Sunday, August 31, 2014

The Last Thing On Our Mind

She was having excruciating pain in her pelvic area.  I pulled the sheets down cautiously and noted the bruising encircling the waist and inching towards the thighs.  I finished my exam and retreated to the nursing station of the skilled nursing facility to comb through the chart.  ER records, floor notes, consultations, but no X-ray of the pelvis. There was no mention of pelvic pain.

The emergency room physician had dutifully ordered a cat scan of the head and neck to rule out injury.  The hospitalist had noted a fourteen point review of symptoms.  The social worker had informed the patient that she was admitted as an observation.  He made sure a discharge plan was in place before two midnights which effectively meant that the patient would foot the bill for her whole rehab stay.  Notes upon notes documenting that the patient was not able to return home.  But no mention why.   She couldn't walk.  She couldn't walk because she was having excruciating pelvic pain.

The next day the X-ray confirmed my suspicions.  She had a pelvic fracture.  I called the nurse and ordered an orthopedic consultation.  Although I knew that she would not need surgery, I felt that they should examine her and comment on weight bearing status, etc.

Of course, it was only hours before the director of the nursing home was calling me on my mobile.  No orthopedist in the area could fit the patient it.  Furthermore, the nursing home was doing an investigation and had to prove that the fracture was a result of the fall that brought the patient into the hospital and not an an on site injury.  The wrath of the state weighed heavily on their minds.

So they wanted to transport the patient back to the emergency room.  Document the injury, get an orthopedic consultation, dot the i's and cross the t's.  Don't worry, they will send her right back!  There was no consideration of the cost of such deliberations.  No concern for the discomfort or pain that the patient would have to suffer.

So this is what we have come to in medicine:

Shoddy, rushed hospital care.
Offloading costs from Medicare to the patient.
Bending backwards to meet the requirements of the state.

And the comfort and suffering of the poor patient lying in the bed in front of us,

the absolute last thing on our minds.

Wednesday, August 20, 2014

The End Of Days

Sometimes my day is like a book.  The first chapter may begin in the darkness of a self imposed corner as a phone call is made.  A voice, full with the thickness of slumber, answers unexpectedly.

I think today is the day.

No matter how many years I have been discussing death I still find myself using poor euphemisms.  The bain of medical school teaching, I often struggle with the directness.  Your mother will die today.  So cold.  So hard to muster the courage and keep one's voice strong and confident.  I used to shy away from such dire predictions.  I no longer do.  Better to tell prematurely than not at all.

I pick up my stethoscope and jacket and move on to the next room, the next hospital, the next home.  And the memory of the fading elderly woman falls into the recesses of my mind.  These days are so full, the plot so complex, that plans are made, thoughts are compartmentalized.  Family called (check), Roxanol and Ativan written for (check), DNR, Do not hospitalize (check).  There is nothing more I can do.

The next stop may be a hospital.  Where a leg is broken, or saliva aspirated, or hearts fail.  The clickety click clack of the computer keyboard is accompanied by the ringing of phones.  Family meetings are carried out in hush tones in corners or conference rooms.  The rise and fall of a chest, a sigh.

I have an octogenarian to visit at home.  He just returned from the hospital after a pneumonia.  He still needed a few more days but was afraid to leave his wife alone.  Her memory is not as good as it used to be.  She had never stayed by herself before.  Fifty years of marriage and she had never slept without him by her side.

Work life quickly intermingles with personal.  I pick up the kids at their grandparents as I absentmindedly squawk into the blue tooth.  Most days there is some activity.  Violin, tennis, or Spanish.  The phone calls pepper my afternoon and evening.  At some point we find time for dinner.  Maybe a short jog with the family or a long walk.  Have you ever seen a jogger talking on his mobile?  That was probably me answering a page.

I might take a quick shower before  bed or watch some TV.   My phone almost always goes off when I am in the shower.  Almost always.

Around ten, I climb the stairs to the bedroom.  After brushing my teeth and hobbling into bed the phone buzzes one last time.  It's the nursing home.  The prophecy from the beginning of my day has come true.  I give my condolences to the daughter and turn off the lights.  I can't sleep.

It's like a book, you see?  There is a beginning.  Then a muddled and twisted middle that almost makes you forget.  But everything comes full circle eventually.  I put my head down and jerkily fade into sleep.

The end of one's day.

The end of one's days.

Tuesday, August 12, 2014

Why Come To The Doctor In The First Place?

William was doing great.  His C Diff  was finally gone after a month taper of vancomycin.  He was stronger.  The nursing home staff reveled in how much progress was being made over such little time.  It seemed every one was ecstatic, except for, of course his family.  Every step this octogenarian took forward was accompanied by a litany of concerns and complaints from his daughter.

