Sunday, May 24, 2015

Emergency Diverted - part One

Here is the first paragraph of a story I'm writing about a dying patient and their family with unrealistic expectations.

I sat on the edge of Ms. Thompson's bed at the nursing home. Her room was at the far end of the north wing, far from the ringing bells and voices of the main nursing station. Her bed sheets were clean from the wash and as white as the walls of an operating room. Ms. Thompson's tiny body was too small for her bed, like a baby in their parents bed. She was in the last stages of dementia. A disease that first robbed her of her short term memory, but at its latter stages effects her body too. The effects of dementia decreased her appetite, and created problems with her swallowing. It made her weaker to the point that she could no longer stand up. This was all normal. There is no cure. There is no way to stave off the disease. I sat in deep thought about my uselessness for this patient when a nurse passed the room. She saw that I was there and said in a relieved voice.
     "Dr. Mash, I'm glad you're here, Ms. Thompson's family is here and they wanted to know if you could arrange for her to get a feeding tube?"
     My mouth stood agape, I was really not prepared to have this discussion with her family today. I had to coach my sons soccer game soon. That is a difficult and sometimes long discussion, and I wasn't sure if I could maneuver the difficult terrain in the short time I had.

Friday, May 15, 2015

The Sword Of Damocles

At that moment I was sure that I had failed Mr. Short as a doctor. Just 3 days ago he and I sat in my clinic room. He was holding hands with his wife and I had convinced Mr. Short to be admitted to the hospital so that I could figure out what was wrong with him.
“Mr. Short,” I said confidently, “your birthday is only 3 days away. I am going to get you out of the hospital before your birthday.”
It was 3 days later and he was getting worse. On his birthday I had to transfer him to another hospital that had specialists who could look in more detail at his problem. I felt I had lied to him. I felt like I had let him down. As the ambulance drove him away to the Ivory Tower of the University Hospital, I had mixed feelings. I felt like I was less of a doctor because I couldn’t figure him out. But I felt hopeful that finally someone would figure him out. Little did I know that although he got better, no one could figure him out.

I had met Mr. Short about 9 months earlier. He had moved from Pennsylvania with his wife after he had retired. He was not medically complicated at the time. But he had this strange history of diarrhea that had happened a few times. When he was in Pennsylvania, he had actually been seeing Gastroenterologists there. And what caught my attention was that the Gastroenterologist in his hometown had referred him to another Gastroenterologist at Johns Hopkins - yes that Johns Hopkins. The “Ivory Tower” of them all.  That specialist did some testing and came up with a diagnosis of Celiac Disease. This is a disease that effects the way we absorb food. It can cause a whole myriad of symptoms that make it difficult to diagnose: fatigue, changes in stools, abdominal discomfort. So he was sent back home and was supposed to change the type of foods that he ate so that his diarrhea would improve. Only his symptoms didn’t improve.

He was okay for many months then one day he began having diarrhea. My basic strategy for someone with diarrhea that lasts a while is to order lab studies on their stool. That can help me see if it is due to an infection. He actually did have one that time. It was a specific type of bacteria called C. Difficile. That’s a dangerous one for an elder to have. If not treated adequately people can die. So I put him on antibiotics and he got much better. Only weeks later it came up again. This time he had such bad diarrhea that he was very dehydrated and I had to treat him in the hospital. That episode went well also. He went home feeling better.

But then it happened. I got a call from his wife that he had had watery stools for about a week. He was feeling too weak to come in. After some convincing I brought him into my clinic. He sat before me very frail and weak. It was obvious, he was in no shape to go home. Whether this episode was due to his celiac disease or an infection I needed to figure out as well as treat his dehydration in the hospital.

“Mr. Short,” I said confidently, “your birthday is only 3 days away. I am going to get you out of the hospital before your birthday.”

Yes, I know, you shouldn’t give patients unrealistic expectations. But this episode did not seem any different than any of the others he had.

In the hospital he only got worse. I had to replace his lost electrolytes with IV fluids, and I ran every test I could think of. I even called a good friend of mine that is a gastroenterologist for advice. No luck. The diarrhea wasn’t improving. I had to send him off to the University Hospital where he would be the “interesting patient”. By the way- you never want a doctor to say something about you is “interesting”.

