Intro to Palliative Medicine

This month I am doing something very different, and very rewarding.  Palliative medicine.  Most people get a glassy "what?" look to this term.  Palliative literally means "Relieving or soothing the symptoms of a disease or disorder without effecting a cure"  It is simply end of life care.

Friday was my first day on this service and it was a very full day. I was involved in two cases in the ICU of patients who were being taken off life support.   One 80 year old woman was very alert and awake, but wanted to be off the breathing tube, knowing it meant her ultimate death.  With her 4 grown children and grandchildren around we completed the process of taking the respirator away.  She had a few hours to say goodbye to loved ones before she passed.

During the second pt's extubation there was a stat page overhead to the oncology unit for our team. This was very unusual and unexpected.  The palliative care nurse and I went rushing up to the oncology floor to the room with all the action.  A crowd was gathered outside.  We opened the door, not sure what to expect.  The room was very dark, just a small light from the sink area.  A young woman in her 40's was lying in bed, unconscious. Her children surrounded the bed.  A young blond 6 year old on his 13 year old sister's lap, and both sat clasping mom's right hand.  Another young 9 year old boy sat on the bed grasping the left hand.  Around the bed were about a dozen friends and family.  The room was quit except for small sobs from the kids and the occasional gasping breath from the dying mother.  In an instant I understood she was close to death.

The nurse shuttled us outside to whisper why we were stat paged to this room.  "she's likely to die any minute, and her kids suddenly thought they'd like to have a plaster mold of their mom's hand to keep". The palliative nurse nodded her head and said she had it taken care of, to just giver her a minute.  She rushed off, and I went back in the room.  The space between breaths was lengthening.  The silence would often be pierced with the daughter shouting- "breath mom, c'mon, take another breath".   At one agonizing moment even the dying woman's sister pitched in "You breath now sister, please, breath".    In no time the molds were there, and one by one we had each child take their mother's hand and press it into the mold.  While they did this, we told them how much their mother loved them and had them tell her goodbye.  We stepped out to let them have the last moments alone, and solidified the handprint, something they can have with them always.

Although I was near and involved in 3 people's deaths that first day, it was a very fulfilling day. Traditionally we as doctors have done well with making the process of coming into the world better.  Of course the process of living is always being improved upon...it's high time we look to the end, and attempt to make it as meaningful and comfortable as possible too! 

Generous gifts

In my travels to other countries, I have often been struck by the generosity of people who literally have nothing. I do not think, however, that this is unique to other cultures.  At least, I have recently seen this phenomenon alive here in this very country.  I just didn't realize it would take the expectant life of my newborn to make me aware. 

The patient population I care for is very indigent.  We use this term around the hospital a lot- our "indigent" patients.  The definition of indigent means "lacking food, clothing, and other necessities of life because of poverty; needy; poor; impoverished."  Yep, that's our patients.

I have been surprised several times during these last few weeks of my pregnancy by patients bringing me baby gifts. As I have taken care of them for several years now, I know their social histories.  These are people who've been unable to afford 3 dollar copays on certain medications and who wear the same dirty t-shirts to multiple visits.  Yet, they've shown up with their gifts-  the dollar general labels still on them- sometimes gift wrapped, sometimes still in the plastic bag from the store.  I want to tell them no, to use the money spent for themselves, but there is always such pride and pleasure in their eyes as they hand over the present, that I can't. 

It's overwhelming when you encounter pure generosity. I think these gifts of clothing and baby powder and diaper wipes will be cherished even more than the gifts given with ease.

Toenail nest

You wouldn't guess my podiatry month could get any more exciting than long toenails.  But it has.

This week we had an add-on emergency visit.  It was hard to imagine what a podiatry emergency could possibly be.  An elderly gentlemen in poor health was brought in by his caregiver wife.  He weighed about 350 lbs and had portable oxygen on.  The wife's story was that he had stubbed his toe this morning stumbling upstairs.  She could tell it was oozing a bit, small blood there. She had him sit so she could clean it up.  AS she bent closer to clean it, she was alarmed to see small white wormy things moving around under the nail.

You may have guessed it- he had maggots under his nail.  Our job was to clean these guys out, one by one...ultimately taking off about half the nail to get to them all.

How could this have happened?  The wife explained that with their several cats, they often leave the door open when weather is nice.  This does allow a multitude of flies into the house...which they have grown accustomed to. The older gentleman likes to sleep with his feet exposed from under the covers- creating the perfect egg laying spot for a pregnant fly.

The wife understandably was a bit hysterical at her find.  I felt like being hysterical assisting in plucking out the maggots. 

In case you needed a reason not to let flies in your house-  beware the toenails!!

P.S= was going to post a maggot pic, but just looking up the images was making me sick....will spare everyone

Personal tragedy

I'm now back on the inpatient side for a few weeks.  The stories I encounter are often hard to believe, if not tragic. 

One case I can't get out of my mind is a young man we saw recently.  25 years old and already with 4 very young children. He had been in Iraq for a 1 year tour, and has been home for just a few months.  I suppose the adjustment, and stresses of life were just too much.  He choose to end his life, taking a gun to his chin and pointing upwards.

The tragedy, besides the act of suicide, is that it failed-  he was brought to our hospital, with the bullet passing through his nasal passages and eyes.  Unable to swallow or talk from the injury they placed a trach tube - that thing people can breath with under the adam's apple. Severe damage to the eyes made it necessary for now to sew the lids closed.

Can you imagine? Already the perception of his life was too much - now he's woken up to a black sightless reality, unable to talk.  He communicates with a notepad and pen- often, because he can't see, he invariably writes over words already there, making communication very difficult.  As you can imagine, he can't be alone- he'd be unable to call for help, or see to find a button to alert the nursing staff.  

