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.

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."