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.”

Sunday, October 5, 2014

Lying To Patients

Years ago people thought that a patient with dementia should be confronted with the truth at all costs. If a patient has delusions, or hallucinations they should be reminded of what their reality was. That is no longer the case. Those hallucinations are real to patients with dementia and are very stressful.
The other day I was sitting at the nursing station at the nursing home and Mrs Carson slowly walked to the nursing station. She was almost at tears,
"Maam," she said fearfully to the nurse, "I think someone is breaking into my bank account and stealing my money, I wont have enough money to stay at this hotel."
The nurse held her hand gently and said, "Ms Carson, we just called your bank and everything is okay.
A rush of relief washed across Ms. Carson's face. She began to smile. "Thank you,"she said, "you've made me feel so much better."

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.