I'm not sure how he's going to make it, but he scribbles on his notebook, "I want to go on, to get better, to be here for my kids"

Unintended closure

Emotionally she was worn down. Just weeks earlier, and very unexpectedly, her father, who lived continents away had died. She made the trek to mourn, but being so far away missed the official funeral ceremonies.  She returned to the states to continue her duties as a resident in my residency program. It was evident she was hurting, feeling guilt for not being by her father's bedside in death.  As a Hindu, her faith gave her no hope for closure.  And yet, how mysteriously God works...

She was working in the ICU after her return.  A tough month regardless, but compounded by her emotional instability.  Mr. J was an elderly lung cancer patient in her care. All knew he was close to his end. On this particular night, all signs pointed to this being the time. All day he had been inquiring about the arrival of his only son. He made it clear he wanted to tell him goodbye.  Sunitha, my friend, knew all to well how important it was for both of them.  His son arrived mid afternoon, and was by his bedside constantly.

Around 8 o'clock Sunitha came again to check on her patient, Mr. J's son decided to head to the vending machines to grab a snack and something to drink. He walked from the room and Sunitha inquired about those medical things like pain and anxiety.  Suddenly as the two talked, Mr. J looked at Sunitha and said, "The time is now, I'm dying." Sunitha in a panic looked for the son, wanting to escape and get him back in the room.  Mr J, however, looked Suintha in the eyes and quietly asked, "Please don't leave. Will you just hold my hand and say a prayer for me".

In that moment, Sunitha the Hindu, took this dying man's hand and though not clear on what kind of prayer this man wanted, she opened her heart to God on his behalf. She tells me that it became her father's hand that she held. She wept and told her father goodbye.  Such a profound peace and closure came over her as Mr J slipped away.

The timing of his death, though seeming to be at the worst time - in those minutes his son had stepped away, was perhaps perfect in a grander sense.

Abuse

I don't mean for all of my tales to be sad, but it's the extremes that have stuck out these first few weeks. Here's another psychosocial dilemma.  What do you do if you're dying at home on hospice and your spouse is abusive? It's hard to "leave" as we encourage in other situations, when you are trapped in your bed dying of cancer.  This was the predicament of a woman I admitted yesterday.  In her case, coming to the "house" was a safety issue.  So now, he's not allowed to come and visit, and she hopes to end her days not being threatened or abused.  

Things to do

I had a bit of a shock yesterday with one of my patients.  He is a 41 year old who had a very swollen left leg.  His upper thigh was tight, red and very painful.  Without my prompting he said he had noticed it was hard to breath the last few days.  The combination of these complaints will send off warning flags in any medical provider. His leg and breathing shouted blood clot.  Worse than that, he could have a piece of the clot sitting in his lungs.

I calmly told him my suspicions, and the plan to admit  him to the hospital to do the tests we needed to see if this was indeed a clot. I was shocked then, when his blank stare ended and he shook his head and said "nah" like he was turning down a request for an extra slice of cake.

"I don't think you understand what I'm saying" I explained. "If you walk out of this clinic, that clot could dislodge and go to your lungs and instantly you'd be unable to breath, and could die"  I say this trying not to sound condemning.  He again just shook his head and said "we all have to die sometime".

There's not much else to do in these situations. I tried exploring the reason WHY he didn't want to come in- but no real reason was apparent besides "I've got things to do at home" He did add, "I guess I could come in some other day" Sure, I thought, when it's convenient for you to save your life, we'll talk.

I ended up having him sign something called an AMA paper.  It's a document protecting me in case he dose drop dead once he gets home. He signed this document that says he knew he was leaving against my advice.

What keeps playing in my mind is the eerie similarity of this encounter to one I had when I worked a month in Papua New Guinea 3 years ago. A man about his age had come to our hospital in the highlands of new guinea with what seemed to be clearly a blood clot.  I recall having a similar conversation with this man about coming into our meager hospital for treatment and having him refuse.  He had things to do at his village.  Death was a real possibility, and just like my patient, he made some comment about the time to die coming for everyone.  At the time I attributed his insolence to the ignorance of the new guinea people.  I was shocked at the carelessness of his attitude.  Now I know, it's not something immune to a developing country.

I know we do all have to die sometime, but it seems irresponsible to play rush and roulette with that life!

"Goodbye Doc"

My colleague told me a great story today from her years of experience. 

An 80 year old spunky female patient of hers had made a sudden appointment to see her.  When Dr. C entered the room, this kind old lady let her know she had taken 3 different buses to get to her appointment.  “And why have you come to see me today?” Dr. C asked.

“I came to tell you good bye.” Dr. C’s brow furrowed, and she waited in silence for more of the story.  “I just know I’m going to die soon. I don’t feel sick, or have any pain…I just know it’s coming.  I’ve pressed my husband’s nicest suit that I want him to wear for the funeral, and I’ve written him a note of the order of service, and now I’ve come to see you."

Dr. C still thought there must be something else to this, and dug deeper into medical symptoms.  She finally got this elder lady to say that perhaps her back was hurting a little more than usual.  In Dr. C’s adeptness she asked another question, “I have a feeling the pain you are feeling is your heart, do you want me to do anything about it?"

To this the patient, well known to Dr. C over the years, replied with a knowing twinkle in her eyes, “No. I know it’s almost time, Dr. C ,I just wanted to come all this way to tell you goodbye, not for you to do anything” 

So, honoring her wishes Dr. C said goodbye, but added, “I’m not going to let you take those 3 buses home!”  Dr. C stepped out and arranged for her medical assistant to drive the patient home – she helped her into the car, cane and all, and hugged goodbye.

