Wednesday, September 2, 2015

I Cannot Win

Ms. Williams was a patient of mine at a nursing home with Dementia. She had been stable for years in fact I always forgot who she was when I was supposed to check in on her because she just had no real problems except for her memory. Unfortunately about 4 months ago she abruptly got worse. She began having hallucinations and became very paranoid. She kept thinking green men were outside her window and thought people were trying to get to her room to harm her.
As a physician the first thing you have to do is make sure there isn't a disease like an infection that would explain this quick change. I ran all the tests I could think of and all were normal. So unfortunately I had to treat her with medications that make the hallucinations go away. Sadly, as with all medications there are side effects. So as I increased the doses of these medications her hallucinations went away, but yesterday she was found more confused and she had a fever and was coughing. When I got the text from the nurse (yes no one calls me anymore, my phone goes off at least 2-3 times an hour with texts from nurses), a sinking feeling entered into my stomach. Like a fog rolling into San Francisco. I immediately knew that she had aspirated (she must have swallowed food into her lungs) and developed a pneumonia from that.
I immediately asked them to transfer her to the ER. But when EMS got there she wouldn't go because she thought they were out to take her to Russia and work in a camp. So I had to hold my clinic and drive to the nursing home and sit at her bed and remind her that I was her doctor and I think she is very sick and should go to the ER. Finally, she agrees and they take her to the ER, where sure enough she has a pneumonia. So now when the pneumonia resolves I'll have to figure out what medication to give her for her hallucinations that won't cause another aspiration event.

Sunday, August 23, 2015

My Redemption

I think this will be a good story, here is the gist of it and someday, when I have time, I'll work on making it a story.

Years ago, I was new to my practice. A patient of mine was in the end stages of their dementia. I had wanted him to be as comfortable as possible during his death, but he developed an inability to urinate because his prostate was too large. I had to put in a catheter directly into his bladder so that he could urinate. but the process was extremely uncomfortable for him. His wife sat in the room and couldn't take the agony and screaming from my patient. She became so upset that she grabbed my arm and violently pushed me out of the room. She didn't want him to deal with that.

I was at the beginning of my career and wasn't sure what to do. So I continued to give pain medications to my patient in an attempt to help. But it wasn't enough. As he couldn't urinate, he became more and more agitated with his pain. And the more pain he was in the more his family blamed me. They finally fired me and asked another doctor in town to care for him instead. This other doctor is a good friend of mine. His method of dealing with families and patients is much more authoritative an paternalistic than mine. My friend walked into the room with confidence and immediately removed all the tense family members, the then placed the catheter into the patients bladder without worrying about the patients pain. Literally a gallon of urine came out and the patient immediately calmed down. he died in piece days later.

For years I have regretted how I had handled that situation. For years I was frustrated.

Then last week I had an admission waiting in the Emergency room. It was a dying patient who had bladder cancer. He was at the stage where he was so weak his family had to do everything for him and they were just too overwhelmed. The hospice services in our area don't have facilities to admit patients into a "hospice house" so I admitted him to our hospital for "comfort measures"
The complication was that his bladder cancer was a large mass that obstructed his urethra (the tube that empties the bladder through the penis. So he had just stopped urinating.
His bladder kept getting larger and larger. I began having flashbacks of what happened to my patient years ago. As my patient writhed in pain the family kept looking at me for direction. If his bladder kept enlarging with urine it literally could have burst. that would be a horrible death. No attempts at putting in a catheter trhough his penis worked. the bladder cancer had grown large enough and was blocking it.
So I took charge and arranged for my patient to be transferred to another hospital where a doctor could put in what are called "percutaneous nephrostomy tubes" - literally tubes that go directly through the skin into the kidneys and drain urine- that way bypassing the bladder.
He was sent directly back to me in obvious relief.
He was still dying but the agony of an enlarging bladder wasn't part of his pain. He died peacefully days later with his family with him.
To them, I was a hero. I didn't feel like a hero because of what had happened years before. But I did feel redemption. In a way I felt like the patient from years ago had accepted my apology.