I got regular reports from the doctors at the hospital, and from his wife. It turned out that no one could figure him out either. Specialists and subspecialists came and went. Every test I had run and many others were done multiple times. It wasn’t an infection, it wasn’t celiac disease or anything else they could find. Finally one day- 1 month later he stabilized. His diarrhea slowed down. However, he had lost so much nutrition that the muscles of his throat weren’t working. Because of this he couldn’t swallow food correctly.  They had to put a tube down his nose into his intestines (called a doboff tube). He ended up tolerating that and was in good enough shape to be sent home. Some doctors had actually had very little hope for him. One had asked if he wanted to be sent home with Hospice (to make him comfortable if he were to die). I got word of this and definitely wanted to see him. Unfortunately, he was way too weak to come in and see me at my clinic. So I made arrangements to go to his house for a home visit.

He lived in a beautiful house with the back facing the Shenandoah Mountains. I walked hesitantly up to his front door and knocked. I wasn’t sure how I’d be greeted. Would they be upset that I hadn’t been able to fix him at first? But his wife greeted me warmly and led me to their living room.

I sat there in his comfortable couch, facing a window with a view of the Shenandoah Mountains. It was late afternoon and the sun was moving into the western sky. Like a balloon slowly losing helium. He sat there in his La-Z-Boy recliner. He was thin and white as a sheet. He had lost at least 50 pounds. Cachectic, like a person dying from cancer. Out of his nose a tiny yellow tube hung out. It was his doboff tube.

“Mr. Short, I’m so sorry about this horrible situation.” I said.

“It’s okay, I’m doing better, I think I’ll be able to eat soon. I can’t wait to try ice cream again.”

We talked and I made adjustments in a few of his medications. I left that day certain that he wasn’t going to survive this.

But he did. He slowly got stronger. His nutrition improved, and he actually was able to eat on his own. A couple weeks later they pulled out the doboff tube. A few months later he came to my office to check in.

“I feel great” He was holding his wife’s hand, smiling and almost glowing. He and his wife were leaving the next week to take an RV trip to the ocean.

I felt ecstatic, he was better and could live normally again.  What bothered me though was that I had no idea what caused his illness in the first place.  No one knew. If this happened again I don’t think he could survive. If I didn’t know what caused it it could inevitably happen again. The thought of him having this again must be overwhelming to him. Like the Sword of Damocles hanging above his head.

“Mr. Short I’m really concerned this can happen again. To be honest with you I feel helpless for you.” I said sadly

He sat quietly for a minute and then looked at his wife. “Dr. Mashaw, when the end of the world is coming just keep planting your trees.”


Wednesday, May 6, 2015

Always A Parent

Mr. South was 82 years old. 82 years old and he sat in the plastic, grey clinic chair in front of me crying as if he were a 5 year old boy. His daughter sat next to him and tried to comfort him, she held his hand tightly with one hand and her arm wrapped around his shoulders with the other. The night before Mr. South's 60 year old son had committed suicide. He was found in his garage dead of a gunshot to his head.

I watched as Mr. South's tears flowed like a river overflowing after a storm. He clutched a wrinkled tissue with one hand and his forehead resting on the other. His body convulsed with his cries and his cries so loud that the patients in adjoining rooms could hear him through the walls. I had seen him many times in the past and he was always a man full of dignity and without emotion. He had lost all of that in those moments.

His daughter had brought him in to see me because she was worried he might be a danger to himself. And that was my job, but my heart went out to him and at first I couldn't think of anything other than how horrible it is to lose your child.

But I regrouped, and he was okay, I had no concerns that he was at risk and I thought he was grieving normally. I saw him over the next few weeks and although sad he still was coping well.

Then today, his name showed up on my schedule. Months after his son died he needed to follow up with me about his other medical issues. But as I broached the subject of his son to see if he had issues with depression, the look on his face showed that he still mourned his son's loss greatly. 82 years old and his son's death was as if it happened when he was just a boy. That is what struck me. My children are young now but no matter what, my emotions for them will never change. My fear for their health will never go away. My anxiety about their success will never go away. My fear for them dying before me will never go away. Even at 82. Mr. South was still grieving even though his own son lived a long fulfilling life. He was his father and nothing else mattered.

