Rebounding from Frailty

Mr. Katz sat on the edge of his chair in my clinic room. His eyes wide like a child in the principals office. I had just discharged him  earlier in the week from the hospital. His stay in the hospital was one complication after another. His final list of problems when I sent him home was a page long. He had developed blood clots in his lungs, and the strain from those caused heart failure and subsequently, excess fluid in his lungs. Those setbacks caused him to get weaker and weaker. When I finally was able to send him home, he needed a walker and oxygen. He had gone from tending to his acre sized garden one day to having his wife follow behind him with his oxygen tank. His eyes and mannerisms told the story of a man beaten and down.

The problem when we get older is that we don't rebound as well.  When an elder can't rebound from one illness and develops another, and another,  then sadly sometimes they just spiral towards death. Like a feather floating towards a lake. There are a million factors that can cause an elder to be able to rebound from an illness or not. In Geriatrics we sometimes use the term frailty. There is a lot of research done to see why one person is able to rebound from a disease and another isn't. But in the end many times there are those intangibles that you just can't measure.

    "Well Mr. Katz, You've been through a lot. You look frustrated."
   
   Mr. Katz chose his words slowly, "Dr. Mashaw, I used to have a 1 acre garden. Not 6 months ago I went on a trip up to Maine with my wife. Now I'm not even able to walk to my bathroom without getting short of breath." He went on hesitantly, "yesterday an old friend of mine had invited me to go visit them at their cabin in Tennessee. I sat there holding the phone and cried. You see I don't think I'll ever be strong enough to travel again."

"Mr. Katz, your standing at a doorway" I said with confidence. "You have been knocked down and I can tell you feel like you don't see the light at the end of the tunnel. But I promise you, you can get better from all of the problems that have happened when you were in the hospital."

My words seemed to overwhelm him. He had a look of confusion, like an exhausted mountain climber looking at another half of a mountain to get over.

"Listen, " I began as honestly as I could, "I'm not the best person to tell you this, because I can't do it myself,  but you just have to take things one at a time. You have recovered from the worst of it, your body is weak as a kitten right now. If you could just focus on getting stronger, everything else will follow."

I was doing my best cheerleader impersonation, and he seemed to buy into it. His eyes followed me like a fishe's when food hits the waters surface.

As a Geriatrician, physical therapy is one of the best tools to improve my patients endurance and strength. I was able to convince Mr. Katz to start Physical Therapy. He seemed to get up out of his chair that day with something new to accomplish. We agreed that he would try to do his best with physical therapy so that he could feel strong enough to visit his friend in Tennessee.

And he did. During my lunch break every day I go over to the gym and jog. Each day, there he was,  working with Therapy. Intensity in his eyes. After about 4 weeks I walked into the gym and saw him on the treadmill walking. I was stunned. I've seen elders die 4 weeks after being unable to recover from illnesses like the ones he had.


Geriatricians have studied many factors contributing to the concept of Frailty. Some are easy to measure, but Mr. Katz's wasn't. His inner spirit to live, to get up from the boxing mat when it looks hopeless was one I admire. Many of my patients just give up when they're faced with illnesses. But taking things one at a time led Mr. Katz to recovery and independence. The other day I got a letter in the mail. Inside was a picture of Mr. Katz smiling next to a cabin in Tennessee.

What Now?

I admitted Mr. Good from another hospital last week. He was 81 years old and lived alone. He has children in town but they only get the chance to check in on him once in a while.  He had fallen and had a seizure when he was at home and was taken care of at a nearby hospital. Unfortunately he had a drinking problem. And while they were taking care of him his body withdrew from the alcohol and he required intensive treatment. If left untreated, a person going through alcohol withdrawals can die. It can cause seizures or cardiac failure. It turned out that Mr. Good was a very heavy drinker. He drank several drinks daily and, according to his family, would drive to the liquor store sometimes drunk in order to stock up.
It isn't something we pay enough attention to. Although alcohol problems are often under reported, alcohol use remains common among older persons. In a study of community-dwelling persons 60 to 94 years of age, 62 percent of the subjects were found to drink alcohol, and heavy drinking was reported in 13 percent of men and 2 percent of women. Overall, about 6 percent of older adults are considered heavy users of alcohol.
With Mr. Good after he was treated for alcohol withdrawal he was left weak as a kitten. So that's where I came in. I admitted him to our hospital under a special status called "Swing Bed". Among other types of diseases, this status allows us to help people that are weaker after an illness and keep them in the hospital to mainly get stronger. So Mr. Good needed a little more work with the Physical Therapists.
But he's going to go home soon. He's  an alcoholic and doesn't want to admit it. I've tried to discuss this with him several times during his stay here. But he just won't hear it. He's still in the "It's only a couple drinks at night to help me wind down, I can stop anytime" stage. Addiction isn't something doctors are very good at treating. We don't do a good job screening for it and don't do a great job treating it when we have. I feel helpless at this point but Mr. Good will go home and be drinking that same day I'm sure.

