Wednesday, November 28, 2012

My Son Is Crying

My son is crying.

Not the "I'm in so much pain" cry but more like the "who just pulled the rug out from under me?" cry.  His face contorts into abstract gyrations mirroring the profound melancholy vibrating through his innards. 

He's not in physical pain.  He didn't just lose his favorite toy.  This calamity is far more subtle.  After a thanksgiving full of cousins and joy, it is time to return back to normal life.  His cousins have left for the airport and he feels empty; consumed by longing for togetherness.

My son is sensitive.  Normal emotions that others brush off, he feels to the core of his soul.  It is part of the unbridled uniqueness that he brings to the world.  He fills me with such pride and envy, yet I worry.  But should I?

Am I not also a protege of Achilles?  Being in tune to the morass of humanity has allowed me to be a father, writer, and physician.  It is such qualities that fight the unbearable indifference facing any monumental task. 

Except, I am not my son.

My sensitivities have a limit.  The pain only goes so far.  I do not feel things the way he does.  Or maybe I should preface such statements with the qualifier: anymore.  The death of my father at the age of eight has had untold consequences.  I can only imagine the hardness of heart such things require the soul to imbibe.

He is more than a father could ask from a son.

So why am I so afraid?

Saturday, November 24, 2012

The Old Ways

It's funny that I happened to see it on Thanksgiving morning.

Sarah Liston was well into her eighties when she walked into my office for the first time.  Her legal blindness was only a small impediment to her daily functioning.  She breezed through the door with calm and confidence.  Her monthly visits became a unique pleasure in my busy schedule.  Over the years I realized I was one in a small number of connections to the outside world.

She had a few friends here and there.  She had long since stopped visiting her ophthalmologist formerly, but they lunched on a regular basis.  Painfully past trying to fix her vision, the much younger woman offered companionship instead.

As Sarah became more and more debilitated with age, I worried about who would take care of her.  She had no children or relatives.  Her husband died decades ago.  We spent time talking about what would become of her things when she was gone.  She had a luxurious house and a comfortable bank account with no one to leave it to. 

Once Sarah remarked how she had given an expensive peace of jewelry to her ophthalmologist.  At first feeling unseemly, I eventually warmed to the idea.  The young woman had become more a friend than a physician.  And in some ways, I was learning to fulfill the same role.  Only with experience was I becoming aware that the greatest gift we give others, patients or friends, is the love and respect that resides in our hearts.

Sarah's health was turning.  We planned for her death as if it were a trip yet to be taken.  When the time came, she was comfortable.  A few weeks prior she had my nurse take a picture of us in the exam room.  She framed it and sent it over with one of her caregivers.  I was staring at the picture when the call came.

Five years to the date, on Thanksgiving morning, I was thumbing through the financials of my local hospital system (that comes in the mail annually).  I scanned through the donor information looking for names of people I know.  And there it was at the top.  Five hundred thousand dollars given by the Sarah Liston memorial fund.

I guess Sarah figured out what to do with her money after all. 

On this of all days, I felt like she was thanking me.  Thanking me for being the face of this medical system for which she decided to donate her life savings.

Better yet, she was sending a late reminder. She was pushing me to ignore the current upheaval faced by our backwards health care system. 

Mocking me. 

Tempting me to hold on to the old ways.

Thursday, November 22, 2012

Black Friday Repost

Icicles shot down Lisa's back and into her left calf. Standing out in the cold, waiting in line, wasn't the best place for someone with severe sciatica. But this is how Black Friday had become. At least she could stand.

The police just carted away a belligerent man and his wheel chair bound daughter. There was a kerfuffle with a young couple standing in front of them. It had been whispered among the crowd that the girl had some sort of brain tumor.

The gold slips for the brain MRI's were going fast. Lisa was lucky. Her spine films were not in such great demand. Although she was easily the hundredth person in line, she would likely limp away with the coveted referral form.


Everything had changed since the great healthcare reform. No one had dreamed that hospitals would profit so handsomely. But the provision that allowed billing for uncovered services had unintended consequences.

Fettered by poor reimbursements from medicare and private insurance, the market took over. Every other commercial on the TV was hocking some uncovered medical procedure.

Mercy Hospital is going out of business. Everything must go! MRI's half off, CT-thirty percent discount, elective choleys starting at $5000.

