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.

Wednesday, September 2, 2015

I Cannot Win

Ms. Williams was a patient of mine at a nursing home with Dementia. She had been stable for years in fact I always forgot who she was when I was supposed to check in on her because she just had no real problems except for her memory. Unfortunately about 4 months ago she abruptly got worse. She began having hallucinations and became very paranoid. She kept thinking green men were outside her window and thought people were trying to get to her room to harm her.
As a physician the first thing you have to do is make sure there isn't a disease like an infection that would explain this quick change. I ran all the tests I could think of and all were normal. So unfortunately I had to treat her with medications that make the hallucinations go away. Sadly, as with all medications there are side effects. So as I increased the doses of these medications her hallucinations went away, but yesterday she was found more confused and she had a fever and was coughing. When I got the text from the nurse (yes no one calls me anymore, my phone goes off at least 2-3 times an hour with texts from nurses), a sinking feeling entered into my stomach. Like a fog rolling into San Francisco. I immediately knew that she had aspirated (she must have swallowed food into her lungs) and developed a pneumonia from that.
I immediately asked them to transfer her to the ER. But when EMS got there she wouldn't go because she thought they were out to take her to Russia and work in a camp. So I had to hold my clinic and drive to the nursing home and sit at her bed and remind her that I was her doctor and I think she is very sick and should go to the ER. Finally, she agrees and they take her to the ER, where sure enough she has a pneumonia. So now when the pneumonia resolves I'll have to figure out what medication to give her for her hallucinations that won't cause another aspiration event.

Sunday, August 23, 2015

My Redemption

I think this will be a good story, here is the gist of it and someday, when I have time, I'll work on making it a story.

Years ago, I was new to my practice. A patient of mine was in the end stages of their dementia. I had wanted him to be as comfortable as possible during his death, but he developed an inability to urinate because his prostate was too large. I had to put in a catheter directly into his bladder so that he could urinate. but the process was extremely uncomfortable for him. His wife sat in the room and couldn't take the agony and screaming from my patient. She became so upset that she grabbed my arm and violently pushed me out of the room. She didn't want him to deal with that.

I was at the beginning of my career and wasn't sure what to do. So I continued to give pain medications to my patient in an attempt to help. But it wasn't enough. As he couldn't urinate, he became more and more agitated with his pain. And the more pain he was in the more his family blamed me. They finally fired me and asked another doctor in town to care for him instead. This other doctor is a good friend of mine. His method of dealing with families and patients is much more authoritative an paternalistic than mine. My friend walked into the room with confidence and immediately removed all the tense family members, the then placed the catheter into the patients bladder without worrying about the patients pain. Literally a gallon of urine came out and the patient immediately calmed down. he died in piece days later.

For years I have regretted how I had handled that situation. For years I was frustrated.

Then last week 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 began having flashbacks of what happened to my patient years ago. As my patient writhed in pain the family kept looking at me for direction. If his bladder kept enlarging with urine it literally could have burst. that would be a horrible death. No attempts at putting in a catheter trhough his penis worked. the bladder cancer had grown large enough and was blocking it.
So I took charge and arranged for my patient to be transferred to another hospital where a doctor could put in what are called "percutaneous nephrostomy tubes" - literally tubes that go directly through the skin into the kidneys and drain urine- that way bypassing the bladder.
He was sent directly back to me in obvious relief.
He was still dying but the agony of an enlarging bladder wasn't part of his pain. He died peacefully days later with his family with him.
To them, I was a hero. I didn't feel like a hero because of what had happened years before. But I did feel redemption. In a way I felt like the patient from years ago had accepted my apology.

Wednesday, August 12, 2015

You Keep Using that medicine - I do not think it works the way you think it works

Years ago people used to think that if you have a patient with dementia in the hospital going through "sundowning" you should treat them with anti-anxiety medications. The patients will yell and scream and try to get out of bed. It's all because they get confused. The old way of dealing with this- many years ago was to tie them up in restraints. Thank God that is not done anymore. That became illegal. The next thing was to give "chemical restraints" which is still wrong by the way. But that means giving sedating drugs that will make them fall asleep and stop fighting and try to get out of bed. That is no longer the accepted way of doing things -but there are still doctors who are using that older way.
The other night I had a patient in the hospital - he is an older patient who I admitted due to an infection. He himself has dementia and was in a new place and was even more confused because he had an infection in his urine (a UTI).
That night I was not on call and the patient became confused and tried to get out of bed "to go home"
the nurses freaked out and called the doctor on call who immediately asked them to give the medication Ativan - this is an anti-anxiety medication which causes sedation.
The nurses did it and unfortunately it caused the exact opposite reaction. Which is not uncommon. Instead of calming him and sedating him - it freaked him out. He started having hallucinations that aliens were coming into the room and he grabbed his walker and used it as a stick to try and whack the nurses. He screamed and fought and if it weren't so sad I might have laughed.
They finally kept giving him more of the medication that he fell asleep - he slept for 2 days. It was horrible. I feel responsible.
In reality there are much safer ways to treat this situation. But that medication was not one of them.