If he was not gaining weight, she wanted to know why.  If he then put on a few pounds, she wanted his diet restricted.  Through each "emergency" I calmly talked her down.  I often spent thirty minutes a day defending each minute order that was placed. And through all the commotion, I was able to withstand the barrage because I knew that William was getting better and would go home soon where his daughter could torture him instead of me.

A few days before discharge, I received yet another panicked phone call.  William had cloudy urine and his daughter wanted me to put him on an antibiotic for a urinary tract infection.  I dutifully hurried to the bedside and asked a series of questions.  He had no burning, no pain, no frequency, no hesitancy and no fevers or back pain.  I called his daughter and explained that cloudy urine, and even bacteria in the urine, are not indications of infection, and given the history I believed an antibiotic would do more harm than good.  This answer while appeasing for a moment, quickly became unsatisfactory the next day.  So there were more phone calls, and more discussions reiterating how it was inappropriate to treat with antibiotics when there were no active signs of infection in this elderly high risk patient.

But William's daughter was smarter than I.  She waited till the night before discharge and called the doctor covering for me.  He, faced with little information and an agitated family member, was easily convinced to call in a antibiotic prescription for discharge.  I never even found out about it.

Until, that is, when I ran into his primary care physician while rounding at the hospital.  William was back in the ICU.  He suffered severe dehydration and sepsis do to (you guessed it) C. Diff.  A complication of his recent and unnecessary antibiotic use.

These type of situations happen all the time.  And while I am a big proponent of empowered patients and families, lately it seems that many really want to be managing their own care without the benefit of our experience and years of training.  In other word, they just don't want to listen to us.  This is fine.

But why come to the doctor in the first place?

Friday, August 1, 2014

Diaspora

I fully reject this notion of wholeness.

I have never been whole.  More like an incomplete conglomeration of parts,  friends, lovers, and family have all received a bit of me.  As I have given myself freely.

And I worry, as a physician especially, what will be left.  As I tend to the sick and dying I wonder if that which is transferred will be lost forever with the frailty of the heart beat, the rattle of the lungs.  Much better to be an obstetrician, I reason, who bestows each piece upon a burgeoning miracle.  There is great longevity in such things.

But as I rest at the bedside in those last moments of illness, I wonder if what I am giving is even mine to bestow. Is it me sitting there or my father ( a physician himself who died when I was a little boy)? These thoughts can be dizzying.

The hair on my head grays and grows scarce.  The seasons blur as if someone waited till the middle of the movie and then hit the fast forward button.  It brings comfort to think that although the body becomes feeble, a diaspora of pieces grows and flourishes out in the world.  A human tapestry of parts past far and wide from continent to continent, generation to generation, person to person.  Our bodies die but our souls live on in those we have touched?

The currency of humanity is neither money nor love.  For "love" is an amorphous concept not well defined by us realists.  I have come to believe that it's the best parts of ourselves that we give to others.  These are the ties that bind communities.  This is the bedrock of the generations.

You may ask, my dear reader, how all this rambling concerns the present company.  

As I see it.  Bit by bit, day by day, blog post by blog post.

I am giving a little piece of myself.

To you.

Tuesday, July 29, 2014

Doctors Behaving Badly?

A dozen set of eyes stared upwards.  The nurses ate their pizza and glanced back and forth between me and the dry erase board that I had recently filled with incomprehensible scrawl.  I had given this lecture many times; said the words over and over again.  And yet the response was always surprising.

Why do you think physicians get angry and annoyed when you call?

A simple question.  Every day clinicians yell at nurses.  They bully, they prod, they rush off the phone before fully answering questions.  I have done it many times myself.  The phenomena is so common that most nurses and secretaries accept it as part of the job.  That doesn't mean that it doesn't hurt.  It doesn't mean that they won't cower the next time they have to call that physician again.

I waited patiently for the audience to venture a guess.  In all the times I have asked this very same question, I have never had any one volunteer an answer.  And this befuddles me.  Because most physicians go into the profession to help others.   Most truly want to be there for those in need.  So why when the cards are on the table, when a nurse or patient calls in crisis, is the response so negative?

I threw out a few possible answers myself: they're tired, had a bad day, didn't get enough sleep last night?  I few half hearted nods from the crowd.  All possible explanations, but I could tell that no one was really buying it.  Slices of pizza were now frozen halfway between plates and mouths as the audience waited attentively.

Maybe because they are afraid?  Don't know what to do?

A look of astonishment and then understanding flashed across a dozen faces.  It was like a weight was lifted off their overburdened shoulders.  Faced with difficult and life changing decisions, physicians often react with anger and annoyance due to frustration.  It rarely has anything to do with the nurses themselves.

This reaction is neither professional or acceptable.  And I try to modify my own behavior accordingly.  Some days I am more successful than others.

