Monday, March 28, 2016

Its a Whole Different World

This community is very small and tight knit. People here are from generations past and their generations go back to settlers. Furthermore, peoples land here has been with their family for sometimes the same amount of time. And something that goes with that is that cemetaries are on their own family land. So many of the people that live here will die and be burried on their land. They expect it.
So Mr. Pallup came to me today in a huff. He has a history of anxiety and it was obviously not controlled. It turns out that there is a company near his land that is expanding. He might have to lose many acres of land due to this. Apparently they are trying to finagle it by using the city to do their work for them. Years ago the city took some of his land (I assume it had something to do with public works and Imminent Domain) and unfortunately it meant he had to move his own home cemetary. He had to literally dig up the bones of his grandfather and mother, and move them! Wow, that is crazy.

You Stab me in My Back I'll Stab Yours

Drug abuse is such a big problem in the United States. In a sense doctors have created the problem. During my training as a medical student and then resident, I had been taught how important it was to treat peoples pain. In fact they had been teaching us that "pain is the 5th vital sign". If anyone was in discomfort it should be our job to treat it. Well now that we've done what we were taught, we are dealing with some serious consequences. There are many who are in pain and really do need pain medications for treatment. But there are many who use doctors to prescribe medications when they are really not in pain and either use them for their own addiction or sell those medications on the street. I have been duped many a time.
Years ago I had a patient who would walk into my office limping and moaning- he was obviously trying to convince me how bad his pain was. So I had done all of the appropriate things I'm supposed to do. I had found the source of his pain - he had severe arthritis in his back and when I would prescribe pain medications I would have him sign a "pain contract" which is something all doctors who prescribe chronic pain medications do. I would also regularly check on the amount of pain medications he had as well as check the pain medications he was taking with urine drug screening. One day another patient came up to me and let me know that this patient was selling the pain medications I was prescribing. Yes - it is a very small town!
Nevertheless, I was able to show that this patient wasn't appropriately taking his medications and - that patient never got pain medications from me again.
A couple years later the same patient who let me know about the first patient came into me with her own pain. This was legitamite. She had severe arthritis in her back based on an MRI that was done, and again I jumped through all of the hoops that I as a physician need to do to make sure a patient is truthful. I also had her going to a pain management specialist who was contacting me about the procedures he was doing to help her.
Anyway, about a week ago, I got a phone call from someone who's voice sounded suspiciously familiar. It was full of the uneducated southern accent that I had heard from the first patient I described above "yeah, this is an officer from ... [pause] the uhh ... gover-mint... uhh we're being doin an official investagashun on your patient [he name the name of the second patient above] and she's been sellin her pills on the street."
My response was respectful "well thanks officer - can you tell me your name and a phone number? what government agency are you with?"
A pause
"... uh, well thats gonna be uhh... forth-comin.. I'll get back to yeh" and he hung up.
You can't make this stuff up.

Friday, March 25, 2016

When You Don't Realize the Changes Around You

Dementia is one of the most tragic diseases I've ever come up against. As doctors we can prevent heart attacks and strokes. We can immunize against life threatening infections. We can treat and completely resolve cancer. But Dementia - specifically Alzheimers type, is something we know little if anything about. We really don't know why it happens, what brings it on and despite all of our medications we can't treat it. Sometimes I just feel like I am sitting back and watching helplessly as my patient drifts away into another world.

Alzheimers Dementia is a disease that initially takes away parts of our short term memory. So patients forget names more easily or misplace their keys more easily. These are really subtle things. Things that their close family (a husband or wife) don't catch onto. I mean really, whenever I forget something I'm always asking my wife for help anyway. So sadly, sometimes, when the disease is really diagnosed is when there is a major difference in who the person really is. Like there was a tipping point that was impossible to ignore or notice.

Last week I admitted a patient into the hospital for confusion. His wife was frantic because her husband was paranoid and yelling. I sat next to his bed and spoke with his wife, not about how he was in the last week but really just questions about what he was like a year ago compared to now. And sure enough she was full of examples of how his short term memory had been worsening over a long time. She had only noticed when there were obvious changes in his personality and memory. And the tragedy is that now we're left with a new person, a new set of challenges, new hardships. His wife was completely unprepared. She will now have the burden of being his caregiver as his body is slowly affected with the disease as well: changing his diaper, feeding him, calming him. And there is no pill to fix this, no treatment to fix it. There are many things to slow the effects, to help calm him. But nothing will stop it. All I can do is sit back and watch helplessly.