Was it Worth It?

Ms. Millweather saw me for a regularly scheduled visit a couple months ago when she described having a cough that would just not go away. I had ordered a chest xray and there ended up being a mass in her lung. I was worried right away. I immediately referred her to a pulomonologist (a lung doctor) who scheduled her for a biopsy. Unfortunately, during her biopsy her lung collapsed and she required a chest tube. She was transferred to the Intensive Care Unit because she had to have a machine breathe for her. From there it got worse. Ms. Millweather developed a pneumonia (an infection in her lungs) and a bleed in her stomach from an ulcer. She nearly died, but made it through. She woke up 1 week later and was told that the mass was just a benign (non-cancerous) piece of tissue. All of those horrible things, almost dying. And basically for nothing. This lady could have gone the rest of her life and never had to worry about that mass. But obviously that's not the way we think about it. What if it was cancer? It was important to at least see.

My Daughter and her Band Aids

My daugher (she is 2 and 1/2) has a theory. She thinks all I do at work all day is give people band aids. No really she literally pictures me sitting in my clinic and people walk in and say "I have an ouchy here Dr. Daddy" and they point to where it hurts and I put a band aid on the spot.

Okay I can hear the readers now: Que the jokes about Geriatricians and primary care doctors (Ha Ha, very funny, I can assure you we do more complicated medicine than that!).

 So I was at home one Saturday afternoon. I had rounded at the hospital that morning. There was one patient that I was worried about. He was a tough old guy who never really went to see the doctor. He stayed at home with a pneumonia and waited until it was almost too late. He was septic (which usually means that his infection was in his blood and that his body was responding to a life threatening illness). I wanted to go into the hospital later that day and check on him.

At home, when we had just finished lunch and I mentioned that I had to make  a quick trip to the hospital to check on a patient.

   "Daddy, I wanna come with you. I go get my princess band aids!" My daughter said excited as if her favorite cartoon character was coming in to visit at that moment. Before I knew it she was running for the bathroom where we keep her band aids.
My wife and I exchanged glances as if "Why not".
 
The next thing I knew I was driving for the hospital with my daughter singing happily behind me in her car seat. Hugging her box of band aids with little princess pictures on them.

   Mr. Hanson was actually doing well. With my daughter tugging my pants at my side. The nurses updated me on his condition. His vital signs were stabilizing and he was awake and irritable (which according to his family means he's getting better).

   I stood at the entrance of his room and asked, "Mr. Hanson, I'm sorry but I wanted to check up on you and my daughter wouldn't let me leave the house unless she came with me. Do you mind if she comes to see you too? "

  Mr. Hanson was 83, he used to be a farmer, he had 8 grandchildren and the look on his face told the story of his happiness to see children. His face went from bland to glowing when my daughter walked in. Proudly holding her box of band aids. She must have thought she was doing what her daddy does every day.

   "Whats your name little girl?" Mr. Hanson asked smiling

   "I'm a Big Girl!" My daughter responded as if being offended.

    "Oh I'm so sorry big girl!" He smiled again.

And my daughter proudly and slowly placed a princess band aid on Mr. Hanson's weather worn forearm. Over a red mark from that mornings blood draw site. In her mind he was fixed.

   "Okay Daddy we can go now!".

    "Thank you big girl" Mr Hanson smiled again. He seemed even more awake and happy.
After that I listened to his heart and lungs happy that he was doing so much better. I bought my daughter a Hershey's chocolate bar from the vending machine as a prize and we made our way home.

The next morning on rounds Mr. Hanson still had the band aid on his arm. He was doing better. 

Paradigm

I became a doctor to fulfill what felt like two dueling portions of me. Part of me felt compelled toward altruism. To help people in need. I also felt the beauty of the black and white truth of science. And medicine became that way to resolve what felt like conflict within me. I could collect the data from an ill patient and piece together a diagnosis in order to help them. But in medicine there are a lot of aspects that just don’t fit into a scientist’s yes or no box. Pain is one of them.

In 2010, approximately 7.0 million persons were current users of psychotherapeutic drugs taken nonmedically (2.7 percent of the U.S. population).

Everyone’s paradigm of pain is different. One person’s agony is another’s discomfort. There are volumes written on the topic of understanding a patient’s pain. However, part of being a doctor that takes care of patients in pain is having to deal with the fact that some of those patients are taking advantage of you. They are selling the medications that you prescribe, or taking them to get high. The percentage of this happening is actually very small. But once you’ve been duped a few times, you begin to think that even the 70 year old grandmother who sees you every once in awhile for her arthritis, is out to take advantage of you.

When I was early on in my residency, I briefly worked in a very small hospital on the coast of Oregon. The days were beautiful. My wife and I used to go to the beach and watch the sunset everyday after work. During this stint, I worked every fourth night in the emergency room of the hospital. This was a tiny ED. There were only 3 beds. One trauma bay, and 2 other private beds to take care of patients. It was so slow that I could stay at home through the night. When a patient came in the nurse would work them up, get their vitals, and call me to come in. One night I got a call from the ED at around midnight. The nurse had just admitted someone for “pain”.