But at least today, a good day, a handful of caring people left the lecture room with full bellies

and a sense of well deserved vindication.


Tuesday, July 22, 2014

Come And Knock On My Door

The house was getting cold.  My wife and kids snuggled in their blankets as I crept out of bed and checked the thermostat.  The subzero winter air howled as a blustery morning took shape outside our windows.   I looked at the digital display with disbelief and manually tapped the screen with my finger, hoping that the jarring motion would loosen the exact faulty screw leading to our frigid state.  No luck.  The thermostat was working just fine.  The problem was much more sinister.  I covered myself with a blanket and ran to the basement.   I paused for a full minute to listen.  Not a peep.  The furnace was absolutely silent.

A few hours and a hefty credit card charge later, a workman strolled into our house.  His bag overflowed with a  gaggle of steel and electronic tools salivating at a chance to sink their jaws into our machinery.  After much tinkering, adjusting electrodes, and forehead scratching, a pronouncement was made.  A few pieces of equipment were procured from the van and adjustments were made.  To our relief, the sweet hum of air passing through vents once again filled our house.  We  sat underneath the counter top, and bathed in the heated air rising from the bowels of the house.

Until, of course, an hour later when a loud clanking sound announced the end of our geyser of contentment.  The temperature plummeted.  Phone calls were made.  And the process started all over again.  Two weeks, various repairmen, and multiple diagnostic tests later, we were no closer to an answer.  The heater would spit and sputter, work for a few hours, and then shut down ominously.

Finally, one of the workers noticed that our air intake valve was pointed in the exact same direction as the exhaust.  Hot air was leaving the exhaust, entering the intake valve, and overheating the system.  It took him seconds to adjust.  The problem never reoccurred.

Years later, as I ponder this cold episode in my families life, I am flabbergasted that a supercomputer didn't exist that could have been hooked up to our furnace and immediately diagnosed the problem.  It appears that heater repairmen are unlikely to be put out of business by the vast expertise of technology.  And they are not alone.

As of this time, no one has created the technology to replace lawyers, accountants, or airline pilots yet either. Sure there is quickbooks, and auto pilot, and legal zoom.  But when push comes to shove, the technology to overthrow these fleshy human beings is just not agile or savvy enough.

Yet time and again, technophiles dream of a world in which Dr. Watson or Dr. Google takes the place of our stethoscoped brethren.  They say that instead of diagnosticians, physicians will be trained to be experts in empathy.  They will be culled from film schools, and broad liberal arts educations.  They will recite poetry instead of treatment plans.

I can't help but think that maybe these oracles, these technologists, need to refocus.  Shouldn't we concentrate on logical systems with finite variables to practice on first?

Figure out how to replace auto mechanics and appliance repairmen.  Then maybe, maybe you should knock on my door.

Monday, July 14, 2014

The Novice

It's a strange thing to be driving about in your car in the middle of the day.  For one who has spent the majority of his professional life sheltered in dark offices and aseptic hospitals, the summer sun and fresh breeze is quite lovely.  One almost begins to approach humanness.  Normal.  This must have been what it felt like before immersion into the tribe of medicine.

Sometimes I have trouble remembering my premedical days.  The divide seems vast.  It is not only the effects of age but an emotional chasm that has formed over the years.  The optimist says I was naive, inexperienced.  The more harsh reality is that I have developed a cynicism, a coarseness which permeates all aspects of life.   I am a person, I am a doctor.  The two mangled halves rarely come together to approach a whole.

But my new reality has begun to unravel the protective coating super glued to my insides.  My clinical encounters are but small punctuations in a day filled en route from location to location.  Homes, hospitals, nursing homes.  I spend more time in the car than anywhere else, and when I am there,  I roll down the windows.  I turn the radio up.  And I am just another guy, speeding down the expressway or caught in traffic.

This feeling like a regular person has had profound affects.  It's helped me look at the world through what seems like an ancient lens: that of a human being first and a doctor second.

I was cruising down a side street the other day when I came to a backup.  I cursed as I slowly progressed through the line of cars.  It took twenty minutes to traverse a single city block.  When I came to the head, I witnessed a macabre scene.  An ambulance was pulled over and a couple of paramedics were performing CPR on a shirtless man on the sidewalk.  His arms were splayed to the side and his chest flailed with each compression.

Within seconds I was moving again, and the the ambulance was barely visible in my rear view mirror.  A lump stuck in my throat and I took a deep breath.  I have watched hundreds of people die, I have performed CPR countless times, but this was somehow different.

For just a moment, I had escaped the curse of all those years of training and experience, and was able to just feel.

I am hoping to carry this with me from patient to patient.  To use all my knowledge and experience to diagnose and treat, but to care for my patients like the uninitiated.

The novice.