Thursday, August 21, 2014

The Straw That Broke the Camels Back

What would it take for you to give up? What would it take for you to say "I just can't take care of my wife at home anymore?" That breaking point is different for everyone, everyone is different. 
I admitted an 88 year old man into the hospital yesterday for a stroke. I've been taking care of him for years, and slowly his ability to take care of himself declined over time. Because of the new stroke,  he was brought in to the ER by his wife at her breaking point. She just couldn't take care of him anymore by herself. We spoke for a long time about what would happen next. She had spent a lot of time thinking about it and realized what it meant. She realized that if her husband was going to go to a nursing home that the financial burden would break them. She just couldn't physically or emotionally take care of her husband at home anymore. She had already put up her house to sell in order to afford a nursing home stay for her husband. It was heart breaking.

Saturday, August 16, 2014

Objectification

  Every day at work, every night at home I learn a new fact about a disease or medicine. I am learning about the science of medicine every day, it is just what a doctor does.
But being a doctor, especially a primary care physician. You have to learn how to interact with patients. How to communicate, how to empathize. During medical school, we had to learn about many aspects of the history of medicine. Years ago, doctors tried to objectify everythng, including patients. As they rounded in the hospital they would stand in front of each patients bed and say:  "Okay here's the gallbladder." then move on to the next patient's bed "and this is the stomach cancer".
    Years passed and the trend has become to realize that we can still be good scientists and treat our patients as humans, to empathize with them. I remember rounding with an attending during medical school who wanted me to describe one personal aspect of each patient as we discussed them, "Mr. Carson is a 89 year old with pneumonia. He has a cat at home named Toonces". - it was that attending's way of teaching us empathy so that we could interact more personally with our patients.
I learned so many peals about personal care during medical school that carried me to today.
    But during my medical school we didn't yet use computer medical records. We still saw a patient and wrote a progress note on paper or later dictated into the phone.
But over the year's we now predominantly use Electronic Medical Records (EMR's). There are only a handful of doctors now who still work with paper. And I find myself learning new skills about how to make my patient think I still care about them. I mean, I have only 15 minutes generally between each patient. It generally takes 10-12 of those minutes to input my information into the computer. I definitely don't have time to type into the chart between patients.  It is so unbelievably easy to spend the entire visit and only once look into the patients eyes (to do my exam) before leaving.
As physicians, without even meaning to - we have again objectified our patients. Our patients see us looking at a computer and not them for the entire visit. They don't get a sense that we care about them as people. And we can't empathize with them if we can't carry on a conversation while typing into a computer the whole time. Without interacting with our patients personally we have delved back into the objectification of our patients. We can't empathize.
So I'm back to learning how to interact with my patients - learning how to force myself to move out of the way of the computer and sit next to my patient and talk to them again. Just like with medical knowledge, I learn something new each day.

Friday, August 15, 2014

You Can Tell A Lot

When I take care of elders in the hospital, my job is not just to take care of their medical issues but to communicate with their care givers at home (usually sons or daughters). But that isn't always easy. You can tell a lot about what is going on at home based on how easy it is to get a hold of the caregiver. Sometimes they are sleeping in a cot next to the patient. Sometimes there is a hand written note from them left on the table next to the patient with 5 or 6 phone numbers to call "just in case the first ones don't work". Then sometimes, I find nothing, no phone numbers, and in the chart is an "emergency contact" listed with an old non-working phone number. Sometimes this is due to apathy of the "caregiver" but sometimes it is due to the exhaustion of the caregiver. It shows how much the caregiver needed a break from job of caring for the patient.

Friday, August 8, 2014

Dine and Dash

I walk in to the ER room and all that I see is an old lady with fluffy white hair. She is sleeping fitfully as if fighting off a nightmare that is worse than her illness. She is hooked up to a monitoring device to constantly measure her vitals, it beeps frenetically. Into her left hand is an IV, like a leech attached to its prey. The patient is supposed to get fluids to help her obviously dehydrated body. The machine beeping ineffectively, calling out an alarm to no one in particular that it cannot do its job.
I look around for any other information I can. Nothing. In her chart are some relatively useless labs.
I was called by the ER doctor to admit this lady to the hospital because she is sick. So at this point I need to gather enough information about why she ended up in the Emergency Room to do my job. Thats the problem. The lady is asleep and when I am able to wake her up enough all I get is an angry groan, as if to ask, "How dare you wake me up". The ER doctor got only a little more information.
I sat next to him as he fumbled with the computer system, "So why in the world is the lady in room 6 here again?" I ask irritated.
He answers not even looking up from the computer, "I don't know man. Some family member, a weird looking man with a beard, brought her in and quickly left mumbling something about their laundry, or was it their oven was left on?"
His explanation trailed off as he focused on finishing a task on the computer medical system in front of him. He regained his attention and looked at me, "You know what this is, its a 'dine and dash'; but she is sick enough to be admitted. That's all I care about." And his attention was back to the computer.
Yeah, I knew what he meant. It happens more than we realize. A family has spent years taking care of their loved one and it just gets overwhelming. Sometimes the patient isn't even sick, and when we go to contact the family member to talk about sending the patient home, they can't be found. The phone is either out of service or no answer.
It isn't medicine, but it is a major issue I have to deal with. In the past I've even had the police go to the persons house and force them to call me. That was a surprise I'm sure.  one of my jobs is to help people during those difficult transitions as we age. And the transition when someone can no longer live with their family is a "doozy".