Wednesday, August 12, 2015

You Keep Using that medicine - I do not think it works the way you think it works

Years ago people used to think that if you have a patient with dementia in the hospital going through "sundowning" you should treat them with anti-anxiety medications. The patients will yell and scream and try to get out of bed. It's all because they get confused. The old way of dealing with this- many years ago was to tie them up in restraints. Thank God that is not done anymore. That became illegal. The next thing was to give "chemical restraints" which is still wrong by the way. But that means giving sedating drugs that will make them fall asleep and stop fighting and try to get out of bed. That is no longer the accepted way of doing things -but there are still doctors who are using that older way.
The other night I had a patient in the hospital - he is an older patient who I admitted due to an infection. He himself has dementia and was in a new place and was even more confused because he had an infection in his urine (a UTI).
That night I was not on call and the patient became confused and tried to get out of bed "to go home"
the nurses freaked out and called the doctor on call who immediately asked them to give the medication Ativan - this is an anti-anxiety medication which causes sedation.
The nurses did it and unfortunately it caused the exact opposite reaction. Which is not uncommon. Instead of calming him and sedating him - it freaked him out. He started having hallucinations that aliens were coming into the room and he grabbed his walker and used it as a stick to try and whack the nurses. He screamed and fought and if it weren't so sad I might have laughed.
They finally kept giving him more of the medication that he fell asleep - he slept for 2 days. It was horrible. I feel responsible.
In reality there are much safer ways to treat this situation. But that medication was not one of them.

Tuesday, August 4, 2015

What Is Wrong With You Part 2

Here's another story I think will be good when I have time to write it.
I had a patient from another story called "My Redemption" I think its posted on June 28, 2015

 I had an admission waiting in the Emergency room. It was a dying patient who had bladder cancer. He was at the stage where he was so weak his family had to do everything for him and they were just too overwhelmed. The hospice services in our area don't have facilities to admit patients into a "hospice house" so I admitted him to our hospital for "comfort measures"
The complication was that his bladder cancer was a large mass that obstructed his urethra (the tube that empties the bladder through the penis. So he had just stopped urinating.
His bladder kept getting larger and larger.
I had tried to put a catheter into his bladder through his penis (called a foley catheter) and no matter what size it was the cancer mass kept blocking it.
So the only other choice was for him to have a special tube put directly from his back into his kidneys called "percutaneous nephrostomy tubes" placed. This would collect the urine and it would run out the tubes into a bag. Therefore skipping the bladder and urethra (the tube that empties the urine out of the bladder into the toilet).
That is NOT a hard or complicated procedure. Usually a radiologist does this. Unfortunately at our small hospital we have NO specialists (just me and the ER doctor). So I asked my head nurse to arrange a transport ambulance to come and take my patient to the nearby hospital with specialists. then wait there while he gets the tubes placed (no more than 45 minutes including all the paperwork) and then they would bring him back to me so that I could make  him comfortable in his last days - dying from cancer.
Sounds so perfect.
So I call the Radiologist - his answer - "I'm so sorry man, its Sunday, I'm not in the hospital and I'd have to come in specially to do this. Anyway, I never do these things unless a urologist is around to advise me"
AAAHHH
"Thank you so much for your time" I respond
AAAAAHH
So I hang up and page the Urologist on call - here we go again - another hot potato [see my first post entitled What Is Wrong With You]
This specialist sounds horrified at my story "You should be transferring this patient to the university hospital who has been treating his cancer" he says, "he shouldn't be here" Oh yeah and its Sunday, I finished rounding on my patients and I'm at home lounging at my pool.
"I respond - this man is dying  - if he doesn't get the perc neph tubes his bladder could burst, the University Hospital is 2 hours away and you guys are 45 minutes away. I'm not asking to transfer him. I just want him to get the tubes placed."
"No there's too much risk in that" he answers. Don't you see I could be held responsible if something goes wrong"
REALLY - like my patient might die? He is dying!
So I was met with a brick wall. I couldn't let him die in agony like that. I just couldn't
So after a long discussion with the family, we agreed with my plan and I transferred him to the Urologist in charge of him at the university hospital 2 hours away. All 8 of the family had to go down there and be with him during the days that followed.
- being a university hospital they misunderstood my plan and thought that they should be more aggressive - yeah that meant trying to treat a metastatic bladder cancer that had no chance of saving a 86 year old man in poor health. Finally the surgeries they did didn't help and they gave up and guess what - they put in Percutaneous Nephrostomy Tubes - and sent him back to me weeks later to die with dignity. Which he did. But after countless days of agony when their fruitless procedrures were performed.
This was a Geriatricians nightmare. But I was helpless to do what was right for my patient.



