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."

Monday, July 6, 2015

Letting Go

Ms. Lang was only 69 years old. She was happily re-married and had a loving daughter. She developed a severe type of arthritis in her back called spinal stenosis which causes weakness in her legs. That weakness got worse and worse. And a day ago I had to admit her to the hospital because she was so weak she couldn't walk or get up. My plan was to admit her place her on medications for her pain and weakness and discuss her case with a neurosurgeon the next morning. The next morning I woke up to a phone call from the nurse
  Her voice was frantic, "Dr. Mash, she isn't waking up and she's only moving her left arm and leg, I don't understand, I just gave her her meds this morning an hour ago."
I reviewed her vital signs and then my answer was quick, "make sure you let her family know to come in as soon as they can and get this lady into the CT scanner"
I thought for sure she had had a stroke, I threw my clothes on and rushed into the hospital.
By the time I got to the hospital she was back into her room. she wasn't speaking and just moving her left side of her body. I felt sick, I felt like throwing up, I felt like taking my white coat off and walking away, far away, maybe Montana and living off of the land, never to see a patient again. But there was hope, I thought that her stroke had just happened about 1.5 hours ago leaving me time to give her an anti-clotting medication to reverse things.
I called the radiologist who had just gotten into the hospital himself.
His voice was grim, "She's had a Hemorrhage man, it looks massive and its shifting her brain to the right."
I felt even sicker, she was bleeding massively into her brain and the only way to even try and fix things would be if a Neurosurgeon were to put a hole into her skull and drain the blood. Immediately I called the University hospital and was on the phone with the Neurosurgeon.
"This isn't really survivable," was his response "she really only has less than a 20% chance of surviving, and even if she did she'll be left aphasic and without the use of her right side"
- translation, she would be left a "vegetable" (which is a term I really do despise).
My heart sank and I took the long walk back to her room to break the news to her family.
My job was to discern what Ms. Lang would have wanted in this situation. Would she have wanted us to transfer her with a helicopter to the hospital for this major procedure? With no chance in meaningful recovery. I had to get this information fast because if the answer was yes then time was of the essence. If not then my job was to keep her at our hospital and keep her as absolutely comfortable as possible.
Her husband was frantic with this information, " What would you do doc?" was his reply.
I really feel on the spot when I'm asked that, but I answered without hesitation, "First of all sir, I want you and your daughter to know that you shouldn't feel like this is your decision, I want you to answer this based on what she would have said if  you talked to her 5 years ago and  told her something like this might happen."
That seemed to help them. After many tears and sadness, her husband and daughter were in agreement. That is not something she would have wanted. They wanted her kept comfortable.
I stopped all her medications and switched her to medications for pain and calming her down. Her family by her bedside she died peacefully the next day.

Thursday, July 2, 2015

Medical Terminology

These are some medical terms and phrases I've learned along the way. Mainly during medical school and Residency. 

O-sign  - here the patient is recovering from a major illness like in the ICU and is sitting there with their mouth open just staring out into space

Q-sign -  here the patient is potentially getting worse or is really bad off and staring off into space with their mouth open and tongue out.

Code Blue - someone is actively dying - run (don't walk) to their room and start Advanced Cardiac Life Support measures (CPR, shocking, intubating)

Code Red - a fire

Code Brown - someone pooped and it needs to be cleaned up - and it's gonna smell.

JPC - Just Plain Crazy (see my post from 6/7/13)

LOL - little old lady

NAD - no acute distress


LOL in NAD - little old lady in no acute distress

To Cut is to Cure - what Surgeons say... pretty much all the time.
Where there's pus there's steel - surgeons also say this. 

The enemy of good is better - sometimes when you think you can do just a tiny bit better - it goes all down hill.

Walkie-Talkie - term for a nursing home resident who can walk on his own and talk in a normal conversation

Tuesday, June 30, 2015

What is Wrong With You

This will be a good story someday when I have time to write it out.