The old woman of course died, right in the medical assistant's car on that drive home. Not exactly what the med assistant bargained for in volunteering for the lift home (and as you can guess a little traumatic).

I had to smile at this story, sometimes you just KNOW it's time!

Cynicism in the ER

You get pretty cynical when you work in large ER centers.  Intermixed with the real emergencies, comes a variety of complaints that belong simply with “Ask a Nurse”.  Instead, I am amazed at how long people wait to be seen (often 3-4 hours) to ask about a swollen lip, or a mild case of diarrhea.  It’s 2 in the morning, why in the world would you care about a tick bite right now?!!   But, still they come, for whatever reasons, clogging our hallways and rooms and giving those of us who work shifts in the ER a dismal outlook on humanity’s judgment of the term emergency room. 

The problem is, you can’t let the cynicism encase you.  I was reminded of this last night during one of my weekend ER shifts.  The young woman I came to see said her complaint was “bumps in skin”.  I felt the wheels of “oh brother” starting to turn in my brain.  Still, with utmost respect in my voice I asked about these 2 bumps just noticed that day.  They caused no pain, had no redness surrounding.  One was on her lower belly, about a ½ inch felt just below a small fat layer.  The other, on her back thigh was a similar size, and also soft and movable.  It felt very similar to a lipoma, or small fatty blob we all get sometimes.

I told her they were nothing- internally rolling my eyes, that she had felt this was of such importance that it would be an emergency.  Before I walked away tho, I asked her about the cough she had been exhibiting throughout the exam.  “oh that”, the young 25 year old said, “ I was just diagnosed with cancer last week, it’s in my lungs, but they aren’t sure where it came from, maybe my uterus or cervix”

Just like that, grace abounded.  Her unreasonable medical “emergency” didn’t matter any more.  This poor girl was dying.  I found out she had had a CT scan last week, so went to see if these bumps were there last week.  The blobs were there on the scans, and more likely little cancer mets in her skin than fat collections. I glanced at her xray, showing the diffuse metastatic cancer riddling her lungs.  While still not emergency material, I realized now why this patient was in our ER.  She was afraid. She had cancer spreading and chewing it’s way thru her body, and she had every right to worry about bumps in her skin.

The lesson of course is to give everyone the right for their silly complaints.  I might disagree with how emergent their reason is for walking thru our doors, but I’m still their doctor, and it’s still my job to help heal- even if it’s just respectful reassurance.

Pain vs Harm

There is one thing, I think most of us would agree is tough to deal with- pain.  Although in medicine we say it is the 5th vital sign, it remains largely a mystery.  What makes it so difficult is it's subjective nature.  Doctors like objective findings; tests, numbers, X-rays.  When we must trust the experience of the patient only, it is uncomfortable.

There is however, a certain attitude we Americans have adopted about pain that I'm not sure I agree with.  Like our demand for immediate gratification, and sense of entitlement, somewhere along the way we've decided that we cannot experience pain.

There are ramifications to this mind set that ricochet thru every aspect of society. I saw it last month in OB, and I've seen it this week hourly in my orthopedics rotation. In an argument with a patient who is trying to get disability status from the back pain she's incurred over years of working with heavy machinery, the doctor I was working with said simply. "Look, your back condition is painful, but it is not dangerous.  Going back to work will not harm you" This patient could not separate the two - pain from harm.  In her mind to have pain was to have injury.  But in fact, it's not the same-

This is where society has erred- to link these concepts together.  IF we assume pain is damaging, and injurious, we avoid it at all costs, and will not tolerate it.  Thus our tendency to self medicate and avoid pain - with alcohol, drugs, and other bad habits.

One huge problem with the idea that pain must be avoided - is the impossibility of this. Thus, one is already doomed to failure in pursuit of never experiencing pain. There is something necessary about pain as well --it teaches. Child psychologists remind us to let infants stumble into tables and touch a flame- because guess what, they learn not to do it again.

All that said, should pain be treated? Of course. The caveat is that a residual amount of pain is okay, and expected.  Once my chronic pain patients with arthritis, injuries, etc realize that we can't take away the pain, just make it bearable - they do great.  It's those who continue to strive for a pain free existence that fail, and live out miserable lives.

Pain won't kill us.  It sounds harsh, but it's true. I'll continue to try and minimize pain for my patients, and myself.  But I also want to adjust mind sets, and separate pain from injury. The two may both occur in an event, but pain itself does not injure. Finally, pain is allowed, and will occur simply because we are human beings. So, pass the word along: PAIN HAPPENS

OB stories

My month at the army base is nearing a close. Unlike first thought, I don't have even xanga access while I'm there. Thus the long entry.

My call on Thursday was a day of highs and lows. In the morning we had a 41 year old woman pregnant for her 9th time. She had 7 children already at home.  Although she was at her due date, the baby was still lying sideways. This was just too dangerous to allow to continue, so she was able to choose either a c-section or a "version" (AKA we attempt to turn baby from the outside).  She choose the version.  So, with about 10 people on hand, outside the hospital room, ready for an emergency c-section, another doctor and I went in to try this procedure.

At the bedside was an ultra sound machine and heart monitor. We lathered up her belly with gel. I then felt for the feet and rear end and pushed counter clockwise as the other doctor found the head and pushed down/counter clockwise.  With all our might we pushed, as the patient moaned from the pain.  The room was silent and all waited with heightened anticipation. After about 30 seconds there was a shift, we paused and took the US probe to check. The baby had moved quite easily! "We're done" we announced, as the room exploded in applause and excitement.  It was much too easy - and not supposed to go so smoothly. 

We immediately started the induction, and a few hours later, very naturally, I delivered a 10lb 6 ounce baby from mom, who choose the hand/knee position to deliver. I had just cleaned up mom, and was leaving when the nurses told me about the next room I was to go see.