Thursday, July 23, 2015

Game Face

This will be a good story (someday when I have time to write it)
Every profession I'm sure has their moments when you have to have your "game face" on. In sports you have to look confident and sure of yourself against the other team. so that your opponent and the fans think you know you will win.
As with me. The other day a patient of mine was crashing quickly. his vitals were horrible, and I knew a code was inevitable.
But if I had freaked out and yelled and screamed and waived my arms. The family sitting next to my patient and the nurses and staff would have lost all confidence and freaked out themselves. So I had to smile and speak with affirmation. speak evenly and patiently. It settled everyone, and when the patient did code. I led the code and things went so much more smoothly.
Yes, I was screaming and crying and running away from the hospital like an embarrassed soldier running away from the battlefield. But that was in my head.
The code went okay. The patient actually survived. I had to intubate her (put a breathing tube down her throat) and and the helicopter came to send her to a hospital with specialists.
I looked like a hero.
Because of my game face.

Monday, July 13, 2015

Why Do You Want To Be a Doctor?

I am letting a few college students follow me in the last few weeks. It is summer and its time for college students to think about what they want to be when they grow up. I think back to those days of my life and remember how excited I was about how many opportunities I had. How unsure of my future, how scared I really was.
But then when it came time to apply to medical schools the number one question on my application was: "why do you want to be a doctor?"
It was one of the most common questions when I would go for my medical school interviews.
Why become a doctor?
Back then I had all the usual answers: I love problem solving, I love doing things with my hands, I love implementing biology.
I am a doctor now and I'm trying to answer that question with: Why do I like my job?
I really love helping people. I love diving deep into the humanity of it all. preventing death, bringing life into the world, helping people out of this world. The intensity of this life all tied into one single day.
In one day I go to clinic and see a 7 day old baby and make sure there are no issues with their birth. I help his parents with the simplest of tasks - how to feed their child. That same day in the hospital a patient of mine dies at the age of 93. Then later that night at the free clinic I treat someone for pneumonia with a prescription for an antibiotic worth $15- Preventing a hospital admission worth $10,000.
I love a job that allows me the chance to help someone get better from a life threatening illness, or prevent them from getting it in the first place. I'm honored that all of these people allow me be a part of this shared experience.

Thursday, July 9, 2015

Finish Your Sign

Please note: I do have permission from this patient to post his pictures.

One of my favorite patients is a 93 year old man who still lives alone and is living a full and busy life. He still drives and is an artist. He gets pieces of wood and paints pictures on them. He sells them and is actually pretty popular. He was asked by a local business to make a large sign recently. A couple weeks ago he came into my clinic to check in. We were finished with our visit and he asked me to check on a lump he found on his groin. I checked and a sinking feeling came over me. I really didn't want to believe it but it looked a lot like a type of cancer. I was so upset I sat down and looked up at him.
The gist of our conversation at that point was what he wanted done. 
"If this was cancer would you want to know?" I asked.
He wasn't sure, he thought for a while. Finally he decided he would. So I referred him to a surgeon to take a biopsy. 
About a week later the results came back that he had metastatic malignant melanoma - a kind of skin cancer that had traveled all over his body. There is no treatment for that. 
As soon as I found out, I had asked him to come back in and see me. I never want to deliver news like that over the phone. I sat with him and gave him the bad news. We talked for a while and I answered his questions. After that he left looking obviously devastated. 
I never like to deliver news like that with anything other than that he has cancer. after that they don't hear anything. 
He followed up with me this week. He looked like he had been coming to terms with this diagnosis.
My next question is would he want to know how advanced the cancer was? That way we could come up with an answer about how much more time he had to live. 
But he just looked at me and said
"Doc, I'm sick of all these visits. Coming in to the hospital for tests, visiting the doctors, I just want to finish my sign."
I remembered how excited he was to get this project making a sign for someone. 
Then it struck me. I'm so caught up in preserving life, and so caught up in knowing what my patients are up against. He knows he's going to die. He has come to terms with that. He just wants to simply live his life and whenever he dies is not the point. He looked at me again and said, "if my life is ending that doesn't mean I have to stop working on my sign."