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.

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.

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?

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.