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.

Sunday, July 6, 2014

Well Said

One of the most difficult things for me to learn was that if I didn't want to go crazy, I had to learn to separate work from my life. This article by Starla Fitch says things well about how difficult it can be.

Friday, July 4, 2014

Sunday, June 29, 2014

It Makes It all Worth It

Last week I was at my Free Clinic when I saw a lady with a bronchitis and a COPD exacerbation. She could barely breath. As usual she had put off getting treatment until it was almost too late. I knew she'd be fine if I could just put her on some antibiotics and a steroid called Prednisone. If she started that night she wouldn't need to be admitted to the hospital. So I wrote out the prescriptions and handed them to her. She hesitated. I knew that look, the look of  "How much is this going to cost me?" Well both medicines will be on the $4 list at Wal Mart - meaning that each was going to cost $4 for a total of no more than $10 with tax.  
But for this patient - at least that day she couldn't afford it. I know I'll get paid Friday" She said. 
So I dug into my wallet and handed her $10. She looked horrified. She didn't want to take it. But I felt more horrified thinking that she might not take the medicine. I felt one or two more days, and she'd have to get admitted to the hospital. That would be several thousand dollars instead!
After explaining this to her, she reluctantly took the money. 
Then this week a nurse handed me a folded up piece of paper. As I unfolded it there were 10 old tattered, $1 bills. She had repaid me and left this note. 

Sometimes I get so frustrated with medicine, and entitled patients, and never feeling like I'm helping. And sometimes it feels worth it.

Wednesday, June 25, 2014

Drive Through Fast Food

I saw a patient of mine in clinic today. She was a 68 year old lady with a cold. I was discussing her treatment when she let me know how sick her husband had been in the last couple days. He has a chronic lung problem that makes it much easier to develop worsening infections. So I encouraged her to bring him in as soon as he would come.

I looked up at my schedule after lunch and it turns out he heeded my advice. He was scheduled later that day.
He showed up a little late that day and he looked a little out of breath. However, he looked happier than I'd ever seen him.
It turns out that he was actually waiting in his truck at our parking lot when his wife was being seen. He was too out of breath to come in with her. As they were driving home she was convincing him to come in and see me. Suddenly he stopped the car.
    "Dr. Mash, you wouldn't believe this but on the side of the road was a 23 pound wild turkey. A beaut!" He said, both out of breath and with pride at the same time. "I pulled out my shotgun .."
- apparently he just keeps a loaded shotgun in the backseat of his pickup truck!
"... and shot that bugger from my window. I was so out of breath I couldn't get out of the truck to shoot it. We had enough time to take it home and dress it and wash up and come in and see you."


