Monday, September 1, 2014

Hidden Agendas

Both doctors and patients have a plan about what they want to do with a patient before they even walk into the room.
Sometimes, that is the battle. I have a plan in my head about what I think should happen that encounter. And the patient has a plan in their head about what they want me to accomplish as well. Sometimes those two notions don't match. Sometimes I and the patient don't do a good enough job communicating those ideas. Furthermore, sometimes I don't even realize that I had an agenda in the first place - nor did the patient. It's hard to reconcile two different ideas when neither party knows what they are.  It is an "art" of medicine that takes a lot of work to fine tune.

Tuesday, August 26, 2014

NKDA

"NKDA" - no known drug allergies. When I see a patient and have to prescribe a medication, I love seeing that term. Because that means that I don't have to worry that the medication that I'm prescribing can cause an allergic reaction. Now allergies to medications can cause rashes and sometimes the allergy can cause a life threatening anaphylactic reaction. There are also side effects to medications - upset stomach, diarrhea. Sometimes patients think that a side effect is an allergic reaction. They call it an allergy and years later forget what happened when they took the medicine. For me that is frustrating.
Today I was at the nursing home and a patient was sick with a pretty bad urinary tract infection. I picked up her chart to write an order for a antibiotic to treat the infection. Then I looked at her allergy list:
Penicillins, Cipro, Keflex, Dilantin, Macrobid, Nitrofurantoin, Egg shells, Seafood, Cat Dandruff, Tetracycline, Codeine, Hydrocodone, Seroquel, Zoloft, Lisinopril, Sulfa's, Vancomycin, Benedryl, Gentamycin .
I took them all in and sighed sadly - this won't be easy. When people list these medicines as allergies they don't realize that a moment like this may occur. I had no idea what to prescribe this person because they had so many allergies. I think sometimes that patients think the list of medications is endless, but obviously it isn't. Were some of these allergies just side effects? I don't know. Now I had to take the "chance" of prescribing one of those medicines in hopes that it wasn't a true allergy.

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.