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.

Sunday, January 25, 2015

Stressed

A couple months ago a patient of mine died due to her severe dementia. People many times believe that dementia is a disease that only effects our memory but in fact it slowly damages our physical bodies as well. Our ability to swallow and eat for example get worse with dementia.
My patient was married and she had a loving daughter. Both watched in horror over the years as she went from a vibrant, sharp lady into a shell of a person.
Then last week the daughter brought her father in. He had been having worsening memory problems and they were both terrified that he might have dementia.
It must be horrible to have watched someone go through that - as you sit helpless watching. Then to think it will happen to you.
In the end Dementia is a very hard disease to diagnose. Your memory can be effected by so many things. And sometimes memory changes can be subtle and difficult to elucidate. However, I think that he did not have dementia. He was still recovering from the loss of his wife. And depression or grieving can definitely effect memory. He could still have dementia and I warned him about that. But there is just no way to tell at this point. When I told them this a wave of relief rushed over both of them. They both hugged me.

Thursday, January 22, 2015

Do No Harm

Many times as we age, our bodies and sometimes minds falter. As things progress there ends up being a breaking point - a point at which we are no longer safe living independently. For example we become too weak or our balance is off enough to simply walk across the room. What happens then? What happens when we are no longer safe to live alone?
I used to think that prolonging someones life (within limits of course) was the ultimate goal. There have been so many patients who live alone.  There was a lady who had progressively worsening weakness in her legs, and over the course of 6 months I had admitted her to the hospital 4 times for complications due to falling. She was obviously not safe to be alone at home. I fought this lady tooth and nail to get her placed in a nursing home. But she absolutely did not want to go. She wanted to go "back home". 
These people could live many more years if they were cared for by someone else - either a home care provider (which ends up being expensive  - too expensive for some), or at a long term care facility. I think they would be pretty happy too. But many just don't care. There is a sense of being that comes with living independently and many people believe once they've lost that - their life is no longer worth living. Is it really my place to tell them otherwise? 
As long as they are not hurting anyone else - then if they die alone that is their choice. 

Sunday, January 18, 2015

Transitions

My wife's parents are starting to think about what their lives will be like when living in a big house isn't as easy. They are looking at CCRC's (Continuous Care Retirement Centers). Here is an article about what a CCRC is. What I find interesting is that they are not even thinking of living with or near their children. Many countries - actually most, have a culture in which we spend our last years with family: our children.
I think it is a sign of our culture, of what it is to be American. Not being with our children in those last years is a sign of our independence, our need to prove that we can do it all on our own.
But truly I would want my children to care for me in those last years.  Whether I was living with our near my kids,  I would want to be near my children so that they could be involved with my care.

Saturday, January 17, 2015

Geriatrics Isn't Just Medicine

I saw a patient yesterday in clinic. She was the daughter of a patient I took care of 2 years ago. The patient I took care of 2 years ago had colon cancer and was dying. She had been a longtime patient of mine and unfortunately was losing her battle with cancer. I admitted her to the hospital to take care of her due to dehydration. Each day I saw her she looked more and more frustrated.
Finally I asked her what was bothering her.
"I'm withering away and dying here and I can't have a good home cooked meal" was her answer.
I cornered her and asked her what her "perfect" meal would be: steak, green beans, baked potatoe
So that night at home my family and I - including my 6 year old son and 2 year old daughter- cooked her perfect meal, including a chocolate cake for dessert. We packed it up in tupperwear and took it to her room, all of us.
The look on her eyes was pure amazement. I didn't stay to watch her eat but the nurses said she ate every last bite.
Now 2 years later her daughter established care for me. She did so because of how I treated her mother. What I did was not being a good doctor. I didn't cure or fix anything. I just tried to bring happiness to a bleak situation. But her family was still thinking about it.

Sunday, January 11, 2015

Wow update - communication is key

Yeah, he did get the biopsy of the "mass" found in his head on the CT scan. It was a cyst. So for these 2 years he has been under the impression that he had cancer. He put it off because his wife was undergoing chemotherapy for her breast cancer and he didn't have health insurance himself. Whatever the real story is - I think that the doctors who cared for him in the past didn't communicate to him clearly that he might not have cancer. It's happened to me many times unfortunately. I do my best to make clear that a polyp I took off during a colonoscopy was NOT cancer but "precancerous" and I overhear them talking to someone "Yeah the doc said I have cancer".
Those words of advice during medical school were so true- when you have a patient with cancer or possible cancer - all they hear during your conversation is the word cancer. So don't make it complicated and drawn out with details.

Tuesday, December 30, 2014

Wow

Today I did an EGD (a scope that goes down into your stomach) on a man who was told 2 years ago he had "throat cancer" and "Barretts cancer of the esophagus". He was admitted by my partner last night and when I saw him this morning his story became more and more depressing. Apparently 2 years ago he went to an emergency room - he didn't have health insurance. He was admitted to the hospital because one of his labs was abnormal. During his stay there they did a pretty extensive workup including a CT scan of his head and neck and then an EGD. When he was leaving the hospital they told him to go to a cancer doctor because he had "stage 4 throat cancer" and "barretts cancer of the esophagus". But he didn't have health insurance and at the time his wife was being treated for breast cancer. He chose to ignore the advice. He wanted to deal with it after his wife got treated.
A year later his wife was in remission and he told her about it. Her response was to leave him because she lied to him.
Then yesterday he went to the ER because of vomiting and diarrhea. He most likely had an infection and we admitted him to the hospital for treatment.
I wanted to work up his "cancer" so I got another CT of the head. There was a lesion in his throat but it was a common cyst. I had my radiologist review it with a university radiologist. Furthermore, I did an EGD on him today and there was absolutely nothing wrong with his esophagus or stomach. To make sure, I took as many biopsies as I could.
Hopefully the biopsies will be fine. I will also refer him to a specialist to take a biopsy of the cyst. But I really don't think he has cancer.
Can you imagine? He's gone the last 2 years thinking he has life threatening cancer when he really didn't. He even lost his marriage due to it.