Tuesday, November 18, 2014

The End of The Greatest Generation

I sat at the nurses station that morning and reviewed the list of patients I was going to see that day. Next to the computer was another computer with the EKG tracings of many of the patients in the hospital. All tracings were normal. That screen glowed with the lines of normal heart rates, like shooting stars on a starry night.
As I focused on the next patient a nurse stepped up next to me.
She was hesitant at first, "Dr. Mash, I think Mr. Carson is dead"
It was more of a statement, but she was asking me to confirm. I looked up at her. She had tears in her eyes. Mr. Carson was a favorite in the hospital at the time. He was 92 and a World War II Veteran. He was always bright and cheery, like a game show host.
"That doesn't make sense," I said, "look at his telemetry tracing. He's still got a heart rhythm."
We looked at the computer screen next to me. Sure enough there was a normal heart rate tracing on the monitor.
I stepped up and walked across the room to Mr. Carson's room. As I walked in I could see the bluish tone to his body. I had seen that many times before. The look of death. I listened to his heart with my stethoscope and heard nothing. No breaths, no heart beat. The monitor wasn't lying. He had something called Pulseless Electrical Activity. Where your heart is still sending electrical signals but the muscles aren't pumping. He was dead.
I looked up and the first thing I saw next to his bed was his hat. One of those black hats with "World War II Vet" written on it in yellow letters. He was so proud of that. He was 92 and still talking about it with the nurses. I realized then that we are losing that generation now. These are our last men and women from that generation. Still so strong and ambitious and full of hope for the world. We are losing them one by one in one hospital after another. One nursing home after another. These are not ordinary deaths.

Saturday, November 8, 2014

Mass Casualty

I've been as nervous as any other doctor about Ebola. We've been talking about disaster protocols at our hospital and it reminded me of a time when I was at a party with a friend of mine who is a doctor in a bigger city.

He is an ER physician. We were comparing experiences. He was telling me that a while ago they had to enact their hospitals Disaster Protocol. Basically whenever something horrible happens they need to have multiple doctors and nurses and other staff available so they have ways to get them to come in. Sadly a bus had crashed and had run over a group of children standing on a corner. It had crashed because of a gang shooting nearby had caused the person shot to drive their car into the bus. Everything turned out okay, no one actually died!

Contrast that to the small town here.
"Well," I smiled, "the last time we enacted our Disaster Protocol, was during our Winter Parade. There was a float that was being drawn by some horses. A drunk Parade goer got so excited about one of the floats that he pulled out his concealed gun and shot it up in the air. It freaked out the horses and they jumped up and then forward into another float, that float then crashed into the other. All the people fell of their floats and were rushed to our ER." My friend was laughing so hard at this point he choked on his coke.  "Our disaster protocol is to call all 5 of the doctors in this town to come in and help the ER physician. We were all at the parade anyway so just drove on up next to the ambulances."

Wednesday, November 5, 2014

Hope

  When I think of my father. I always have an image of him from when I was 8 years old. I had just slipped from a rock as I was trying to cross a stream and he picked me up and put me onto the other side. Stepping in the stream with his shoes on so that he could get a better grip. He held me as I cried in frustration. At that moment he was unbreakable, invincible. All these years later I still have that image in my head when I think about him.

     Last week I admitted a 80 year old patient of mine into the nursing home. Up to that point he was healthy with just some hypertension and high cholesterol. Unfortunately, he had had a stroke and was left with some dementia (his short term memory was effected). He was also weak and unable to care for himself at home. We admitted Mr. Pearington to the nursing home so that the physical therapists could work with him and hopefully make him stronger. When I met him though, I knew it would have to be permanent. There was no hope for him to improve his strength and memory enough to be able to go back home alone. His son also lives near here. He was a successfull businessman here. He was at his fathers bedside when I first admitted him to the Nursing Home. He was at his fathers every beck and call. Fluffing his pillows and tucking the sheets twice, three times. There was a sense of urgency. He was much younger than his father maybe 50 or 60 years old. But you could still tell he was Mr. Pearington's son. The strong jaw and piercing eyes.