Saturday, June 21, 2014

A House Call

My voice was rushed, nurses were talking in the background, as my phone connected with my patients niece, “Okay Ms Pierce, can I come by around noon? I should finish rounding on the patients here in the hospital by then.”
    “Of course Dr. Mashaw” Ms Pierce said, excitement in her voice, “We really appreciate it, I don’t think there’s any way I could get Aunt Lucy to your clinic.”
    Ms. Pierce gave me directions, “turn left at the Old McMillan chicken house, go over the one lane bridge, pass the Baptist church on your right and about a mile later I’ll be waiting at the bottom of our driveway”.
    I was in a rush to finish rounding in the hospital, so I didn’t catch her last statement. Huh? Waiting at the bottom of the driveway? Anyway, I thought, I’ll figure it out when I get there. I finished rounding on my hospital patients and got in my car. The chaos and anxiety of my small rural hospital was behind me. I was driving away, down small country roads.  I followed her directions past her landmarks. I’d never had recognized them if I hadn’t been living here for so many years. “I am truly a local now” I thought proudly. I finally made it to her driveway and sure enough her big SUV truck was waiting at the bottom. I pulled over and walked over to Ms. Pierce’s car.
    “So why don’t I follow you up to your house?” I asked
    “Oh no, your car would never make it up there”. She said horrified.  
    I was offended. I loved my car. I had a 2009 Subaru WRX. It is the first car I could ever afford to buy. I bought it because it is a car used for rally car racing. Her dirt driveway looked perfect for it. But I didn’t want to start my home visit on the wrong foot. I didn’t want to offend her.
    “Ok” I said hesitantly. I climbed up into her truck like a mountain explorer, with my white coat on and medical equipment. Unaware of what was about to happen.
    At first the rocks on the road were small, “My drive is about 2 miles long” my guide said as the bumps increased. Then I saw larger rocks in the road as we winded to the left. “My car could easily do this” I thought, “she must have thought I’m some sort of city guy”. The road dipped and in front of us was a 15 foot wide and 2 foot deep creek with much larger rocks. My mouth dropped and my guide smiled. “This road got washed out a couple years ago” said Ms. Pierce as her voice vibrated with the bumpy road. That was just the beginning. I thought I was in a Jeep commercial.  We dipped into a 2 foot deep crevice, and the rocks got bigger’ we bumped up and down as we climbed a big hill to her house. At one point I caught myself gripping the glove compartment in front of me. But finally we pulled up to her house. I can only say it was worth the roller coaster ride. Sitting at the top of a huge hill, the view of the Shenandoah Mountains was breathtaking. The sparkling noonday sun of February was warming me.  I felt exhausted and exhilarated.  And I hadn’t even seen my patient yet.
    Lucy Karn was an 87 year old who I had met 3 years ago after she had moved to our small town. She had been living with her son in Philadelphia.  He had lost his job and couldn’t afford to help take care of her. She had severe macular degeneration and couldn’t see anything but shadows anymore. Her niece Patsy agreed to take care of her.
    Ms. Karn was a diminutive, kind lady. She was short and weiged 115 pounds. When I first met her in clinic she was sitting at the corner of the room next to her neice, her white hair pulled back in a smooth pony tail. She wore large, medical sunglasses to diminish the glare that worsened her vision. When she spoke, she spoke softly and I had to sit next to her to hear her. But she was very opinionated. She always spoke her mind and it was always work to get her to agree to my plans for her care.
    “I don’t want some young doctor telling me what to do.” She would say in her stern but kindly voice.
    She was against many of the medical treatments I would suggest. At times it felt like pulling teeth to try and start any new medications or even check labs to make sure her medical diseases were stable.
But in time we became good at compromising with her medical care.   I grew to enjoy my visits with Lucy. We would joke about how exhausting my kids were. She would tell me stories about her son. When he was young he wanted to fly, so he opened the window of his room on the second floor of the house. He then jumped out while holding an open umbrella.
“He didn’t break anything, but was limping for a week.” She would joke, the pride of a parent glowing in her face.
One day I noticed Ms Karn’s weight was much lower than it had been in the past. Generally an 87 year old should not be losing much weight. I made note of it in the chart and asked her to follow up in a month for a recheck.
A month later her weight was down even more. I was concerned and brought it up with her.
“Ms Karn, I wanted to talk to you about the weight you’ve been losing, I’m a little worried.” I said hesitantly, I knew she didn't like it when we delved into anything that might end up with me suggesting she take medications or might need to be “worked up”.
“Dr. Mashaw” she interrupted, “I dont’ think that’s necessary. You have to be the first doctor who’s ever been upset about a patient losing weight.”
I back pedaled, and realized I needed to explain, “Well, when an elder loses weight unintentionally, it’s sometimes a sign that something is not right.” I said patiently, “It can be something as simple as not eating nutritionally balanced foods, or depression. Or sometimes it can be a sign of a more serious disease like cancer.” I spoke slowly and was trying to choose my words carefully.
She didn’t even flinch. “I don’t care doctor.” She said tersely “I feel fine, and I don’t need a bunch of blood tests and xrays to tell me so.”
I was convinced she was in denial. But I wanted to know why she didn’t want to know. “Ms. Karn, I’m sure this isn’t something horrible, but what if you had some sort of disease like cancer and it was treatable. Wouldn’t you want to at least know that?” I asked calmly.
Again, Ms Karn didn’t even hesitate. “No doctor, I’m 87 years old, I’m so happy for the time I’ve had, if its my time to go then it is”.
Our visit was over. She had made clear what her Goals of Care were. I thanked her for coming to see me and asked her to return in the next couple months to catch up on things.  She smiled and walked slowly out of the room and down the hall.
We all strive to keep living. When I was young I read the poem by Dylan Thomas named “Do Not Go Gentle Into That Good Night”, It is a beautiful poem in which the speaker tries to implore his dying father to fight against imminent death. How our intentions should be to “rage against the dying of the light”. Those words rang true for me then and all through my life. How foreign it is to not want to fight an illness. To fight those last moments, to fight for each last breath, each last pulse. When I was learning to be a doctor, I learned that many times we push so hard to cure our patients even when we know the result is futile. We and our patients picture some Hollywood ending where a shock of some electricity magically saves someone. Or their cancer is suddenly cured and they walk out of the hospital intact. We aren’t realistic about how few of our older patients actually survive in real life. That is what I learned after many years of working with the elders who taught me so much more than what was in my medical books. When your life has been blessed with so many experiences, who is to tell you how your story ends? When you feel it is your time, it’s okay NOT to rage against the dying of the light.
Months passed an I hadn’t seen from Ms. Karn. Then one day I got a message from her niece. Lucy had had some pain in her abdomen and went to the emergency room. After some tests, it turned out that she had signs of cancer in her liver. True to herself, she wanted no further workup. She was given pain and nausea medications and went home. My first thought was that we should get Hospice involved. We should make Lucy as comfortable as possible. But her niece Patsy had had a few bad experiences with Hospice. Patsy was actually an experienced in-home nursing provider. She didn’t feel like Hospice could provide any type of care for Ms. Karn that she couldn't. She just needed my help with the medications. During my Geriatrics Fellowship, I had spent quite a bit of time working with a Hospice.  I felt comfortable with some of the treatments Ms. Karn would need. That is what led me to visit Ms. Karn on that sunny warm day in February.
As I walked into her house, Ms. Karn sat quietly in a rocking chair by a window that looked at the beautiful Shenandoah Mountains. Her neice hadn’t told her that I was coming “because if I had she would be fretting all day”. As I walked into the warm sunlit room, Ms. Karn’s face lit up, as if the sun had just shone on her. She smiled and even let out a little laugh. I walked up to her, knelled down and gave her a little hug. I sat in a chair next to her and we talked. Nothing medical at all. Just about the show she had just watched and what she was going to have for lunch. I was again reminded of how important living in the moment was to Ms. Karn. During our conversation one thing kept nagging at me. I still wanted to know why she never wanted to be worked up all those months ago for her weight loss. As her doctor it bothered me so much that perhaps I could have caught her cancer early. What if it was from another source that was treatable? As our conversation progressed, I steered it more towards her disease, I broached the subject.
    “Look doctor,” she said in her patient quiet voice, “ its February and 60 degrees outside and sunny, that is what I want to enjoy”.