My patient had a blockage in her small intestine. There was something on the CAT scan that showed an "obstruction" at the small intestine causing swelling there and food from the stomach couldn't get through. It was getting larger and she was in pain.
Luckily there was a surgeon at our hospital that day (they come to help us one day a week from a nearby bigger hospital). He consulted on my patient and made the decision that the thing causing the obstruction was probably not something that could be fixed with surgery. A GI specialist would have to do an EGD (a scope that goes down the throat into the stomach) and see what was causing the problem. "I'm sure its an ulcer or something" the surgeon said.
But my patient had many medical problems and our hospital wouldn't be a safe place for this to occur. We had no specialists in our hospital (I, and the surgeon and the ED doctor were the only doctors there). So I had to transfer the patient to another hospital.
Her other specialists were at the sister hospital that I work at. "The mother ship" we call it.
So I called the GI specialist and before I even got through my short explanation of the patient - he stopped me and said "man I don't think you understand the situation, we don't admit patients, the hospitalists do and then then consult me. By the way don't you realize that tomorrow is Memorial Day weekend?" - that was a weird answer I thought, first of all they need an EGD and second of all GI doctors first do an internal medicine residency and third of all what the heck does memorial day weekend have anything to do with it. This is a sick patient. But I could read between the lines, - If I transferred the patient to their hosptial that would be "one more patient" he'd have to see that weekend if he were on call.
So I called the hospital and got the hospitalist. I explained the situation to her and she paused. Her response was one of horror. "There's no way I'm the one who should take this patient" she said. "this patient has an obstruction, don't you realize that this is a surgical problem?"
my eyes rolled (since she couldn't see over the phone) and I explained for the second time that I had just had a surgeon consult on this patient and he said that it was not a surgical problem.
"then why can't the GI service take this patient she asked" I knew she knew the answer because she knew the game, my eyes rolled again - "the GI specialists I guess are so "special" that they don't admit patients, they consult you guys."
She paused, "I just dont' feel comfortable accepting this patient in transfer until you've talked to the Surgeon on call"
Fine,
I finally get a hold of the surgeon on call after paging him and waiting another long while. I had to be put on speaker phone because he was in the OR. I explained the situation for the millionth time and he paused. the beeping of the heart monitor equipment from his surgery in the background. "Man that's not a surgical problem" - as if I hadn't heard that before - " and don't you realize Memorial Day weekend is coming up?"
Jeez Luize I thiought. I hung up and called the hospitalist. Her ansewer was that she had just called the GI doctor and they both "conferred" about the patient and reviewed her records "we saw how many medical problems she has, including previous abdominal surgeries, and we feel she should be at a university hosptial."
"I'm confused I said angrily" Doesn't your hospital have the same specialists?" she hemmed and hawed explaining that there must be special equipment and subspecialists in the case that this patients situation were to go awry. I could read between the lines - Memorial Day Weekend.
AAAAAH
"Fine, thank you for your time," So I hang up and call the university hosptial. I wait 45 minutes to call the hosptitalist - who is a new resident that knows nothing. He sounds tired. but had no reason NOT to take my patient. Well I call the university nurse who is in charge of making the transfer arrangements and she responds to me "I'm glad they accepted her but our hospital is full, we're not accepting transfers at this time.
AAAAH
So I call the "mother ship" again and the hospitalist finally accepts my patient as if she's doing me the biggest favor in the world.
I checked the EMR and look at the chart every day.
That whole process of playing "hot potato" took from 8AM until 4PM that afternoon. I missed much of my clinic and all of it was unnecessary.
It turns out the patient got the EGD and indeed had an ulcer - no surgery needed. they put her on acid reducing medication which treated her and she was better an eating in days.
When I saw her back in my clinic after discharge she hugged me. She had known what I had gone through just to get her to where she was. I on the other hand didn't feel happy, I felt embarrassed for my profession.