Sunday, May 3, 2015

Defense Mechanisms - Humor

Every career has its stress, but it becomes absolutely necessary for a doctor to put it into perspective. One tool used is the defense mechanism. Defense mechanisms are psychological strategies used to cope with reality and to maintain self-image. They provide a refuge from a situation with which one cannot currently cope. They keep us sane and healthy. At times, without them we would be unable to face our fears, unable to be grounded in who we are. As with the many different situations I have faced, I have used many different kinds of defense mechanisms.

An example of a defense mechanism is humor. Humor is pointing out the funny or ironic aspects of a situation. This is used within Freud’s fourth level of defense mechanisms. The fourth level of defense mechanisms is commonly found among emotionally healthy adults and is considered the most mature. Although, at times I would not think so.
My wife, a physician also, once was on call and had to admit a drunk, homeless person found hypothermic in the middle of a winter night. During the admission she needed to call the Intensivist for help. Weary and tired, he answered the phone. She described in detail the situation. There was silence, and after moments heard on the other end: “Another bumsicle huh?” It became an ongoing joke. Who could admit and resuscitate the chilliest bumsicle? The record that year was 82 degrees.
Why would one say such a callous thing? Aren’t we supposed to be the devoted, altruistic ones? But we are only people. We must formulate some way to deal with those who we didn’t picture when we chose to become physicians. One night I was called down to the ED for an upcoming admission. The ER doc was old and experienced. He had heard a call from the EMS scanner. It was a person being brought from the police station with what seemed like intractable seizures. He knew it was just a formality for this patient to be evaluated and treated by him. “Your medical team would have to admit this guy so why not just come down here and help me evaluate him. You might even get an intubation or central line out of it.”
He was smart, I loved procedures, and that was all the incentive I needed. I was waiting by the trauma bay when the patient arrived. He was a big man in his forties. Writhing his body from side to side. Yelling obscenities that I could not make out. His right hand was handcuffed to the *cart*, being pushed by the EMS *people*. But behind them to either side of the patient were two police officers. We exchanged glances.
“Watch out, this guy is a spitter!” stated the police officer, interrupting the EMS *person* described the situation. This was helpful information indeed as I backed away just as the angry man sprayed a mist of spittle from his mouth that permeated the immediate area with the foul smell of alcohol and a hint of vomit.
The EMS tech described to us what had happened in their succinct fashion. When they had arrived at the police station, this man had been writing in rhythmic motions with his body. These were “definitely grand-mal seizures” he described with bravado. “We tried to place an IV en route but he kept fighting us. We were finally able to place a 18 gauge in the right antebrachial” “he’s gotten 15 of Valium and it hasn’t really touched him.”
During our evaluation of this inflamed man, we had to put a mesh over his head because he kept trying to bite at us or spit at us. And a couple times he even stopped this and writhed rhythmically with motions that convinced us he was having seizures.
Because of the way he was acting and what we thought were intractable seizures (status epilecticus), the decision was made to intubate and sedate him. He didn’t seem to be protecting his airway through all this and was at risk for a dangerous pneumonia due to aspiration of whatever awfulness lay in his stomach contents. I stood at the head of the bed with this man growing ever more frantic. His arms held down by cloth restraints tied onto him by the nursing staff. Intubation equipment held tightly in my hands. I had a plastic protective gown and *shield* covering my eyes. I was wearing *?* gloves but it felt like even a space suit would not protect me from the vomit staining and spittle draining from the corner of his mouth.
Medication was injected into the IV in his arm and he quickly relaxed his flailing arms and jaw. I opened his mouth and slid the Laryngoscope blade into his mouth. Pushing upward I revealed two clear gray-white flaps, his vocal cords. The same cords that just moments ago shouted obscenities at me. I slid the endotracheal tube between the slits of vocal cords. They would no longer be able to shout obscenities at me. We attached a ventilator to the tube and oxygen was pushed into his lungs. His chest raised and retreated. Medicine was injected into his veins to keep him sedated, and we prepared him to go to the Intensive Care Unit. He was stabilized now. The final solution to prevent his stubborn fighting and what looked like incurable seizures.