     We talked for a while and then I did my examination. Through all of this I was barraged by questions. His father's stay at the hospital was a nightmare. He suffered the stroke and was treated in the intensive care unit because he subsequently had a pneumonia (an infection in his lungs). No one every answered any of his questions about his father and he was frustrated when we were in the room together.
     "Why is my fathers blood pressure so high? Why can't my father eat as well? Why aren't we talking about putting a feeding tube in his stomach? why is he on this medication called Plavix? " The questions zoomed by like cars passing by in a racing video game.
     I answered as patiently as I could. Minutes went by that turned into 2 hours. My answeres weren't helping Mr. Pearington's son. Finally I realized that he was having a hard time realizing that his father  wasn't invincible anymore. Sure we see our parents grow older and stumble. But his father is no longer his father. His personality is different now because of the stroke and he has lost some of his humanity because he can not take care of himself.

     "Mr. Pearington, my heart breaks to see you deal with your fathers situation." I finally said. "If this were my father it would be so hard for me to realize that he isn't going to get better."

     Mr. Pearington's peircing eyes wavered, his strong jaw began to shake. He cried then. As he realized that the hope he had been carrying for his father to get better was probably not going to come true. He held his fathers hand, and I stepped out so that Mr. Pearington could be with his father. To come to terms with how his father had changed.

Thursday, October 30, 2014

Learning New Skills

    Every day at work, every night at home I learn a new fact about a disease or medicine. I am learning about the science of medicine every day, it is just what a doctor does.
But being a doctor, especially a primary care physician. You have to learn how to interact with patients. How to communicate, how to empathize. During medical school, we had to learn about many aspects of the history of medicine. Years ago, doctors tried to objectify everythng, including patients. As they rounded in the hospital they would stand in front of each patients bed and say:  "Okay here's the gallbladder." then move on to the next patient's bed "and this is the stomach cancer".
    Years passed and the trend has become to realize that we can still be good scientists and treat our patients as humans, to empathize with them. I remember rounding with an attending during medical school who wanted me to describe one personal aspect of each patient as we discussed them, "Mr. Carson is a 89 year old with pneumonia. He has a cat at home named Toonces". - it was that attending's way of teaching us empathy so that we could interact more personally with our patients.
I learned so many peals about personal care during medical school that carried me to today.
    But during my medical school we didn't yet use computer medical records. We still saw a patient and wrote a progress note on paper or later dictated into the phone.
But over the year's we now predominantly use Electronic Medical Records (EMR's). There are only a handful of doctors now who still work with paper. And I find myself learning new skills about how to make my patient think I still care about them. I mean, I have only 15 minutes generally between each patient. It generally takes 10-12 of those minutes to input my information into the computer. I definitely don't have time to type into the chart between patients.  It is so unbelievably easy to spend the entire visit and only once look into the patients eyes (to do my exam) before leaving.
As physicians, without even meaning to - we have again objectified our patients. Our patients see us looking at a computer and not them for the entire visit. They don't get a sense that we care about them as people. And we can't empathize with them if we can't carry on a conversation while typing into a computer the whole time. Without interacting with our patients personally we have delved back into the objectification of our patients. We can't empathize.
So I'm back to learning how to interact with my patients - learning how to force myself to move out of the way of the computer and sit next to my patient and talk to them again. Just like with medical knowledge, I learn something new each day.

