Utility and Functionality

It is one of the most ancient stories wending it's way through modern history.  The hotheads of late have coined the term creative destruction.  But this concept of replacing old with new,  or innovation upending tradition, is no more novel than the concept of change itself.

There is nothing truly original in the world.

I ease off the gas pedal of my already outdated hybrid Prius.

My job will eventually fall prey to a computer named Watson.  My practice will be gobbled up by the nearest Goliath medical center as history scoffs at the arthritic physician bending over a doorbell with leather bag in hand.

There is no flash of glory here.  No smart technology.

The echo vibrates through cracks in the sidewalk and drags me unwillingly forward to the unkempt house at the end of the block.

Adapt or perish.

I open the door without knocking and find a decrepit figure slumped into a reclining chair in front of the television.  His car keys were long ago taken by some relative or another.  He waits for nothing in particular.  Scraps of food have been left on the side table by a home health aid.

There are memories of being gainfully employed.  Road trips across barren lands and such.  His son is now grown up and makes decisions on his behalf.  A nursing home is a far safer environment than this empty old house.

My visits to the end of the road are numbered.

Old is replaced by new.

Utility and functionality apparently are relative terms.  

And by and by something is lost.

Why I Disagree With The Government And Use Antipsychotics Anyway. It's Good Palliative Care!

The outcry over antipsychotics has ranged far and wide.  Every one from governmental agencies to senior advocacy organizations have pointed to the abysmal data.  Antipsychotics have a negative impact on morbidity and mortality.  They say we are chemically restraining those who are too fragile to stick up for themselves.  They say we are sedating instead of treating.

And I disagree wholeheartedly.

I manage a large group of moderately to severely demented nursing home patients.  They are agitated and delirious on a regular basis.  Often searches for infections, pain, constipation, depression, and other inciting factors come up empty.  Their behavior is disruptive, dangerous, and heart-breaking for their loved ones.

The correct treatment: impeccable environmental controls, one-to-one supervision, and extensive counseling for the patient and family are often not available or too expensive.  Our choices become limited.

We have moved away from physical restraints in the skilled nursing facility environment.  They are dangerous, inhumane, and often add to agitation.

Sedatives (the benzodiazepine class: ativan, xanax, clonazepam) can increase agitation and are frowned upon among geriatricians.

Leaving patients floridly delirious without treatment is unduly burdensome to the family and nursing staff, pulls clinical support away from others who need help on the unit, and leaves patients upset and suffering.

Antipsychotics are effective.  They calm quickly with few physical side effects.

Using antipsychotics in a demented person suffering delirium is a prime example of palliative care.  They are prescribed for patients with moderate to severe dementia who have a low quality existence.

This is what defines palliative care.  We trade quality for quantity in a patient population that suffers deeply, and often is only obliquely aware of their surroundings.

It's good for patients.  Good for families.

It's excellent palliative care.

Those Dumb Physicians Aren't Getting The Job Done

The insurance company insisted that they would be saving money in the end.  So they sent the PA (physicians assistant) to my patient's house.  They didn't take in to consideration that I was just there a week before.  Or that I made home visits on a regular basis.  In fact, they didn't even inform me about the appointment.

My patient later told me that the exam was exhaustive.  The PA, who incidentally graduated school the day before and had never seen an actual patient as a licensed practitioner,  poked and prodded the ninety year old woman for over an hour.  He asked her about drugs and sexually transmitted diseases.  He examined every joint and performed a Babinski test.

A few days later I received a call from him.  He tried to leave a message with my secretary, but I intercepted the call.

He had two recommendations.  He thought I should do a better job of addressing the patient's knee pain.  When I asked if he thought it was a result of her polymyalgia, rheumatoid, or osteoarthritis, he had no idea.  When I mentioned that the pain had been treated in the past with various medications (and physical therapy) and the patient had stopped them all due to fatigue (even Tylenol), he was surprised.  When we discussed that she was in the hospital multiple times for pain control before I met her, and now had avoided hospitalization because of better symptom control, he said he was unaware.

His other recommendation was to start the patient on Detrol for overactive bladder.  He, of course, had no idea that her urologist had tried the same thing a few years back and she had become dizzy and broke her hip.

It wasn't the poor PA's fault.  There was no way he could have known what I gleaned from a year's worth of hospital, nursing facility, and home visits.

He just didn't know the patient as well as I did.

Which, of course, brings us back to the insurance company.  They believe that complex problems can be solved with simple solutions.

Just get some PA to go over there and make recommendations.

Those dumb physicians aren't getting the job done.

Till Death Do Us Part

Even though they were such carelessly spoken words back then, Jill took her vows seriously. Till death do us part.

She was just a child when she married Tim. He, a few years her senior, was like a father figure. But they grew together: first professionally and then personally. 

When the kids came, everything changed. He spent late nights at the office, and she transitioned her schedule to part-time so she could be home in the afternoons. 

Jill’s love grew and expanded. Of course the romance was still there, but what she valued as she grew older was the companionship. Her and Tim were partners in every sense of the word. They traversed life’s paths together, avoiding roadblocks, and choosing carefully for their little family. 

The kids were well into high school when Tim developed the numbness and tingling. Jill wasn’t concerned in the beginning, until his symptoms progressed. A flurry of doctor’s appointments later, they held hands in the neurologist’s office and listened attentively to his description of multiple sclerosis....

Read the rest of this post at The Medical Bag.