Sunday, July 27, 2014

A Parents Mortality

It Was 4:00AM and my 6 year old son's voice was full of fear as he ran to my bed.
"Daddy, I had a dream that you died. Someone was putting a candle over you."
He cried and I held him. An hour or so later I could feel his rhythmic breathing as he finally slept in my arms. I think that was the first moment he realized that I was not unbreakable. Not invincible.

      Last week I admitted a 80 year old patient of mine into the nursing home. Up to that point he was healthy with just some hypertension and high cholesterol. Unfortunately, he had had a stroke and was left with some dementia (his short term memory was effected). He was also weak and unable to care for himself at home. We admitted Mr. Pearington to the nursing home so that the physical therapists could work with him and hopefully make him stronger. When I met him though, I knew it would have to be permanent. There was no hope for him to improve his strength and memory enough to be able to go back home alone. His son also lives near here. He was a successfull businessman here. He was at his fathers bedside when I first admitted him to the Nursing Home. He was at his fathers every beck and call. Fluffing his pillows and tucking the sheets twice, three times. There was a sense of urgency. He was much younger than his father maybe 50 or 60 years old. But you could still tell he was Mr. Pearington's son. The strong jaw and piercing eyes.

     We talked for a while and then I did my examination. Through all of this I was barraged by questions. His father's stay at the hospital was a nightmare. He suffered the stroke and was treated in the intensive care unit because he subsequently had a pneumonia (an infection in his lungs). No one every answered any of his questions about his father and he was frustrated when we were in the room together.
     "Why is my fathers blood pressure so high? Why can't my father eat as well? Why aren't we talking about putting a feeding tube in his stomach? why is he on this medication called Plavix? " The questions zoomed by like cars passing by in a racing video game.
     I answered as patiently as I could. Minutes went by that turned into an hour. My answers weren't helping Mr. Pearington's son. Finally I realized that he was having a hard time realizing that his father wasn't invincible anymore. Sure we see our parents grow older and stumble. But his father is no longer his father. His personality is different now because of the stroke and he has lost some of his humanity because he can not take care of himself.

     "Mr. Pearington, my heart breaks to see you deal with your fathers situation." I finally said. "If this were my father it would be so hard for me to realize that he isn't going to get better."

     Mr. Pearington's peircing eyes wavered, his strong jaw began to shake. He cried then. As he realized that the hope he had been carrying for his father to get better was probably not going to come true. He held his fathers hand, and I stepped out so that Mr. Pearington could be with his father. To come to terms with how his father had changed.

Sunday, July 20, 2014

The Sword Of Damocles

At that moment I was sure that I had failed Mr. Carson 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. Carson to be admitted to the hospital so that I could figure out what was wrong with him. 
“Mr. Carson,” 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. Carson 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. Carson,” 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. Carson, 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. Carson 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 and you are planting a tree,  just keep planting your tree.”


Thursday, July 10, 2014

Benefits of Living in a Small Town

    Beads of sweat formed on my forehead like condensed water on the side of a cold glass. I had just finished my daily jog, that I do during each lunch break. I was driving back to my clinic when I got a call from the office. One of my patients had just died. It was not unexpected. She was 92 and her family wanted us to withdraw any type of aggressive medical care and make her as comfortable as possible. But I wanted to pay my respects to the family and the patient. So I drove to my clinic to change into my dress clothes and run up to the hospital. As I stepped out of my car, a county Sheriff was standing upright in front of me.
   "Whats the rush son?" He said as if to try and convince me to admit my guilt. For what I had no idea. I was sure I hadn't been speeding. After I got my car I got 2 speeding tickets in a row. That taught me in a hurry to watch my speed.
   I had forgotten I was in shorts and a tee shirt "I'm so sorry officer, my patient had just died and I was going to the hospital to see." I said still out of breath (probably from surprise and fear).
   A look of realization came over his face. And at that moment mine; he was actually my patient. He hadn't recognized me in my jogging clothes.
   I have to give him credit, he regained composure and said respectfully,  "Dr. Mashaw, you forgot to put your registration sticker on your license plate."
   Thoughts raced through my head but the main idea in my head was "Man there are benefits of being in a small town". I profusely apologized and promised to put them on before I left that night.