Thursday, November 12, 2015

So Close

I had felt sorry for Ms. Stauffer. She had many medical problems, and although she only had a third grade education she seemed like she cared about her health. Unfortunately she didn't have money for a phone or transportation. She had to rely on rides from friends to come in to the doctor. If I had to contact her I would have to call her neighbor who would in turn have to walk a block to her house and find her and get her to come back to his house to talk to me (and thus I really couldn't contact her). This difficulty came to a head one evening when one of Ms. Stauffer's labs was so abnormal that  I needed to get a hold of her immediately. There was no answer at the neighbor's phone, and so I had to resort to what I call my "nuclear option": I had to call a Sheriff's Deputy to go to her house and call me from his cell phone. Not that big a deal, because the Deputy on that night was a patient of mine and he knew Ms. Stauffer, so he understood.
The problem with Ms. Stauffer's labs meant that I had to admit her to the hospital. After that admission I made her promise to contact me with any problems. She had been pretty non-compliant up to that point and the hospital admission, I think, helped her realize that she needed to take better care of herself.
Within months she had become a model patient of mine. She never missed appointments, she took all of her medications, and she even took care of her diabetes and kept track of her blood sugars. I was so proud, like a glowing parent.
Finally, I felt like I had her medical issues under such good control that the last time I saw her I had decided that she didn't need to see me for 3 more months. Unfortunately she saw me today, 4 months later. It turns out that after I had seen her last she lost her Medicaid (a state funded health insurance for the very poor). She then ran out of all her medications because she couldn't afford them, and a week ago she had a stroke. The stroke was because she had sky high blood pressure - because she stopped taking her hypertension medication - because she couldn't afford it.
So she came in to see me today for a hospital follow up after she was discharged from the hospital because of the stroke.
My heart just sank when I saw her. Things were going so well for her and one bump in the road was catastrophic.

Friday, September 25, 2015

The Power of a Minor Procedure

I had a patient who has malignant carcinoma of the liver. His cancer causes backup of fluid into his abdomen. It causes fluid to build up into his abdominal cavity (ascites). It was causing so much ascites that it was pushing on his intestines and even up on his diaphragm (his breathing muscles). It was painful and even made it difficult for him to breathe. Today I performed a parascentesis. Basically I stuck a needle into his abdominal cavity and took out about 3 liters of ascites. I could visibly see his abdomen go down during the procedure. His oxygen saturations went from 90% (barely safe) to 98%. He was breathing so much better that he started crying with happiness. This man who will die very soon. He knows it, his family knows it. But he was so happy to recieve comfort from my procedure that he hugged me. This minor procedure meant the world to him today.

Sunday, September 20, 2015

Jeez Luise

We all worry about preventing strokes and heart attacks. Some estimates are that about 15% of people will die after a heart attack. Some estimates are that about 20% of people will die after a stroke. But can you believe that almost 25% of people will die about 1 year after having fallen and having a hip fracture?
Most people don't realize how important it is to prevent falls and their horrible consequences.
Ms. Katz was a widow living alone in a downstairs apartment. Many years ago she had had a stroke and it left her with terrible balance. She also had horrible judgement. She would walk with her walker and if she forgot something would let go of the walker and walk back to where she left it.
In the time I've known her she has fallen and caused a serious injury at least 5 times. Once she fell onto a glass coffee table and split open her back. Numerous times she fell and broke her arm. I had to take care of her many times in the nursing home after her fall as she recuperated and got stronger. The physical therapists would work every day teaching her how important it was to use the walker.
Yesterday I saw her in clinic and she was walking into her room with a cane. she saw me behind her and lifted the cane up and walked down the hall towards me carrying the cane and not using it any better than a briefcase. Then shook my hand.
"Doc, I usually don't even use the cane but I knew I was coming in to see you so I brought it! Aren't you proud of me!?"