A 20 year old male was in the ER that morning, and had just been diagnosed with renal cancer. It had spread to his liver and bile duct, and looked very, very bad. They had decided to fly him out to Walter Reed in Washington DC the very next morning. All this was coming so fast, and with less than a day left, the ER docs asked what were some requests he had. 

"I have two requests" he uttered, "to see my unborn child, and have one last home cooked meal". 

My role was to perform the ultrasound for his wife, him mother and himself so that they could see their child for the first and maybe last time.

As you can imagine, a completely different environment from the one I was leaving. The new diagnosis was heavy in the room, but the excitement to see their little child was competing for space. Ironically the wife was exactly as far along as me - the images for them, so similar to the images I had done on myself. They couldn't soak up enough of their little one's movements; kicking legs and arms, twisting and turning.  We printed some pictures for him to take with him.

I prayed silently that he'd be able to see his child in person in November. Until then he'll have these movie like images in mind.

It was hard to quit the ultrasound, but the nurses informed me there were other patients waiting. Puts everything into perspective, moments like this.

Delivery methods

There is definitely a wide range of possibilities when delivering a baby.  I am working with both nurse midwives and doctors old enough to be archives.

I tend to enjoy the philosophy of the midwives...which value natural vs sterile.  As an example - and these are extremes: One of the nurse midwives just uses the hospital bed - doesn't put up stirrups or anything. She puts on a pair of gloves, but no gown.  She sits on the end of the bed and after the babies head is delivered, she has the mom reach down and help pull out their own baby straight up onto their stomach.  This is in sharp contrast to one of the old time doctors. He not only uses the stirrups- but places drapes over everything for "cleanliness", over legs, stomach, everywhere.  There is a bright surgery light that comes down from the ceiling that he uses and what really makes me laugh is that he goes to scrub before the delivery.  Scrubbing is what surgeons do before surgery - it requires special soap and about 5 minutes of sudsy scrubbing. He gowns and gloves up then, including a big mask, as if it was surgery.

The ironic thing is that a vaginal birth is anything but clean. Imagine having just swam through a sewer canal underground...how important to your health is what's beyond the canal opening?  Not too important when you are already covered in grime. 

I'd say my technique is mid ground. I haven't asked any moms to reach down and grab their babies yet... but i do like delivering into the bed.  I imagine back in the time of home deliveries and around the world, this is how they do it.

Stories

If I had the time, I would read the stories of my patient's lives. In the rush of a busy clinic day, it's easy to forget the pages of events that make them who they are.

One gentleman threw out a teaser last week. I just decided to take the time to enter in, and what a story he told. Mr. Rob W is a 69 year old African American and one of my more healthy patients.  Runs still 3 times a week, stays trim and in shape. Back in the 1950's he ran track in high school, and ran very fast. He was recruited by several schools, but decided on Pitt State based on 1 simple experience.  The Pitt sate coach invited him to come run in an AAU competition in Indiana. He wnet, and he won the 100 yd dash, and on the way home the whole team stopped in a local diner to celebrate.  The entire team was white, except for Rob, who remember wasn't even on the team. When they entered the diner, the coach made a point to have Rob sit with him. Rob was confused, but obliged. It wasn't long before the owner of the diner came up and calmly told Rob he was not welcome in the diner, as they didn't serve colored folk.  Rob was unaccustomed to this, but quietly got up to leave. The coach grabbed his arm and rose. "Alright boys, we'll all be leaving now" and immediately, all 30 team members rose to exit.  The owner, shocked, quickly changed his mind, "I suppose we'll have to change our policy for you all"  Rob decided at that moment he'd run for Pitt State.  He knew this coach would be his advocate, and watch over him.  

He went on to tell me of breaking color barriers in track and field...of meets in Texas, where he was the first black athlete to run on the track field.  But also of towns in Texas, where he wasn't even allowed off the bus, or wasn't allowed to shower after meets in the locker rooms.

He ran against the greats, like Bobby Morrow and Dave Sime who won a gold medal and silver medal respectively in the 100m at the 1956 Olympics. He went on to place 1st in the central intercollegiate conference championships 3 years in a row (55-57) and was elected into the intercollegiate athletic hall of fame. 

In his time he was one of the fastest men on earth, and here he sat, humbly in my little clinic room. When I take the time to hear the stories that knit together my patients lives, I am always blessed.

Boundaries

There are some important “side effects” to consider when patients are also co-workers.   The hospital I work at is so large, that it goes without saying that I see some of my patients on a daily basis.  This can be rewarding, as a small town doctor must feel, getting to catch up in the hallways or in the cafeteria.  It also lets me witness some of their habits, which I’m sure they hate- as I walk by them on their smoke breaks, or see them grab that extra cookie at lunch. 

There is of course a huge negative to all of this.  Certain astute patients have figured out how to get my pager number.  Doctors guard their pager numbers as something sacred. It is instant access, at any time.  Because these numbers are shrouded with privacy, when I’ve had a patient, who for instance is also a nurse, page me with a personal health question, I feel violated.  Boundaries are a part of every relationship in life, and are especially important in the doctor/patient relationship.

Some might think this extreme- but if even a couple hundred patients of mine could call me anytime – I’d have calls of “doc I’ve got a headache”, “my temp. is 101, what should I do?” “Hey, I need a refill on my meds” every evening.  It’s not how I want to spend my precious little time at home!

Choice

At 61 the swollen glands under her arm and knot in her breast were concerning.  She somehow ended up at a rheumatologist, who told her he thought she must have metastatic breast cancer.

The lump kept growing, despite ignoring it.  Eventually she ended up in our clinic.  Mammograms were ordered confirming her fears - breast cancer. 