Black Friday was the biggest day of all. The people would crawl out of their beds early Thanksgiving morning and push, wheel, or be carried to the nearest medical outlet to stand in line and hope for a bargain. Sure insurance covered many essential procedures, but like Lisa, the panel often denied basic requests. She knew her back surgery would never be payed for unless she obtained the MRI on her own. Once the results came back, it would be a gamble to see if the panel would OK her procedure. If not, the neurosurgeons down the street were having a buy one get one free sale for Christmas. Of course, Lisa would have to hire a lawyer to make the legal arrangements to find and share costs with a complete stranger (anyone no someone trustworthy looking for back surgery?).

Lisa sighed as she crept toward the front entrance. Her chances were good. She wondered if poor John was having as much luck.


John couldn't help but salivate as he watched Lisa and the kids slurp down turkey and stuffing for breakfast. Unlike his wife who would receive a referral to have her MRI at a later date, if John was successful he would be whisked off immediately for the procedure. And, of course, you couldn't eat the morning of an endoscopy.

After breakfast, Lisa's parents arrived to watch the kids and it was off to the races. Lisa dropped John at the GI suites, and then rushed to the radiology center. Luckily the parking lot was not yet full when she arrived.

Twelve hours later Lisa left the facility with her hand greedily clutching the thick gold referral form. She sent a quick text to John, but no answer. She hadn't heard from him in hours.

She clicked the Facebook Application on her smart phone. Amidst the pictures of Thanksgiving feasts and newly purchased flat screen TVs was a mobile upload from John.

He was siting on a gurney dressed in a skimpy gown with his black socks covering his dangling feet. He had a large smile on his face and was holding his thumbs up in mock triumph.

Lisa couldn't help but laugh out loud and exclaim to no one in particular.

Someone's gettin scoped!

Tuesday, November 20, 2012

Proper Vocalization

Even at the age of fifty, he was still her little boy.  And she tried to embrace him in a protectionist cocoon.  She could create calm and warmth in the almost cozy hospital room, but she couldn't undo the turmoil inside his body.  Her son was dying.  Indeed, of the millions of breaths that had left his mouth over half a century, his remaining expirations would be few.  The cancer had spread.  The counts dropped.  The fever mounted and the skin grew sallow.

The strength of her voice misleading for an octogenarian, her arthritic knees buckled as she ambled towards me.  Her questions were focused and deliberate.  The emotion spent on her her contorted posture, her words came out in a dead monotone.

How long does he have?
What will you give for pain?
Is there anything for anxiety?

Her questions, like afterthoughts, came slowly and painfully after prolonged pauses.  The irony of watching her adult child die was not lost on one who was old enough to inhabit the next bed over.  Many times I reached for the door, and yet was pulled back by another halting statement.

Eventually, I left the room to chart at the nursing station.  Moments later, I noticed her limping towards me. She waited patiently as I finished scribbling in the chart.  She started to speak, but then grew silent.  I could feel her needs leap like a lion from her chest in the absence of proper vocalization.  She was struggling.

You know...

I cradled her with my eyes.

I'll take care of him.

Her heart splintered and the aged blood pooled on the floor at her feet.

Yes. Yes.

She smiled feebly.

And then went back to sit with her dying son.

Wednesday, November 14, 2012

Shifting Paradigms

It's my only memory of religious school.  I must have been about ten years old.  The poor teacher really had little chance.  The moment the conversation turned, I pounced.

What do you mean the chosen ones?

Such propaganda seemed anathema to a young upstart in the mid eighties in a town like Evanston, Illinois.  A town where people of different races and colors were bussed into my neighborhood to integrate the school system.  I remember using a child's words to described how divisive these beliefs could be.  My rant began to gain steam as my voice rose.  Eventually the flustered teacher lead me out of the classroom, and made me sit on a bench in the hallway for the rest of the period.

He must have felt bad about it.  Because the next weekend he suspended the morning lesson and took us all to McDonald's for breakfast.  It was my first and last tussle with religion.  Spiritual by nature, I rarely subscribed to any specific teaching or creed.  I believed our actions could be meaningful and holy without reciting incantations or bowing to an embellished deity.  I never really gave it much more thought.

That is, until recently.

As I voyage deeper into end of life care, I find myself more apt to openly discuss religion with my patients and their families.  When the cards are down and the answers are few, it helps the suffering to have a higher power to raise their hands and release their fate to.  More than once, I have slumped next to a grieving family member and spoken words that seemed foreign as they left my tongue.

It's in God's hands now.

Seeing the comfort and relief, I no longer feel like a hypocrite.  While never my personal path, clearly religion brings solace to many.  Because of these experiences, I believe I have reached a sort of truce.

And this evolution largely parallels the truce we as physicians must reach with death in general.  The great bain of the modern American physician, it has taken a paradigmal shift to convince some of us of the true value of palliation and hospice care.