He lay there in suspended animation. Immovable, submitting to our care. I walked to the nurse’s station. The police officers were still there waiting to hear what we were going to do about this man. I was just as curious to see why he was held by the police. Sometimes I feel a kinship with police officers. 
ideals but yet we spend a great deal of time with people that don’t appreciate, or even show hatred toward us. This causes us both to be cynical at times. This mysterious and angry man it turns out was pulled over for reckless driving. Immediately after pulling him over his car tore away in escape. The man was drunk and so drunk in fact that he only made it a mile down the road when his car veered off into a ditch and was stuck in the mud. He staggered out vomiting and was wrestled down. After being taken to the police station he was identified and it turned out was wanted in an adjacent state for sexual abuse of a minor. In the holding area, he became belligerent and then began flailing his extremities in what they thought were seizures. EMS was called and he was brought to us. So this was it. I was attempting to cure a drunk driving child molester. I couldn’t find the words to explain why I should invest my time to do this.
But I pressed on. I began formulating orders for his care. How to stop his seizures. How to manipulate the breathing machine to help him breathe correctly. I was a resident and so all of my care plans went through an attending physician. Tonight I was on with Dr. Hollander-Rodriguez. She was my favorite. She was smart and compassionate. She would help me justify in my mind why I do this. My mind was conflicted and it turned to the humor and Irony of the situation to help with perspective.
The phone rang and a weary voice answered on the other end.
“Dr. H,” I said “You’ll never believe this. Before I present this guy to you, I want you to picture every reason you became a doctor. All of the altruistic things you do. Now picture the exact opposite of that embodied in one person.”
I heard a chuckle, and I went on to explain the case. We developed a plan and my orders were sent along with the patient to the Intensive Care Unit. I bade farewell to my police officer comrades, saying that I’d call the police station when the patient was discharged.
I sat at the workstation in the ICU for hours checking labs and monitoring this patient. I’m not sure what kept me motivated? Was it the complication of the critical care? Was it the object of getting him fixed and out the door. But all the while, I was amused. The irony of the situation kept me smiling and I suppose motivated. This man did no good for this world. He brought harm to innocent children. His drunk driving could have killed my wife on her way home from work that evening. But medicine did
not care about that. A doctor does not make utilitarian decisions. Every life is equal. When pregnant woman is hemorrhaging, we attempt to save both her and the baby. The same with this man. It is his life not his doings that matter. So I pushed on.
By morning we decided to take off his sedation and take out the breathing tube. When this was done, he lay there, as docile now as he was agitated the night before. We began talking over the previous evenings events. Our conversation was actually even more hilarious than I would have thought. It turns out that this man had no history of seizures. He had been pulled over by the police when he was drunk and knew he would face jail time if he was arrested. He had learned from a friend in the past that if he faked a medical illness that he would be rushed to the warm cozy hospital and probably released soon thereafter to home never to see the police again. He didn’t realize that he would be put on a breathing machine, but he sat now in the hospital safe and sound, not in a jail cell. I sat dumbfounded. I had been taken advantage of. Used. And so had the hospital and nurses. All of the money spent for my time, the equipment, the staff time. He sat there smugly eating his breakfast.
When he was ready for discharge, I called the police station. It was time for him to get his comeuppance. He was ready to be hauled off to jail. But it turns out they were “too busy”. They didn’t have anyone to chaperon him to jail. He was to be discharged home and maybe they could stop by his last known address to pick him up. He had won. I could do nothing but laugh. My humor would help me through this strange situation. It allows me to cope with what I felt was an unjust situation. I still smile at the seeming inequity of what happened.