She, however, decided not to see an oncologist.  She said that she'd seen her mother and grandmother die of breast cancer, despite treatment.  She'd watched friends, sick from chemotherapy, still dying.  As every patient has the right to do, she refused any further treatment.

Unfortunately, whatever notion she had of quickly dying in her sleep from this ravaging disease, didn't happen.  Instead, the tumor, now softball size worked it's way to the surface and fungated.  It's a term that looks as bad as it sounds.

This I've seen in other countries, and am including a picture I took of a woman with a fungating breast cancer in Papua New Guinea. Most people don't have a chance to see and smell cancer, because usually it's confined within our bodies.  But it smells, and leaks fluid, and worse, is a visualization of the cancer that lives within.

This woman has changed her mind now on treatment. Tho, much too late.  We'll help take away the mass, but can't take away the cancer.

Honestly, it surprised me to see a tumor left to grow unheeded by treatment. It's not something you see everyday in the united states. Unlike places such as New Guinea, where lack of medical care allows tumors to progress this far, it's eerie to think this happened because of free choice- we let our patients have the ultimate say.

Indecision

There's one thing I just don't have patience for - indecision.  This is more bothersome when dealing with sick people in the hospital.  This week's attending, a.k.a. boss,  is a new employee of  the hospital and doesn't want to commit to anything.  I understand her hesitancy. Being solely responsible for an entire team of residents and patients can be overwhelming. But, as the leader, we all look to her for the final word.  Which means, we need a FINAL word.

We spent such wasted minutes today on whether to give someone 20mg of a drug or 40mg.  After our fearless leader had changed her mind no less than 6 times I was ready to take a field trip to the dumpster. Anything would have been better than listening to the agonizing non important banter of what strength to use.  At one spot the attending turned and asked "well team, how many think we should send the patient home with the diabetes medicine?"  Are we voting now about patient health? All in favor of the blood transfusion say "I", those wishing him to bleed to death say "nay".  Not that drastic, but all this wishy washy conversation was so wasteful.

I think I actually prefer an attending that's wrong but decisive.  At least they commit and we can move on. If later we find that attending was mistaken, we learn - and again move on.  Indecision feels like being stuck in thick molasses. No matter how much effort, how many words, and how much time...no progress is made.

Saliva facts

I learned an interesting fact today - on average, adults produce 1.5 liters of saliva a day.  Picture it - that 2 liter of coke in the fridge, 3/4 full of spit....everyday we do this.

You may wonder why this is important.  It's really important to hospice docs and nurses, the people who take care of those in the process of dying.  Often terminal patients, when close to the end of life, don't do the simple things like swallowing anymore - we have reflexes that keep us breathing, and keep our hearts going when we're in those deep comas close to death - but the swallow mechanism is often absent.  There's that 1.5 liters that has no where to go.  We give special medicines to help stop the saliva production... thus the interesting fact of how much we make everyday!   Just to round off the saliva discussion - did you know that the tongue couldn't "taste" food without saliva...  a dry tongue will taste nothing.  

Fun facts to pass around and mull over during your next meal.

Elevator talk

What type of personality talks to strangers in an elevator?  I take multiple elevator trips daily, and am always shocked when people talk to me.  "Boy this weather! Of course I have to pick up my sister at the airport at 5 tonight, of all days!"  I smile at the woman telling this to me before she jumps off on her floor. 

One day a woman said, "whew, what a day!  My son was arrested last night, my husbands in the hospital and they just turned of my electricity because I was behind on the bills." 

"Well here we go, I'm hoping today my doctor tells me my tumor has shrunk with the chemo"  A man told me prior to my stop.  

I dislike these sudden bursts of intimacy.  What am I to say to such revelations?  Usually there's time for 1 or 2 words before the stranger and I part ways eternally.  "So sorry", "good luck" or "that's rough".   What compulsive urge is in them that causes this eruption of personal information?  Whatever it is, I lack it. 

Growing up

I've decided, being a resident is a lot like growing up.  As children we trust everything our parents tell us, without even acknowledging that they may be wrong. Their words are truth, and accepted as such.  Then we start growing up, and somewhere along the way, have that startling realization that they could be wrong.  Some innocence is lost when we find out that a lot of what comes out of their mouth is opinion, or their idea of the right answer, rather than fact.

The same thing happens in residency.  We start out, as interns, trusting and naive.  We assume that those staff and attending doctors that guide us are all knowing. The words uttered we take as truth.  We assume, like children, that medicine is black and white...and we are on our way to knowing the right answers.  Then we grow, and progress and it starts to dawn on us - that realization that the doctor training us could be wrong. At first it feels like our trust has been betrayed.  But then our brain's start understanding that it's more gray out there than black and white, and that what's often spoken as truth is merely opinion.

In that midway point now in realization, it's strange when the interns ask me questions expecting absolute truth. They still don't realize that it's just me...my opinion on the right thing to do.  "What's the precise amount of IV fluids to start on a 65 year old admitted with pneumonia?" they'll ask.  I do my best to say that there is no precise amount - just pick something - 100 an hour, 150 an hour, 70 an hour- does it really matter?  But they will wait for a definite answer, then write it in some notebook as if it were truth.  They'll soon learn, like children, that those ahead of us speak in opinions more than fact.

Guardianship nightmare

When I think back to my genetics class in high school, there is one disease process that still haunts me - Huntington's Chorea;  A debilitating and progressive genetic disease that strikes in your mid 30's - and usually causes death in 15 years.  The problem is that most people have had children  by the time they get symptoms- and have inadvertently passed the disease on to their kids.  Kids have a 50/50 chance of getting it. 