Like religion, we don't have to love it.

We don't have to strive towards it.

But we must learn how to embrace it to ease the great suffering of our patients.

Sunday, November 11, 2012

The Keepers

The agent stands above his victim thoughtfully.  The white walls and the sterility of the room are mocked by the spatters of old blood on his frayed laboratory jacket.  The tools of torture lie restlessly on the counter: a probe for the rectum and genitals, a tube to be shoved down the nostrils, various needles and catheters, electric current.  Behind him, in a chest, potions and truth serums ache for acknowledgement.

The memory of the agent's humanity had been submerged long ago under the weight of a brutal apprenticeship.  Loathing and despair were squashed with surgical precision.  This is the price of the health of a nation.  The currency of the cloak and dagger is not to be glamorized. 

These are not subjects discussed in the genteel parlors of the aristocracy.  Nay, silence is the virtue that binds the keepers of societies dirty little secrets.  And rightfully so, the backroom deals and ugliness of the puppeteer does not necessarily need to be disclosed to the innocent little puppets.

The body writhes on the table.  Vomit and stool stain the loosely fit clothing.  The agent is practiced and calm.  He studies the victim and makes adjustments.  An assistant leans over the counter and and repositions a probe before leaving the room silently.  Light floods the eyes and the ears are assaulted by various beepings and ringings. 

If there ever was a hell on earth, than this would be it.

The agent looks up at the clock and then rushes toward the glass door.  His shift is over and his family awaits.  His son and daughter want to see their father.

He exits the hospital.

His life's work put on hold till another day, till another sad soul with shaky voice whispers the secret code that sets his diabolical training in action.

Do everything.

Wednesday, November 7, 2012

The Beat Goes On

The man steps up to the podium.  He is no longer a candidate.  His voice is hoarse and cracks as he begins to speak.  One can only imagine what the last twenty four hours have felt like.  Heart racing, pulse thumping, and the lack of sleep have taken their toll.  The victorious pause will be momentary.  Today is a fleeting oasis, the challenges of tomorrow a certainty.

My body crumpled underneath a blanket, I try to keep my eyes open with the rest of the nation.  The daunting hurdles of the last call cycle still washing over my listless spirit.  I saw thirty five patients.  Some by choice, most by necessity.  As a nation travelled to the polls, I rounded in the hospital.  I tended to diabetes, hypertension, colds, and various other illnesses in the office.

I helped two patients die.  Or more accurately, I struggled to use primitive tools to enhance the quality of what little life was left.  I talked to their families, huddled with the nurses, and signed all the orders. 

I answered phone calls.  In the exam room, in the car, in the bathroom.  I signed papers, hundreds and hundreds of papers.  So many papers that my hand began to cramp and my signature became an eligible scrawl.

I will awake tomorrow and do it all again.  The pundits will speculate, a president will return to the business of a nation, and the people will go back to the minutia that fills our overcrowded lives.

And the beat goes on.

Saturday, November 3, 2012

The Rise Of The Extended Care Facilitator

Once the red headed step child of the care giving continuum, nursing homes are playing a more significant role in today's health care environment.  The aging of the population, the rise in hospital as well as outpatient acuity, and the focus on rehospitalization rates are driving forces shaping the need and quality of such institutions. 

The modern nursing home is nothing like the barren images of the past.  Ornate buildings with state of the art rehab facilities, parlors, and resident amenities are now the rule.  The beautified facilities, however, hide a more technical and intensive milieu of clinical care.  Total parenteral nutrition, patient controlled anesthesia, and the placement of central venous catheters all take place in extended care facilities on any given day.  Acute care, chronic disease management, and end of life palliation are now the expectation.

While the capabilities and quality have increased, the future of the nursing home as a soft landing place from acute hospitalization depends on an ever increasing clinical skill set.  Once the purview of administrators and directors of nursing, to create centers of excellence a new breed of physicians must rise to meet these challenges.

I propose the extended care facilitator.  These are physicians schooled both in intensive hospital care as well as outpatient medicine.  Leaders who are willing to spend hours a day rounding and problem solving.  The nursing home doctor of tomorrow needs to be agile at acute diagnosis, chronic disease management, as well as understand hospice and palliative care.

These facilitators will have innumerable benefits.  Nursing homes will deliver higher quality care and their numbers will swell as unexpected discharges fall.  Hospitals will experience better integration and lower rehospitalization rates.  Patients will receive state of the art care in comfortable surroundings.  And lastly, physicians will administer advanced medicine to a ready supply of patients without worrying about having enough to support their small businesses.

Its a win, win, win, win situation.