Tuesday, April 22, 2014

So Am I really Doing No Harm?

A few weeks ago I was working at my free clinic. I stood in front of the next patients room with her open chart in my hands. The name on the patients chart was Michelle Lee. She was a young lady I had just seen 2 weeks prior.
It really was a simple visit at the time. She had a urinary tract infection. But as I was writing out the prescription for her infection we got to talking. Michelle had just gotten a job and was in an excited mood. It was a great job and within the month she'd be getting health insurance. Wow, health insurance, in this community that is gold. I am always so excited for my Free Clinic patients who get health insurance. Well, I gave her the prescription shook her hand and let her go. She smiled on the way out.
A week later I got a note from a nearby hospital that Michelle had been admitted. She had unfortunately had a major psychiatric reaction to the antibiotic I prescribed for her UTI. She had to be treated in the Psychiatric ward and after the antibiotic wore off she was sent home. Unfortunately throughout all this she lost her job. And her insurance.
I have felt so horrible about all this. In the end I don't think there is any way I'd know that that could have happened - It is a common antibiotic used millions of times a day. But I cannot feel more sad about how things turned out.

Thursday, April 17, 2014

It Doesn't Have to Be This Depressing

Patients who live at a Nursing Home will eventually die. I mean we all realize it when the patient has to go live in one. So when that time comes, many times their families ask me to make the individual as comfortable as possible. I keep them at the Nursing Home and give medications and care that focus more on comfort. At that point the family member vigil begins. The dying individual is laying in their bed and all their family sits quietly around them.
Whenever I come by to sit as well, I get so depressed, and yeah it is sad. But, while I'm there, we always strike up a conversation.  As we talk, I try to steer the conversation to family members memories of the patient. They are always funny or romantic or happy. We all end up smiling and I think it is my way of sending a signal to their family that we focus too much in our society on sadness during death. There is nothing wrong with spending time focusing on happy, wonderful memories as well.

Wednesday, April 16, 2014

How I do It

Okay I think I have a system. My job has become so busy. I've become spread so thin. I was neglecting this blog because I get home, make dinner, get the kids to sleep, work on my computer chart system and its 11:00. Too exhausted to write a blog post.
But I have so many ideas for postings and stories. I wrote this blog in order to tell stories about my experiences. That is my favorite thing - please see some examples of the stories I've written at the upper right corner of this blog "These are some stories I've written".
Anyway, I do get the chance to jog everyday - I skip lunch and jog. Its a chance to clear my mind and let the thoughts just roll. Many times, I think of an interesting patient experience during my jog and think "that would be a good blog posting". Well, I do have a recorder on my phone, so I've been recording my thoughts on it during my jog. If you could hear it you would laugh - It's me huffing and puffing saying "You should write about Ms. Smith , who ...."
So now I'm looking at my phone and there are about 25 recordings. I am on vacation this week, and am transferring them onto the computer. I think if I post about 2 a week that will last another 2 months. I'll try it that way so that I don't get behind on my blog. I don't think I have that many readers. But if you do read this blog, please post a comment so that I know, it makes me more initiated to write more!

Tuesday, April 15, 2014

Code Blue

We are so caught up in our media's conception of doctors and health care. When I watch television show like Greys Anatomy I see an episode where a patient's heart stops and everyone rushes into the room to save the day. A few chest compressions and breaths of air and the patients eyes open and their family members are able to hug them and walk out of the hospital with them by the end of the episode. So neat and tidy. They don't show that that only happens 0.02% of the time. They don't show what a real code is like. Chaos, blood, the sound of ribs cracking with each compression, vomit, family members trying to enter the room and screaming as they are pulled out of the room to leave. I wrote a story a while ago about a patient who's family had to endure a horrible code. It is at the upper right of this blog page entitled "DNR".