I am taking care of my first Huntington's patient. She is 55 and at the end stages.  Her eyes are gray and empty, probably blind. She cannot talk, but occasionally a guttural sound escapes her lips.  She is twisted and bent with muscle contractures.  She has the hallmark character trait of Huntington's, the chorea movements- which look like continuous writhing of her arms and neck. I am not sure if she is aware any longer, there's no way to know if she hears us or has thoughts.

She came to us because the feeding tube that sits in her stomach came out at her nursing home. We were charged to replace it. We were also told when she arrived that she was a full code.  This simply means we are to be aggressive in keeping her alive - if she stops breathing we must put her on a respirator to keep her alive.  This didn't make much sense to me, why would her family choose to prolong this woman's suffering by keeping her alive on machines if the time came?  Why wouldn't they just allow her to pass naturally from her disease? 

I soon discovered it wasn't her family's decision. The family, once learning their mother had this disease, and watching her slowly degenerate just took off.  It was too hard to watch. There was probably some anger from the kids - knowing they had a 50/50 chance of getting this. Fear as well, realizing what they witnessed could soon be them.  Regardless, no one could find any family. Certified letters, telephone calls, all went unanswered.  So, the court took guardianship.  The court now is calling the shots - which means the court will do anything to prolong her "life", even artificially, even if she lays there writhing, hooked to a machine for years.

False positive

There's a specific reason researcher's spend so much time deciding what tests are good screens for doctor's to use.  For example, it's worth it to do a colonoscopy and mammogram in people over 50.  While most people would think- what's the harm of just testing for everything? Why not do body scans every year? Well here's an example why not to!

A 40 something executive woman came to clinic in a panic. When I walked into the room, she was nearly sweating with fear. She handed me a letter from her work and she explained she'd recently taken part in a job related health screening. "They took my blood and blood pressure, then I just got this in the mail"  This letter was a form letter: "based on you blood work, there was an abnormality, please see your doctor immediately" Then there was a space to write in the lab that was abnormal. Penciled in was "CA 19-9" no value, just this.  The patient had of course gone online to find out what this was- and found out it is elevated in people with pancreatic cancer.  There she sat, tremulous, after days of certainty that she must have pancreatic cancer. 

I don't get angry very often, but wanted to call her work up and let them have it. This was ludicrous!  What asinine lab director would suggest this specific test to screen for? CA 19-9 is not meant as a blood test to do on random people - WHY? because if I took 1000 normal people with an elevated CA 19-9, 998 would NOT have cancer.  If I tested it only in people with pancreatic cancer already, then yes a majority would be elevated-  but it has only a 1% positive predictive value.

This poor woman! How could I reassure her not to worry? Were my numbers and stats enough? Would my obvious frustration with her work place for doing such a stupid test help? Or will she forever worry now, wonder if at any moment her pancreas will sprout a tumor?  Some may say we should still test- for the 1 in 1000 who will have the cancer.  But to what harm? If 998 are forever psychologically altered, then is it really worth it?

Bacon

In line for a well deserved post-call breakfast in the hospital cafeteria this weekend and a cute old man in his 70's was in front of me getting some bacon. His left hand held a slightly tremulous plate of biscuits & gravy and hashbowns, while he bent low to the bacon and sifted, with great concentration, thru the pieces with his right hand.  I wasn't in too much of a hurry, so I just stood watching him, surmising why he was being so picky.  Finally he looked up, and apologetically explained, "I'm trying to find ones with the least amount of fat"

I chuckled as he let me grab a few strips myself - now that's rationalization!  I'm sure those grease soaked pieces he finally located with less fat to meat ratio really will make a difference in the long run!

Uncomfortable moments

Sometimes there are uncomfortable moments we must overcome.  For instance... I was scheduled to do a "re" pap for one of my colleague's patients. This in itself is awkward - who wants to come in a second time for a pap because the 1st doctor didn't get a good sample ?!  The pressure's now on for me- to do everything perfectly.  Then I saw who the patient was, a 50 year old named irene, and my nerves plummeted.  The last time I had seen this particular patient was several months ago in the hospital.

Her mother, betty, was one of my favorite patients.  A few months ago betty had come into the hospital on a night I was on call.  Tho supervising a younger intern, I stopped in the hospital room that night to double check everything.  This very sweet, energetic 78 year old was having diffuse abdominal pain. The scans done in the ER had pointed to diverticulitis, an infection in the bowel wall.  We'd started the right medicines and were keeping her comfortable with pain pills. I can still remember that night as irene and I helped betty shuffle to the bathroom, her gown gaped in the back and her two classic gray braids adorning each side of her face.

The next morning I came to work and was greeted by a cement wall.  That's what it felt like hearing about the sudden death of betty overnight.  What had happened? I had left her stable, and so unexpectedly she was gone. It had happened just an hour or so before, thus I went, wearing my heart on my sleeve, into her room, packed full of family members.  Tears streamed from my face from shock, and true sadness. Irene came to me, "what happened Dr.C?" That's right...the doctor, always responsible somehow. I felt fault being handed to me, disguised as concern. Though fault was not warranted, it was easy to take from them, because they were anxious to give it away.

And here was irene again, in my office. I was seeing her for the first time since her mother's death. And of all things, I had to perform a "re" pap! Surely this gets some sympathy as truly uncomfortable!

La Cucaracha

The announcement right before today's lecture was that the "infestation in the call room had been taken care of".  With a word like infestation, you can only imagine the nature of the problem- some grotesque creature(s) had infiltrated.  The actual creature was the world's most archaic and my least favorite of all time- the cockroach.

I had noticed just this week when walking down the hall of the hospital near our call room at least 2 of these beasts squished on the newly waxed floor. I remember thinking that a hospital is not where you want to see these bugs. What can it say for patient care if a cockroach is seen wandering the halls?