Friday, April 24, 2015

Mind And Body

  As a doctor, I have never really believed in any type of significant mind/body connection. Of course stress is related to depression or even heart disease. But I never really thought that we as humans were capable of controlling our bodies responses to disease.  I don't think I'll ever believe that it is possible to heal yourself from a serious disease like cancer from thoughts. But recently, I have had a few experiences with patients that show that our mind can control our bodies much deeper than I realized. These experiences have been just too numerous to be coincidental.

     Last week I admitted a 88 year old lady for the 8th time this year. She was one of my favorite patients of all time. A person I consider a friend. She had lived  a hard life and had many medical problems. I would admit her to the hospital time and time for different medical problems. But she would always fight back and go home with her daughter. Last week was different. I saw her in clinic and she was white as a sheet. She was not breathing very well and the moment I walked into the clinic room I could tell immediately that she needed to go to the ER. I sent her up right away and went there immediately when my clinic was over. As I walked into the ER the ER doctor recognized me as her doctor and pulled me aside. "She has lung cancer." he said in a bleakly. "There is a really large mass on her chest X-ray". Before I had come into the ER I had reviewed her chart and had noted that the last time I admitted her to the hospital 3 months earlier she had a normal chest xray (no signs of cancer at all). I admitted her to the hospital that night and let her daughter know. We both agreed to let her rest and tell her the next morning.

   That next morning She was doing fine, but I did what needed to be done and told her she had lung cancer. It was horrible. I could see the spirit deflate out of her, like a balloon in the dry heat. She had given up the moment I told her. And she died not 9 hours later. A lady who had lived through much worse had just given up and went Gently Into That Good Night. She isn't the only one I've witnessed like this. I've had multiple patients who pass quickly once they have given up on life. It is the ultimate Mind-Body Connection.

Saturday, April 18, 2015

I can't Afford to Gain Weight

At first I didn't pay much attention to Mr. Blanch's weight loss. But over the course of 4 months he kept losing weight. Mr. Blanch was a 72 year old widower. He stood every time I walked into the room. He wore loose fitting jeans and un-tucked black polo shirt. His white hair was short and combed to the side. He had kind brown eyes and as he shook my hand I could feel his coarse skin which told of decades of hard work.
Initially when I realized that his weight loss was not intentional I spent a great deal of time and energy to try and figure out why. When we are younger we are always trying to lose weight. But if we are losing weight and not trying then something is wrong. There are a myriad of reasons. But my biggest fear is if something horrible like cancer is the reason. I'll never let that on to my patients, I don't want them to be unnecessarily stressed out. But, usually when I am doing an extensive workup for unintentional weight loss the patient realizes this on some level - even if it is subconsciously.

But usually it isn't something horrible like cancer. I spent hours and yes many many tests to work up his weight loss. I really found nothing. Everything was normal. That moment is so frustrating. When you've done everything you can and hit a dead end. Like a detective without any further clues. So I had him follow up for another clinic visit. I was really down because I felt like I had failed.
I knocked the door to his clinic room as I walked in, as usual he stood with his hand extended to shake.
We shook hands and exchanged pleasantries.
      As we sat I started our discussion,   "Mr Blanch I'm sorry but I can't seem to figure out why your losing so much weight." I said deflated.
      We talked some more. In my previous visit with him I had just glanced over my discussion with him about what he ate every day. But I felt that I needed to start over. I asked him what he had usually for breakfast and he described a typical cereal breakfast with milk. Then it got more confusing. At first he described having pasta for lunches but I pressed him for more details. In fact I had asked him to review more details about each day of the week, for both lunch and dinner. Then the truth came out and it floored me.

Mr. Blanch was retired and living on social security. He was spending some of his money each month on helping take care of his daughter who sadly was a drug addict. With the rest of his money he really didn't have enough for proper meals. Each week he would go to the town's Charity Thrift Store. This store provided canned foods for people with little or low income. He would then go to a different church each evening that provided free meals to the community. Sadly in our small town there were only a few and that only lasted 3 nights a week. So he was eating canned soup or canned beans each lunch and only 3 or 4 nights a week would have a warm dinner. At one point he said he would cook a gigantic pot of spaghetti and then eat it for dinners each night. Then he got sick of spaghetti and just didn't have anything else he could cook.

My heart was broken. Everywhere I look I see food and this man had none.  Its true though, one of the most common reasons that elders lose weight is not because of a disease but lack of calories.

Wednesday, April 8, 2015

Pajamas

Believe it or not a lot of patients come in to see me still wearing their pajamas. They fit into 2 categories.

1. they are REALLY sick. Whether its kids or the 65yo I saw today. If they are still wearing they're pajamas when I walk in the door I know something's wrong and its not just a simple cold. Its like a physical exam finding. I'll call it the "pajama sign".

2.  they are on disability and that is all they really feel like doing after they've gotten out of bed that day. Honestly, I wish I could feel confident enough to wake up, roll out of bed. walk out the door and go to the store or the doctor's.