Thursday, October 23, 2014

Oh Just One More Thing

It is inevitable. At least once a day, at the end of the visit, a patient will always have one more important thing to ask or talk about.
Yesterday I sat with Mr. Carson in the clinic room. We had known each other for years.  He was the manager at the farm coop, and I had asked advice about my lawn mower more times than I could remember.
He had come in for a regular check up and as with any patient's visit I start the office visit asking
    "So, how can I help you today?"
    "I don't know doc you asked me to come in..." answered Mr. Carson, sardonically.
    I smiled, "Alright, Mr. Carson, then I wanted to review your hypertension and diabetes. "
We reviewed his medicines and symptoms and then, when I wanted to do my exam, I did what I do with all other clinic visits,
    "Okay sir, is there anything else you want to talk about today?"
    "No sir, not that I can think of." was his answer
I then moved on to my review of systems - this is a portion of the exam where I ask general questions like "have you had any weight loss recently?" or "any fevers, or headaches or changes in your vision"
    For the second time during this visit I asked, "Have you had any chest pains or pressures? any shortness of breath?"
    "Nope, I'm fine" was his immediate answer.
After that I moved on to the physical exam - listening to his heart and lungs, checking his legs for swelling. All was normal.
I sat back down and typed furiously into the computer chart. Making sure my progress note and orders were perfect.
     I looked up then from the computer screen, like a mad scientist distracted from his invention, "Okay Mr. Carson, is there anything else you'd like to talk about today? Do you need medication refills? Any symptoms bothering you?"
    "Nope, I'm good" was his terse reply.
I then closed up the computer chart and stood up to shake his hand and leave.

   "It was great to see you again sir, I guess I'll be seeing you again when something else goes wrong with the lawn mower" I joked as I shook his hand.
He smiled and then just as I put my hand on the doorknob to leave he asked,
    "Hey doc, I've had this pain in my chest off and on for a few weeks, do you think there's something wrong with that?"

Wednesday, October 15, 2014

Wow

I just met a lady for the first time here at clinic. She came in to see me for a cold. She is 90 years old. First of all, most people don't make it past the age of 81. If they are lucky enough to be 90 they are generally taking about 4 medications, and live with their children who take care of them.
Not this lady - she lives alone with her dog. She does all her own Activities of daily living. She takes no medications, she cooks for herself, drives, shops, pays her bills. For heavens sake she baked me brownies when she came in to see me.

Wednesday, October 8, 2014

The Old Mans Best Friend

It was late in the evening and I had finished seeing my last patient in clinic. I was excited to get home and see my family. Just then vibrations and the ring of my cell phone came from my pants pocket. The tone a harbinger from the hospital. Reminding me that I was on call. With a sigh, I answered a call from the Emergency Room. It was the ER physician asking me to come in and admit a 98 year old man with a pneumonia.

“Wow, 98!” I thought, it’s not often you live to be 98. When you get that old your body becomes very frail and weak This might be his last day or two of life. Even with the correct antibiotics someone that frail might not be able to survive. I gathered my white coat off of my chair back and walked across the street from my office to the hospital.

Mr. Shilling lay in the emergency room bed motionless. The only noise in his room the beeping of his IV pump announcing that something was wrong with the IV. He must have been very cold because his blankets were wrapped around his body and covered his head, only his face showing. Like a mummy before embalming. He was so skinny that he only took up a tiny portion of the bed. Like a small squirrel hiding in a giant tree during a storm. His eyes were sunken into his head staring up at the ceiling until I walked into the room.
   
The whole picture was pathetic. A flood of preconceptions entered my head. I had taken care of thousands of patients at the end of their life. Many more times than not they were like this. Poking and prodding with needles and useless medications and painful procedures and tests only to prolong an agonizing life by days with no improvement in quality. This looked like another chapter in that tome. Until he spoke.

    “They say pneumonia is an old mans best friend” Mr. Shillings voice quivered, barely audible.

I was caught completely off guard. “Huh!?” was basically all I could muster. I had heard that phrase before. But I was totally surprised a 98 year old  man, lying sick in bed said it. Maybe someone else was in the room. I looked around for someone hiding.

