. It was as hard as cow hide. I had to push down and bear down with my body to cut deep enough into the skin and subcutaneous fat. My less than artful cuts tore the skin up and finally, mercifully, opened up to the muscles of the back. Those muscles were not shiny and red like the meat you buy at the store. The dead muscles, and the preservative used on him made those muscles gray and dull. They did not shimmer under the bright lights of the laboratory. They did not demonstrate what some of my fellow classmates would someday see in the operating room at their graceful hands. But the position of these muscles of the back were perfect and that was all we needed.
I spent months of my life in that Gross Anatomy lab with my patient and the 27 other cadavers. pouring over every muscle, nerve, artery, vein and bone over and over again. I look back on my gross anatomy class and remember vividly the moment I stayed late after a lab and suddenly realized that I was the only living person in that cold room, surrounded by 28 dead bodies. The eerie quiet was like the beginning of a horror movie. But it was the foundation of who I am as a doctor. I know all of my patients now in relation to the anatomy I learned from my first.

At the end of Gross Anatomy… at the end of all those weeks. At the end of all that work. By tradition, we had a ceremony to conclude our journey honoring those who gave their bodies to science. We each stood at our dissection table, no longer in the formalin stenched clothes, but in our normal school clothes, with our hands folded in front of ourselves in a private prayer. Our gross anatomy Professor stood at the front of the class and urged us to spend some time to think about the person that gave his body for us to respect and care for life. Strangely, I did not have an epiphany at that ceremony. I had already spent hours thinking about him in his life. Not his medical problems or what caused him to die. But how he lived and how he loved. When he was my age did he know that his remains would be inspected each muscle and bone at a time? The teaching he did for me in death would be used in my life as a doctor. Would I be able to do as much good in my lifetime as he was able to do in just those 12 short weeks? Those moments I had were not reflecting on his life, but were my time to say goodbye to a close friend. One who taught me to appreciate the life I had, and might someday help sustain others. Yes, it was strange that my first patient was dead. But I believe that my anatomy partners and I would bring good into this world because of him.

Friday, September 12, 2014

Where Are You Going from Here

There are times that elders are teetering on the edge. They are just barely able to live alone at home and one change to their strength or balance or thinking ability and they are just not able to be at home by themselves anymore. So generally when I admit an elder to the hospital I am always thinking about where they will go when their hospital issues are resolved. When we are older our functional ability (walking, balance, strength, thinking) doesn't always change. Sometimes with a little illness like an infection or stroke or fall, we lose some of that functional ability. So with a hospital stay, it is possible that that edge has been lost. Sometimes they still aren't safe at home, but with a little help from an aid that can come a few hours a week or a family member they could still live alone. Sometimes, it's time to stay with their family. Sometimes, sadly it is time for them to move on to an Assisted Living or Nursing Home.

Sunday, September 7, 2014

Surgery Versus Medicine

In High School there are the jocks and there are the nerds. In medicine, there are the surgeons and there are the Internists. Surgeons are doers. Internists are okay wringing hands and waiting for their tests and medicines to work. I was always looking up to the jocks in high school. I wished I was the high school quarterback. Alas, I was only 5 foot 4 and 125 pounds. So in medical school when 3rd year comes along and you are making final decisions on your specialty of course I was drawn to the surgeons. In their glamorous scrubs and their cocky attitudes. I had to be one of them. So when my surgery rotation finally came along I was really excited. I chose to do a Trauma Surgery rotation. To me, the most glamorous of the surgeries. It was toward the end of my third year. During the third year of medical school, after 2 years of classroom learning, you spend the year training with each of the major specialties.  I had done a whirlwind of all the specialties and was savoring the chance to experience surgery. To feel the OR, the adrenaline of saving a life.

Trauma Surgery is glamorous. When a Trauma patient is brought into the ER, the Trauma Surgery Team, is paged into the ER and arrive in hero fashion. Everyone clears out. Funny enough, they even clear out for the medical student on the Trauma team. They are loud and boisterous and call out commands. They are there to save the patient and it needs to be done right away like a TV show. They are awesome.

I was in Heaven. I thought I was the high school quarterback. We were saving lives and could do it within minutes. I thought I found my specialty. During my rotation, every 3rd night I was on call. The thrill of the pager going off was exhilarating, running into the ER to meet the patient. But by the end of the month the thrill of near death had become mundane. I had seen it all. I had seen a man who was in a machine shop accident and all his intestines except for 3 feet were eviscerated. I had seen tons of motorcycle accidents, and car accidents. One man had been shot right  through the tip of his nose. The bullet traveled through the center of his brain missing everything important. He was monitored over night and discharged the next day when there was nothing wrong with him.  I had seen one man who lived on the streets and was run over by a street sweeper. He had every single rib and hips fractured. The stories went on.
That rotation ended. I did another month of surgery, and then my fourth year began . I was obviously still interested in surgery so I started it with Trauma Surgery again (we get to choose at that point).

And then it happened, I remember being on call one night when the pager went off.  Glossy eyed I made it to the Trauma Port as EMS was rolling in an eighty year old man who had just been in a car accident. He was moaning. He could have been anyone's grandfather, or father and was actively dying. We all knew it and there was no magnanimous surgery to save him. But there was no emotional connection to him. We were all too tired and had been through too many of these episodes. Xrays were taken and I remember all of us on the team met in the Xray reading room to review the patient.

Our leader that night was a 4th year Surgery Resident. I don’t even remember his name. But at that stage many of them are jaded and worn.
 “Good old grandpa out for a Sunday drive” He said with disdain. This man was dying but it was said as if this man was troubling the Resident for waking him up. “Can’t they just take their licenses away or something?” we all laughed.... And then I paused. I had laughed too. We were all exhausted and something like this mans death was mundane. It was becoming a burden for me. That moment I realized,  I don’t want to become that Resident. I don’t want to lose any form of my compassion. In those months I had met many compassionate and caring surgeons, but I realized that I could and really already was becoming jaded and worn. I realized my love for surgery was some of the less surgical aspects. I was glad I realized it early on and moved on to be the nerd of the profession, the internist.

What is funny to me is that  I think I ended up one of the furthest specialties away from Surgery as a Geriatrician. I hold my patients hands at least once a day.

Wednesday, September 3, 2014

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.”  

Monday, September 1, 2014

Hidden Agendas

Both doctors and patients have a plan about what they want to do with a patient before they even walk into the room.
Sometimes, that is the battle. I have a plan in my head about what I think should happen that encounter. And the patient has a plan in their head about what they want me to accomplish as well. Sometimes those two notions don't match. Sometimes I and the patient don't do a good enough job communicating those ideas. Furthermore, sometimes I don't even realize that I had an agenda in the first place - nor did the patient. It's hard to reconcile two different ideas when neither party knows what they are.  It is an "art" of medicine that takes a lot of work to fine tune.