Saturday, April 12, 2014

You Have Got To Be Kidding

I am not making this up. This patient's story had me with my mouth agape. He must have been in denial and could have ended up dead because of it.
Mr. Carlsbad is a 72 year old man who I met in the ER after he had fallen. He fell 3 days prior to coming into the ER.
After he fell, he couldn't get up. But for some reason that didn't seem to bother him. He lay there for about 5 hours when he started getting hungry. So he simply called his 93 year old mother into his bathroom: "Mom," he said calmly, "bring me the phone". So his 93 year old frail mother waddled into his bathroom with his phone. she handed it to him. She didn't ask him what was wrong, she didn't ask if she could help him, she just walked back to wherever she was before. So he gets the phone and calls the pizza delivery person and paid over the phone with his credit card. 45 minutes later the pizza delivery person walks into the house per instructions of Mr. Carlsbad and puts the pizza down on the bathroom floor next to my patient. Apparently this guy didn't think there was anything wrong with that. So the next day comes (the day after he fell). Still Mr. Carlsbad lays on the floor of his bathroom and can't get up. Still this doesn't alarm him, he sits there for hours obviously then that evening got hungry - so "Mom, bring me the phone". In comes 93 year old mom - still apparently not thinking anything was weird here and hands him the phone. Again he calls for a pizza - again the pizza delivery person (yes the same guy because I asked that question) puts the pizza on the bathroom floor next to him and again this pizza delivery person must not have thought this was weird because no questions were asked. So finally the 3rd day - I don't know how he used this as a cutoff - he asks Mom for the phone and calls a neighbor. Well this neighbor I guess did think that this is weird so they call my patients cousin who is a nurse. She also thought this was not normal so she called 911 for him.

Sunday, March 30, 2014

I Guess You Just Have To Experience It For Yourself

Typically when someone chooses to be a hospice patient, they have made the decision to be more comfortable in the last months (or years) of their life. Hospice care provides medical services, emotional support, and spiritual resources for people who are in the last stages of a serious illness. There is a patient of a colleague of mine who had a severe case of COPD (a chronic disabling lung disease). It was bad enough that she was put on hospice by her doctor. However, she still had complications like pneumonias (lung infections) and made the decision that when she did she wanted to be admitted to a hospital (some patients on hospice decide not to do that). One complicating factor was that we always ask patients when they come into the hospital what their code status is  - meaning if their heart stops or they stop breathing should we put them on a breathing machine and shock their heart?
Surprisingly this patient had chosen that she would want to be a full code. I was flabbergasted when I first heard it. I just thought there was a mistake I thought she didn't understand. I mean - if someone has chosen to be on hospice it seems like the exact opposite philosophy to chose to be on life support measures.
So one of the many times she was in the hospital we had a long discussion about her goals of care. She did indeed NOT want to be on life support. I felt better only because it was in line with what I thought was right.
A month later I saw that she was admitted into the hospital. I was rounding on her the next day and I saw her Code status was FULL. Again I thought there was a huge mistake, when we talked it turned out that she had changed her mind. She admitted that a family member had forced her to state that she wanted to be a full code in situations like that.
I couldn't change her mind. I tried though. I even had a discussion with hospice in an effort for them to educate her - but no good.
About a year later (last month) I admitted her again, this was the last time. Her infection got worse and worse and one day I knew that if she wasn't on a ventilator she wasn't going to make it. I sat next to her bed and made her absolutely aware that  if she was put on a ventilator, her lungs were probably not strong enough to wean her off. I made sure all of her family members were in the room during this discussion - but she wouldn't change her mind. I am positive that she personally didn't want to be intubated that afternoon but her family members wanted it and she was making the decision for them.
I am still horribly saddened by this, but that afternoon I stood there - me a Geriatrician - intubating a hospice patient and transferring her to the nearest hospital with an ICU. 2 weeks later she was getting worse and her family members made the decision to withdraw life support. She died and the outcome was no different (she probably suffered worse) than if she had just been made as comfortable as possible that afternoon in her hospital bed.
Her family members were asking her to make a decision that they felt was right for them-not for her (from their point of view). When we are young we have youth, energy and resiliency. Of course we would choose to have heroic measures taken, because we have better chances. We cannot understand that our goals change as we get older, that maybe comfort is preferable over the pain of trying to get over a hopeless situation.

Monday, March 24, 2014

You have Cancer but you might not be able to do anything about it

A few weeks ago, I had to break the news to a patient of mine that he has lung cancer. He has a mass in his lung on a CT scan I had ordered. It is obviously cancer, it needs to be taken out. But his cancer is from years of smoking cigarettes and unfortunately the years of smoking caused a severe lung disease called COPD (chronic obstructive pulmonary disease). That disease makes a surgery almost impossible as well, because his lungs might not be able to deal with the surgery. I saw him today in follow up and he has become so depressed. He has a cancer but he can't do anything about it.