    “When I was young, they used to say it because it brought a swift painless death to someone. “ He said explaining. “I guess that is happening to me now” the defeat already exuding from his voice.

I could tell that this was no normal 98 year old. I sat on the stool next to his bed and put my hand on the blanket over where his hand was. Whoever he was, this was scary for him and I wanted to help guide him and make him more comfortable.

    “I’m Dr. Mashaw” I said with as confidently as I could. “I am the doctor on call today and it sounds like I need to admit you to the hospital because you’re pretty sick.” I wanted to sound confident and caring, the opposite of the “Huh” that I unprofessionally muttered earlier.

    “This is not the place I want to die.” Mr. Shilling’s said quietly and flatly. His body lay weak and it was obvious he seemed to be giving up.

But on paper he had an easily treatable pneumonia (an infection in the lungs). So I persisted and slowly I was able to get his history and physical exam over with as painlessly as possible. I assured Mr. Shilling that he was going to be okay. He just needed a couple days of antibiotics and I was sure he might even be able to get home if all went well. What I didn’t say was that I had seen many patients in the past who had given up on life. No matter what the disease, once they had given up some switch was turned and they died shortly after. I didn’t want that switch to turn in Mr. Shilling.  I finished my orders and turned them in for Mr. Shilling to be admitted.

Early the next morning, Mr. Shilling was my first patient to see. I walked into his room with my chart in hand. Mr. Shilling was still wrapped tightly in his blanket, eyes staring at the ceiling.

   “Mr. Shilling, the antibiotics are working!” I said trying to infuse energy into him, “Your blood work is better today and you haven’t had a fever since yesterday.”

With those words something changed in him. He turned his head to me and it was as if color and warmth  flooded into his face all at once. He almost sat up in bed with excitement. He didn’t seem to believe that he might leave this place. I guess thats all it took. I finished up my evaluation and made some changes to his treatment course. I didn’t have much time to talk but promised him that if he was feeling better the next day that I might be able to discharge him home. This time a smile.

The next morning even better news. He still had had no fevers, and his blood work was now normal. He no longer required oxygen and the decision to discharge him home was simple. As I entered his room, he was actually pacing back and forth. He obviously had enough energy now.

As I sat at his bedside writing out his discharge orders, we talked.  It turns out Mr. Shilling is more fascinating than I could ever have imagined. At 98 he is a one in a million patient. I will probably never meet anyone like him again. He had served in the Pacific during World War II,  but in college he actually had gone to Germany to study briefly. There he was questioned for over 3 hours by the Gestapo. His stories were colorful and there were many of them. This man who only 2 days ago lay dying in bed, now was speaking full of energy.

I wondered how it was that someone so weak two days ago could have so much energy now. Sure his pneumonia was the main reason. But when I first saw him he also seemed devoid of the spirit that I now saw in his eyes. As if he was deciding in his mind if he should give up.  Just the other day, I had admitted a lady with a pneumonia. During the workup, I had also diagnosed her with a newfound mass in her lung. She had cancer. This ladies energy poured out of her when I told her, and unexpectedly she died that night. I could not think of another reason other than she had given up.

I described my thoughts to  Mr. Shilling, and his response was interesting. He sat thoughtfully for a few moments. “I think there are definitely two components to our life.” he said at last, “genes, and luck. My mother and her mother  lived to be very old, so that helps. But there were many times in my life when I could have died early. When I was in The War, I was being shelled by the Japanese. There were times the missiles missed me by inches. That was luck.”
    Initially that was all that involved a long life in his mind. But I thought for sure there must be something else. Something else that tells us to get up each morning. What tells us to give up or to keep “Raging against the dying of the light” as the poem goes.

Again he thought. “True, I also wake up every day with the need to do something. That’s it... simply to do something. No matter what, even just to prepare breakfast.” maybe that is the third ingredient. A need to do something." He paused, took a breath and said, " We are all suggestible, maybe I am just more rebellious and less suggestible than others.”