Monday, February 25, 2008

On fighting with the ER

Don't fight with the ER, it's just not worth it

So I get a call this morning at 6am from the er. My paitient, an 80 y/o with diabetes and renal disease, presented to the er with fatigue and cough. His workup showed "perihilar infiltrates" and a blood sugar of 72. Then they hydrated him (without glucose) and his blood sugar dropped to 62.

The conversation with the er resident went something like this.
Her: we would like to admit Mr. S!.
Me: why?...does he look bad?
Her:no he looks great, but he is hypoglycemic
Me: did you give him sugar?
Her: no
Me: when was his last glyburide
her: over 24 hours ago
Me: well if he doesn't look bad why don't you give him him some sugar, moniter, and reasses in an hour since his hypoglycemics were taken greater then 24 hours ago
Her: well, either way, he has pneumonia and needs to come in
Me: is he tachycardic, febrile, tachypneic, desaturating?
Her: no...he looks pretty good
Me: Is the xray reading a radiologist read or an ER read.
Her: It was an ER attending read but look...its pretty obvious
Me: (giving in) okay if you feel the patient needs to be admitted then go ahead but he sounds fine

So a few minutes ago I just rounded on him in the hospital. His blood sugar is now 200. He feels great. And ofcourse

The official radiology reading on the chest xray: no infiltrates, normal chest.

Wednesday, February 20, 2008

On Being Fired

I knew this was going to be diffucult from the onset. The family brought in this 70 year old male with end stage prostate cancer for fevers and fatigue. The gentleman could hardly keep himself up in his wheel chair. The exam was otherwise normal. Based on his general dability and high fever I suspected pneumonia....or a uti...or a viral ilness. Either way he couldn't go home. I argued with the family who felt he was just being "overly dramatic". I finally convinced them to take him to the hospital.

He had pneumonia.....he had widely metatstatic prostate cancer....he had been so weak for the last few months that he couldn't walk, or get out of bed, or doing anything meaningful to take care of himself. Antibiotics helped the pneumonia but the rest is what we struggled with. Based on his rising PSA, failure to respond to a sophistacated regimen, and overall disability I advised the family on hospice and the unlikely possibility of recovery.

And there so to speak is where the shit hit the fan. The family had been told by a radiation oncologist that the patient had 6-10 years to live based on the literature. Not based on the patient condition, not based on the rising psa, not based on the fact that the urologist suggested hospice. Based on the literature.

So clearly I must be wrong. They decided that their family member was just not working hard enough. So they pushed him to do more physical therapy even when he was so exhausted he couldn't lift his head (the social workers called me and thought that they should report them for elder abuse). The family lashed out at the nursing staff when they tried to give him pain medication for his bone mets becuase they didn't want him to "get addicted". And once I had him stabilized and transferred to a nursing home for physical therapy they called the director to complain and to fire me.

So I called the family and assured them that I wanted the best for their loved one. That ofcourse if they were unhappy with my care they had the right and responsibility to have another physician. That it was my hope that their family member would recieve the best care whether it was given by me or one of my colleagues.

And the family relented and decided they wanted to keep me as his physician. And the nurse called to say that the white count is up. So I ordered cultures, ua, cdiff and a repeat chest xray. And, ofcourse, the nurse called back to say that the family was refusing the xray.

Apparently they were concerned that the radiation from the chest xray would be to harmful

Tuesday, February 19, 2008

On Being A Physician-When Death Comes

When Death Comes

Like a mistress cast aside
We dance
In unknowing unison

Down hospital corridors
And exam room tables
She crouches

A stethoscope misplaced
A cadeusius splintered
She waits patiently

And by and by
Death comes
Often unexpected
To reclaim her lover's

Best intentions

From the chapbook Primary Care, The Lives You Touch Publications

Monday, February 18, 2008

On Being A Man

Growing up without a father, I often questioned what it meant to be a man. I wondered what one has to do to become a man? As I entered my early twenties I realized I was far from what most considered manly. I grew up in a woman centered household. I wasn't particularly athletic. I was more likely to call triple A then to change my own tire. I didn't know how to fix things around the house that had broken. I was pretty much useless...or so I thought.

As time has passed I have started to gain an appreciation for my own abilities. Sure I am not as handy as many but getting married and having children has shown me that maybe I am manly after all. When the going gets tough.....when something needs to be done my family can count on me. Whether its driving through the storm, or moonlighting for extra money, or changing the diaper my wife refuses to touch.....I get the job done. And I take pride in it. So much so that sometimes it's hard for me to ask for help.

I have called 911 two times in my life. The first was about 6 years ago when my wife and I were pulling into the driveway and saw someone walking out of our house with our TV. My wife backed out and followed the guy as I dialed my cell phone. The police were there in minutes and caught one of the two robbers. Unfortunately the one with all the stuff including my wife's engagement ring got away. So it goes!

The second time I called 911 was a few weeks ago. It was a cold morning in Chicago and the snow was coming down heavily. I got up early to beat the traffic but unfortunately that meant that I had beaten the snow plows to the expressway. Twenty five minutes into my thirty minute commute to work I lost control of my car and skidded from the left lane into the right and ran smack into the side of a semi. I was going about thirthy miles per hour and the front of my passenger side hit first. Then my car bounced and the back of my car hit the semi and I slid into the embankment.

I was stunned. The next thing I realized a kind motorist had pulled over on the other side of the expressway and ran out to me to see if I was ok. I was shaken up but in good shape. My car was totalled. I called the police and so the story went.

I was closer to work then to home so I had the policeman drive me to the office. I saw a few patients in the hospital and then a handfull of people who roughed the snow to come into the office. Then my wife came and picked me up. I had no interest in getting behind the wheel to driver home. luck would have it this was a friday and I was on call for the weekend. So the enterprise rental car was waiting when I arrived home. And snowed again that night. The next morning I woke up with quite a bit of apprehension. Shaken from my accident the day before but realizing that there was noone else to see the patients in the hospital or the dozen or so office appointments, I resigned myself to what had to happen.

So at 5:30 in the morning I crawled through the fresh snow to turn on the rental car. I cleared the debrit from the windshield. I took a deep breadth and then jumped in head first. I have to admit I was scared. Petrified in fact. But I couldn't live my life afraid of my own morning commute.

Years ago I would have looked at my fear and been skeptical. I would have seen it as just another example of how I didn't know how to be a man. But now things appear much differently. I got in the car that morning because I had to. Because I wouldn't let my fears overtake me. And that....that is the essence of manliness. Standing up to what scares you the most. Not because you want to....not because it the right time....but because you have to. Because there are people who are depending on you to do it. My family, my colleagues, and yes even my patients.

I'm still reticent to get into the car each morning. Especially on the days it snows. But it's getting a little better every day.

I'm Back

Hello.....I'm back. My wordpress blog crashed. Everything is gone. So I am back....on blogger. We'll see if anyone can find me.