Monday, September 7, 2015

A Lesson In Love

Richard Kinsler would always come into my clinic room with impeccable manners. His shirt and pants clean, freshly pressed, and tucked in neatly. He walked with dignity, his head held high and back straight. This was remarkable, considering he had to lug his oxygen tank with him huffing as if he had just climbed Mount Everest. He had the final stages of a lung disease and always looked like he was trying to control a pain that just would not go away. Even with this burden, he never bothered me with discussion of his own illness. He was always concerned about his wife and her failing health.
      She had severe Alzheimer's type dementia. A disease just as tragic and disabling as his own. Dementia is a disease that initially takes away your short term memory ability but as it progresses it takes away your personality and older memories too.  A disease that takes part and parcel of your personality and ability to think, to plan, to be. Joyce would spend her days wandering the rooms of her house, with a blank, bland look on her face. To those of us without the disease it is horrifying. We look at the person we knew as the pillar of our family, our father, or mother or husband or wife. The one who taught us who we are in life. The ones who knew us better than ourselves. To watch that person crumble away year after year, like a dried sandcastle in the wind - We are both horrified and helpless. Joyce had gone far beyond losing her personality. She barely even knew her name, and couldn’t recognize her husband Richard.
There are brief moments for those with dementia called “lucid” moments where flashes of memories of the past do occur. Richard would tell me that he used to live for the moments when she would recognize him. That single glimpse of acknowledgement that she remembered him but then it would go as soon as it came. I am sure it is a brief moment only he could recognize. Only because he had spent 50 years of his life with her. How could someone be with you for 50 years and not even know or recognize you?
Clinically Mr. Kinsler had a lung disease that slowly took him away from this world as well. He had Chronic Obstructive Pulmonary Disease (COPD). A disease that slowly took lung function away every day. The only cure would have been a lung transplant. His breathing took away so much energy from him that he was only skin and bones. Mr Keyser was a model patient. He took all of his medications, and faithfully arrived for every clinic visit. I could tell, however, that he was doing this only for his wife. To stay alive for his wife.
I found my home visits to the Kinslers to be extremely frustrating. Conversations with her were difficult to get any pertinent information. There was no logic in how she thought. She could no longer remember her date of birth. As a doctor we are helpless when it comes to dementia. There are no drugs that can cure it or stop its progression. At times I wanted to grab her by the shoulders and yell "Snap out of it, your husband would do anything for you to remember him for just one day!"
But not Richard, he rolled with the punches, he learned to develop a relationship with that new person, a love based on care and patience, and an undying love. Richard would accompany Joyce on those endless circles of the house. Richard wouldn't force his wife to come to this real world. You could tell Joyce appreciated that. She felt a genuine commradery with him from those quiet times. Their lives were intertwined more than I think I will ever realize. His lungs slowly taking the life and living from him. And her brain slowly draining the ability to develop a new memory. This is the world they lived in, both borrowing borrowed time to be with the other.
      There was a time when Richard developed a severe and aggressive pneumonia. The bacteria was difficult to treat and required his hospitalization and six weeks of IV antibiotics.  He had to stay in the hospital for all those weeks. Away from his wife. In our jail. Iit was because he wanted to live on to be with his wife. I would come in with some good news about his labs .
Short of breath he would reply,  "Have you been in to see Joyce today?"  as if summoning up extra air from his lung.
Happily, after 6 weeks, I was able to release him in better health. I cannot imagine the joy he felt as he went back to his wife. The one he had been thinking about for those 6 weeks.
      Then it happened, Joyce fell ill. She had an infection somewhere, and Richard and his family specifically did NOT want her to go to the hospital. They wanted her comfortable at home. I obliged,  but with her frail body she died quickly. Richard with all of the love in his heart was all about business at that point. He was the leader, as his daughters had wondered what to do, he set up all of Joyce's final arrangements.
I got a call a week later from his daughter, Mr. Kinsler had trouble breathing. I finally convinced him to come in and see me in clinic and then finally after much discussion convinced him to come into the hospital for more IV antibiotics. His second day in the hospital, I sat next to his bed for about 30 minutes. He just didn't look comfortable. He was anxious to get his affairs in order. I remembered his previous treatments, and had confidence that he would once again improve. Even so, I promised to contact his lawyer and accountant.  I said goodbye and went to my clinic to start a long day of seeing patients. Hours later I got a call from my partner. Richard was actively dying. I rushed over to his room but when I got there I couldn't look. He was unconscious. Breathing over 40 times a minute with large breaths, like the waves of an ocean before a storm. Richard had been my patient and a friend for so many years. I had invested so much in his care that I felt like I had failed.  My stomach turned over. I wanted to throw up. All that talk about putting things in order was his realization that his life was over and he was trying to die on his own terms. I walked out of that room thinking that he died because he wouldn't take care of himself as his wife was dying. But over the days, I realized that he really was saving all of his energy to stay alive so that his wife, Joyce, would never be alone. Richard and his wife were intertwined, and as each changed the other changed along with. As she died Richard had no reason for life.