Tuesday, April 15, 2014

Code Blue

We are so caught up in our media's conception of doctors and health care. When I watch television show like Greys Anatomy I see an episode where a patient's heart stops and everyone rushes into the room to save the day. A few chest compressions and breaths of air and the patients eyes open and their family members are able to hug them and walk out of the hospital with them by the end of the episode. So neat and tidy. They don't show that that only happens 0.02% of the time. They don't show what a real code is like. Chaos, blood, the sound of ribs cracking with each compression, vomit, family members trying to enter the room and screaming as they are pulled out of the room to leave. I wrote a story a while ago about a patient who's family had to endure a horrible code. It is at the upper right of this blog page entitled "DNR".

Saturday, April 12, 2014

You Have Got To Be Kidding

I am not making this up. This patient's story had me with my mouth agape. He must have been in denial and could have ended up dead because of it.
Mr. Carlsbad is a 72 year old man who I met in the ER after he had fallen. He fell 3 days prior to coming into the ER.
After he fell, he couldn't get up. But for some reason that didn't seem to bother him. He lay there for about 5 hours when he started getting hungry. So he simply called his 93 year old mother into his bathroom: "Mom," he said calmly, "bring me the phone". So his 93 year old frail mother waddled into his bathroom with his phone. she handed it to him. She didn't ask him what was wrong, she didn't ask if she could help him, she just walked back to wherever she was before. So he gets the phone and calls the pizza delivery person and paid over the phone with his credit card. 45 minutes later the pizza delivery person walks into the house per instructions of Mr. Carlsbad and puts the pizza down on the bathroom floor next to my patient. Apparently this guy didn't think there was anything wrong with that. So the next day comes (the day after he fell). Still Mr. Carlsbad lays on the floor of his bathroom and can't get up. Still this doesn't alarm him, he sits there for hours obviously then that evening got hungry - so "Mom, bring me the phone". In comes 93 year old mom - still apparently not thinking anything was weird here and hands him the phone. Again he calls for a pizza - again the pizza delivery person (yes the same guy because I asked that question) puts the pizza on the bathroom floor next to him and again this pizza delivery person must not have thought this was weird because no questions were asked. So finally the 3rd day - I don't know how he used this as a cutoff - he asks Mom for the phone and calls a neighbor. Well this neighbor I guess did think that this is weird so they call my patients cousin who is a nurse. She also thought this was not normal so she called 911 for him.

Sunday, March 30, 2014

I Guess You Just Have To Experience It For Yourself

Typically when someone chooses to be a hospice patient, they have made the decision to be more comfortable in the last months (or years) of their life. Hospice care provides medical services, emotional support, and spiritual resources for people who are in the last stages of a serious illness. There is a patient of a colleague of mine who had a severe case of COPD (a chronic disabling lung disease). It was bad enough that she was put on hospice by her doctor. However, she still had complications like pneumonias (lung infections) and made the decision that when she did she wanted to be admitted to a hospital (some patients on hospice decide not to do that). One complicating factor was that we always ask patients when they come into the hospital what their code status is  - meaning if their heart stops or they stop breathing should we put them on a breathing machine and shock their heart?
Surprisingly this patient had chosen that she would want to be a full code. I was flabbergasted when I first heard it. I just thought there was a mistake I thought she didn't understand. I mean - if someone has chosen to be on hospice it seems like the exact opposite philosophy to chose to be on life support measures.
So one of the many times she was in the hospital we had a long discussion about her goals of care. She did indeed NOT want to be on life support. I felt better only because it was in line with what I thought was right.
A month later I saw that she was admitted into the hospital. I was rounding on her the next day and I saw her Code status was FULL. Again I thought there was a huge mistake, when we talked it turned out that she had changed her mind. She admitted that a family member had forced her to state that she wanted to be a full code in situations like that.
I couldn't change her mind. I tried though. I even had a discussion with hospice in an effort for them to educate her - but no good.
About a year later (last month) I admitted her again, this was the last time. Her infection got worse and worse and one day I knew that if she wasn't on a ventilator she wasn't going to make it. I sat next to her bed and made her absolutely aware that  if she was put on a ventilator, her lungs were probably not strong enough to wean her off. I made sure all of her family members were in the room during this discussion - but she wouldn't change her mind. I am positive that she personally didn't want to be intubated that afternoon but her family members wanted it and she was making the decision for them.
I am still horribly saddened by this, but that afternoon I stood there - me a Geriatrician - intubating a hospice patient and transferring her to the nearest hospital with an ICU. 2 weeks later she was getting worse and her family members made the decision to withdraw life support. She died and the outcome was no different (she probably suffered worse) than if she had just been made as comfortable as possible that afternoon in her hospital bed.
Her family members were asking her to make a decision that they felt was right for them-not for her (from their point of view). When we are young we have youth, energy and resiliency. Of course we would choose to have heroic measures taken, because we have better chances. We cannot understand that our goals change as we get older, that maybe comfort is preferable over the pain of trying to get over a hopeless situation.