I am even less excited because I am now done with pediatrics and move into the hospital setting. In fact, I will be spending the night in the infestation room this weekend. While the live ones are likely dead after whatever treatment they did, I don't look forward to greeting the corpses that will litter the room.

Young and pregnant

On my schedule today was "new OB". I really like OB patients- partnering with someone for 9 months, mostly healthy and happy. As I was getting ready to enter the room I glanced at her age - and did a double take- 14.   14 years old?! 8th grader? C'mon.

There was no mistake, in the room sat a very young girl, hair in braids, up in these pig tale things. A couple earrings in each ear, tight jeans and trendy shoes. The other woman in the room was grandmother.  "where's your mom?" I asked.  "she's actually here in the hospital, she just delivered a baby last night- a new brother"  Oh great! I'm sure her mom was thrilled to learn as she went into labor 2 nights ago, that her eldest, her 14 year old, was also pregnant.

I kicked grandma out the door to talk one on one with my patient. Believe it or not, although she has a boyfriend, age 15, they had only slept together one time. "only takes once" is the sound bite that began to play in my head, not needing to state the obvious, we moved on to planning.

I often have people ask - what's the youngest you've seen pregnant.  I know our clinic has seen a 13 year old, whose mother was actually 26 (history repeats itself). And an Ob/Gyn doc I worked with had a 9 year old deliver a baby... unfortunately the 9 year old had been abused. And just today working in peds- a girl who got pregnant at age 10 just delivered this week- her boyfriend is 13 and it was consensual, and they plan to raise the baby. The correct answer: it gets younger every year.

At 14 the scope of my concerns were remembering to wear the right uniform for home basket ball games, deciding whether to get chocolate chip cookies or a nutter butter bar at lunch for dessert, attempting to say a nervous hello to my latest crush, and trying to sell more candy than my best friend while fundraising for mission trips. Real similar worries to raising a child...

A different path

We've been excited to watch our neighbors (let's call them rick and sue) to the left go through their first pregnancy.  We share a lot in common- both finishing our basements together, watching each other's dogs, and the husband is even attending the medical school I went to. Last weekend the wife went into labor. We waited each day to see the new baby come home and wish our congratulations...it seemed strange that we hadn't heard any news.

Finally, last night I ran into rick on my way in.  "hey, what's the news?"  "Well last friday we had a little boy - 7 lbs 4 ounces... "oh yeah, congrats!" I interjected. Rick continued, "yes, and, well, it looks like he's got down's syndrome" I paused, shocked. What next to say? What was coming out of my mouth was I'm so sorry - but that didn't sound right...I shouldn't be apologizing for his son's life! But it was still something unexpected.  We talked for quite some time about the experience - 

The most heartbreaking element was the experience they had with their doctor.  After the delivery, rick was looking at their newborn son and could tell something didn't look right.  The Obstetrician finished his work, glanced at the baby and just jetted from the delivery room without saying anything.  Next the nurses left, handing the clearly unusual looking baby back to the parents, not saying anything.

Abandoned now, the silence of the unknown must have been unreal. Both rick and sue were left with their private thoughts, minds whirling at the unthinkable.  Finally rick spoke - "are you thinking what I'm thinking."  They called the nurses back in demanding information.  The obstetrician never did come back in the rest of the day to talk. 

We plan and dream out our details for the future- but really we never know what lies ahead. Their son is by no means a tragedy - it's just a shock.  The blessings his little life will bring are not ones we spend time dreaming about, but will occur none-the-less

21st birthday tragedy

After a long day of clinic yesterday, I had the privilege of working a 7p-7a ER shift.  It was a typical ER night, with strep throats, urinary infections, and drug withdrawals inter spliced with the more serious cases.

One case was especially tragic. The ambulance brought in a guy who had been out celebrating his 21st birthday drinking. What seemed like a mild problem-  having too much alcohol led to a cascade of events.  He must have gone outside the bar, passed out in the 3-4 degree winter night. He likely had thrown up multiple times, and breathed in the vomit, over and over again - too drunk to know better.  So there they found him - laying in his vomit, not breathing, and cold enough to die.  I first saw him as they rushed him into the ER, already with a tube down his throat to breath.  He was not responsive, and almost blue from the cold.  Will he make it? Unsure.  His lungs are full of the vomit, which causes multiple problems... how long had he not been getting oxygen to his brain? another problem.  Damage to his heart? His kidneys? unknown.

The shock his parents must have gone thru, as we called at 2 am to let them know their son, on his 21st birthday was on the brink of death and in our ER.

Neurotic parents

Perhaps my first clue that something was amiss was the complaint the nurse wrote on the chart of "fever, cough, and skin smells like urine".  I walked into a room with 2 parents and 2 boys-  a 3yr old and 16 month old, standing and writing on the chalkboard that is in every pediatric room.  The boys seemed active and by no means really ill.

"So, what's going on with these guys" I asked after introductions.  Mom then handed me 6 handwritten pages of information.  2 pages were filled with the fevers of each child, labeled with the time, the initial for which kid and what they were doing. IE: "c. 101.2, 3:15pm, twitch in right arm and left toe while sleeping"  I'm sure my eyes were as wide as saucers as I glanced thru to the next pages - giving a recent history of the illness each child had from January on - ear aches, antibiotic courses, diarrhea and spit ups.  OKAY, then 2 pages of questions and concerns mom had - including the double underlined "Skin smells like urine". 

"Wow, really organized" I said as I looked again at these crazy people masquerading as parents. I really hardly ever have the problem of too much info, but this was definitely the case- My head was swirling with fevers, twitches, spit ups and urine smells.  What was really wrong anyway? 