“Pain where?” I asked in a groggy voice.

“I don’t know” she responded “he says everywhere.”

Oh dear, pain everywhere can mean two things, they either just had a car accident and broke all of their bones, or they’re searching for narcotics. I thought cynically. I changed into my scrubs, and made my way to the ED.

As I walked down the corridor and into the bright lights of this cozy Emergency room, I saw the patient sitting on the edge of the hospital bed. His legs dangling over the bed and swinging, like a kid at a park bench. He was in the middle of talking to the nurse there. He had a smile on his face but the smile didn’t have the air of happiness. Nor was it a grimace of someone in pain.

A doctor is trained to take as much information as he can as data. I was scolded by an attending once when I tried to help a patient up and walk them to the door.

“Make them do it themselves. Watching them will give you data on their strength and balance.” She said.

With this in mind, I continued to look him over before I entered the room. He had on a black leather jacket. It was old and worn like it had been slept in every night for a year. His jeans were torn at the knees. He had black leather boots with nicks, and worn soles. His peculiar smile, and dress made lights flash in my mind that this was a guy looking for narcotic pain medications to get high or to sell. I entered the room.

“Hello sir, how can I help you tonight?” I asked as friendly as I could muster up.

The patients smile turned immediately to a grimace. “Hey Doc, I’m hurting all over.” His voice sounded burdened, like it was trying to take his mind off of a knife sticking out of his neck.

From that point on my mind was made up. He was a drug seeker, and he didn’t need them to treat pain. I went through the motions of a diagnosis, but his symptoms were all vague, and non-specific and didn’t seem to have a good diagnosis. Next he brought up something that did take me off guard. His pains had started up in the last year when a few bumps started forming all over his skin. He had about 4 of them. They were on his arms and on his left hip. They were soft masses that were each about an inch wide. This was peculiar. I could only think of a few diseases that could cause these lesions. They looked and felt exactly like a benign fatty growth called a lipoma. But my mind was still made up. I still didn’t think he had a true diagnosis that was a cause of the pain he was describing. That didn’t make me stop being a doctor though, I had to work up his symptoms to try and make a diagnosis and treat what he said was pain. It turned out that he had been in the same ED about a few days earlier. I found the notes from the doctor who saw him. They mirrored my thoughts. This was a man who was searching for pain medications with no real diagnosis to be found. However, thankfully that doctor actually took a small biopsy of one of those masses as he was being worked up. It was still being evaluated by a pathologist. In a small rural town it usually takes a while to get results back. I was relieved. That was one of the tests I wanted to do. I ran a few blood tests which were normal and came back to talk to my patient.

“Sir, your blood tests were normal.”, I began, “I don’t seem to have a diagnosis for your pain, but I’m still waiting on the results of that biopsy that Dr. Edwards took.”

At that point I agreed to give him some pain medication in the ED and send him home with a script that would last a couple days. Enough until his biopsy results were back. This placated him and he left quietly.

    The next day arrived slowly. Like a caterpillar crossing a road. I made it to the clinic and a pile of papers was sitting on my desk to review. Many of them labs I had ordered. Half way through the pile it sat waiting for me. His pathology results. My eyes shot open. A jolt of adrenaline shot through my body causing energy and nausea to churn through. This man, this man who I was convinced was taking advantage of me and other doctors. This man had metastatic melanoma. A terminal skin cancer. This man had a death sentence and I had judged him otherwise. My whole paradigm shifted like the Titanic striking the iceberg.

Hours later I had successfully gotten him to come to my clinic to discuss things. After a long heartfelt discussion he was on his way to a Cancer Specialist. But that lesson learned stays with me until today.

Chronic Pain and Generations

A favorite patient of mine had been healthy up until she was 66 when she developed severe spinal stenosis. Unfortunately at that point it caused severe weakness in her legs and uncontrollable pain.
Her pain made her unable to do even the easiest of her activities of daily living (like dressing herself, getting up, bathing etc.). She finally agreed to take pain meds and they helped  a lot. I find it interesting that in many cases, her generation doesn't like asking for pain medications and it takes a disabling illness to take them but as for my generation- we ask for pain meds for even the least painful of diseases.
She finally agreed to surgery and I saw her the other day and its as if her life is new again. She glowed she was so happy and she was able to do all activities.

Old Timey Medicine

An older patient of mine, Mr. Jassup, was in last week. At first he was hesitant to tell me some old remedies he had used when he was younger but after he became more comfortable with me he opened up about some things they used to use "back in the day when we didn't even have indoor plumbing".
- for an ear ache: " momma would blow smoke from a cigarette or cigar in your ear"
- for a cold - "We'd use Colol - you know what that is don'tya?, its glycerine mixed with sugar or apple butter."
- poison Ivy - use white shoe polish "it has special properties"
- cough - "Momma would give me wiskey mixed with honey"
- sore throat - "swab my throat with turpentine"