Monday, March 24, 2014

You have Cancer but you might not be able to do anything about it

A few weeks ago, I had to break the news to a patient of mine that he has lung cancer. He has a mass in his lung on a CT scan I had ordered. It is obviously cancer, it needs to be taken out. But his cancer is from years of smoking cigarettes and unfortunately the years of smoking caused a severe lung disease called COPD (chronic obstructive pulmonary disease). That disease makes a surgery almost impossible as well, because his lungs might not be able to deal with the surgery. I saw him today in follow up and he has become so depressed. He has a cancer but he can't do anything about it.

Monday, March 3, 2014

All You Have To Do Is Lose Weight

I have a patient who is in liver cirrhosis. Cirrhosis is a disease where there is damage to the liver impairing its ability to make chemicals that are integral to your body's functions. Your liver also has a lot of blood flowing through it in order to work. So when it starts failing from cirrhosis that blood flow becomes harder and harder, causing other problems.
Cirrhosis is an umbrella term and there are many causes of liver cirrhosis. One that is becoming more and more prevalent is Non-Alcoholic Fatty Liver Disease (NAFLD) and is due to obesity. My patient, has NAFLD and unfortunately it is progressing slowly but surely. She will finally go into liver failure and die. There are no cures, no medications. There has been a lot of research and the only thing that has shown to improve the disease is weight loss. That's it. Weight loss. You just have to lose weight. But for many of these patients that does not work. They can not lose weight. And that is the frustrating thing for a doctor. As a doctor I am so used to doing interventions in order to fix things. I do a procedure to take out a cancer, I give a medicine to fix hypertension, I give a medication to treat a pneumonia. But there is nothing I have ever done to help my patients lose weight. I have tried spending hours of extra clinic time focusing on their diet journals to help with calories, hours cheer leading, hours begging them to get bariatric surgery. But I have never really gotten anywhere with them. And that is how it is with this patient.
Finally last week I got results of how her liver function is doing and it is definitely getting worse. She may die soon. I sat her and her husband down to give them the news. For years I had been trying to get her to lose weight because of her diabetes, or her bad knee arthritis. She really had been trying, but this time I had to give her something more concrete, "Ms Thomas, if you don't lose weight your liver will certainly fail and you will die."
I am not optimistic that this will work. For many of my patients, obesity is like addiction. You know it is wrong but despite the education you still can't stop.  I have no other ideas. Yes she is seeing specialists and unfortunately no she is unable to get a liver transplant.

Saturday, March 1, 2014

The Doctor is right next to you

I was in the local Pharmacy (there are only two here in this town) to get a card for a family member of a patient of mine that had died. At the other end of the store I heard an anxious voice,
"But I was sure there was another refille on it!."
A man's patient voice responded, "No maam, I'm so sorry but, there are no refills left on this unless you talk to your doctor first."
There was a pause and then a cracked voice, "But, its Friday afternoon and I wont' hear back from Dr. Mashaw until next week. How can I go without my blood pressure medications until then?"
I could hear she was crying from down the hall. It was Ms Thompson, an elderly lady who played everything by the book. If she went a day without her medications it was like the end of the world. I walked down the hall and stopped by the pharmacy.
"Hey Mike," I said to the pharmacist. We had talked a million times over the phone. "Can I just refille Ms Thompsons Metoprolol here? "
A look of awe came over Ms. Thompsons face. Like seeing her first sunrise. I am sure in her mind she was facing an imminent stroke or heart attack if she didn't get her medication, but then out of nowhere her doctor shows up and personally refills her meds.
Mike, the pharmacist was in his middle ages, the hair on the sides of his head showed a touch of grey.  When I showed up his look of concern for Ms. Thompson abated like a rescue ship in a storm. A brief smile grew at the corner of his lips as he said,
"I've been doing this a long long time, and this is the first time this has ever happened."

Monday, February 3, 2014

Dog Medicine?

I was on call last night and got a call from one of my older patients. She sounded frantic,
"Dr. Mash, I don't know what to do I think I took my dogs medication!" she said short of breath.

"Ms. Torth, don't stress, everything's going to be fine. Can you tell me the name of the medication? You'll have to spell the name for me." I said as calmly as possible.

She spelled the medication for me and it wasn't as bad as she thought, it was an allergy medication like Benadryl . The worst that could happen would be that she might get drowsy.

"How in the world did you end up taking your dogs medicine anyway!?" I asked

I explained that everything was just fine, nothing bad would happen to her. Relieved, she let out a breath of relief and answered, "Well, I was getting my pet Chihuahua's medicine and my medicine ready while I was talking to my daughter over the phone. I got so caught up talking to her about the weather and things that I lost track of whose was whose! Then I took my dogs by mistake."

I calmed her and explained to her that the dose of her medicine (for a dog that is the size of an infant) was 1/10th the dose of an over the counter Benadryl.
But that was the first time I've ever heard of a patient taking their pets medications!