As I examined the kids, I found out more disturbing facts - that they both had been diagnosed with unnamed eating allergies- the 3 year old allergic to most foods, including milk (isn't this called being picky in the toddler years?) They were seeing a GI specialist, an endocrine specialist, and a  feeding specialist already, with no clear diagnosis yet.

I tried really hard to find a urine smell- with my nose planted on his arms, his legs, his stomach - praying one of my colleagues wouldn't come in to find me sniffing a little kid. Sure the boys had a cold, like everyone else this time of year- some fevers, some cough - but nothing else.

I left a little afraid for those boys - perfectly healthy, normal boys whose parents are trying so hard to find something wrong with them. All those specialists, not even needed. Unfortunately, it's the parents who need the help!

Grave plots

The discussion today around our Sunday lunch glossed briefly over a mildly disturbing topic.  In a very business like manner I heard how some of the family's grave plots are switching hands.  My parents buying 2 slots from an uncle. The uncle in turn getting 2 places in another state near his parents' grave. This advantageous purchase will allow my parents to be buried next to my grandparents...who, I may add, are currently alive and well, and participating in the grave swap transactions.

Grave plots.  This one wasn't mentioned in personal finance classes in high school. When is the right time to buy a sight? Should I be out hunting for plots now? Is the point to get generations all lined up side by side, or to be laid to rest in the place you live most of your days?  If that's the case, then it's too early to tell where I'll want to be...if buried at all. 

I suppose as creatures who have a hard time believing our lives on earth are finite, discussing grave sights is low on the list. But you may want to find out just what your family's plan is, so you won't be left without any earth to call home. As for the reminder at lunch that life does come to an end, that our dried out bones and leathered skin will need a place to rest, it should be an impetus not for fear of the future, but to love more with the time we have.

Bobby Pin

This month I'm working in pediatrics when not in my clinic.  Besides the typical time of year things like - strep, colds, stomach flu, ear infections - we occasionally do get to see some interesting things.  This came in yesterday.  Use your radiologist expertise to find the abnormality:


Hint:  14 year old girl standing in the bathroom at school, fixing her hair -  She has the bobby pin, used to keep the bangs out of her face, in her mouth. She reaches to her mouth to open the pin first, the other hand holding the stray hair in place. Suddenly the bobby pin snaps out of her hand, and shoots -  down her throat.   There you see it, sitting in her stomach.  Lucky for her, the bobby pin had plastic protective heads.  The specialist in GI matters that came to look at this film decided to just let her pass it.  Hope it comes out okay -

Burn Hazard

There are certain hazards people forgot to warn me about in medicine. I was kindly taking off some anal warts of a 20 something patient in clinic today.  I was using a type of acid solution...which I informed him wouldn't hurt too bad.  In this process, I suddenly had a searing, burning sensation on my leg and realized a portion of this acid had dripped onto my nice pants, thru to my leg, and quite the contrary to my previous reassurances, it DID burn!  I could not just leave him in his awkward half exposed state to take care of my burn, so continued the treatment despite the pain.  When I later went to the restroom to clean up and look at the damage, I was reminded of the uncanny coincidence of another medical burn on this same spot acquired exactly a year ago. That old burn, that left a slight scar, was after a 36 hour shift on call in the hospital.  Not acid, but a piping hot- wait,  let's call it what it was, a boiling cup of hot chocolate poured onto my scrubs before going off call.

No one warned that besides blood products crammed with viruses, cough droplets filled with bacteria and other unpleasant bodily fluids, that as a medical professional I could be harmed by acid and hot chocolate - But now I've got the scars to prove it!

Success

We all measure the success of our days in different ways.  I wonder how aware we are of those unspoken measurements we place on ourselves?  It's different depending on what we do, or what we are after.  In pursuit of someone's affection, our success may be if we spoke to that person during the day.  If there is some behavior we are trying to change, our success may easily be, did we have that forbidden food or smoke that cigarette we swore we wouldn't?  If in school, did we actually get the work done on time?  Everyday, thousands of chances to give ourselves value by "succeeding" or devalue ourselves by "failing". 

It's good to find what we use as a ruler - because it may be completely unreasonable and need changing!  If for instance I made "success" pleasing every person I saw in the day, I'd be a big 'ol failure.  I was thinking of this today because I identified one of those subconscious measurements I've set for myself.  I realized that when I have my own clinic, with my own patients, I gauge my performance on how many times I had to ask a preceptor/staff doctor for input.  If I am autonomous, I give myself esteem.   However, asking another doctor's opinion shouldn't be deemed a failure- in fact, it's probably healthy to ask others for input.  Looks like this is one measurement of success that needs tweaking.

C-section vs vaginal birth

The newest stats on c-sections for 2004 are out at 29%.  That's almost 1 in every 3 babies now born surgically. This is a marked increase if you consider in 1996 the rate was 20%.  One component is the turn to elective c-sections.  While not an option in most of the Midwest - I can see the temptation.   As we American's grow ever time conscious and efficient - being able to schedule the birth of children down to the half hour seems ideal.  Everyone can come into town, the nursery ready, even pre-printed birth announcements-  like the "save the date" cards for weddings.  I could send people "save the birth date - Dec. 11th at 2 pm" 

As C-sections become more and more safe- it's hard from a legal perspective for doctors to deny elective c-section requests from patients. That leaves the ethical considerations.  As alluded to above, if given the option, when my time comes I would likely choose a c-section.  BUT the ramifications of everyone beginning to do this begins to trouble my brain.  Play it out in your mind - in 20 years from now, will our children learn of vaginal births from a historical perspective only? Could it become an extinct behavior of humans?  Does that seem wrong or just a social adaptation?  I'd love some discussion on this ...anyone?

First Semi-Code

Back from a little trip to phoenix. The night before I flew out was my last shift working nights. Of course, I should have known something would go wrong. I had my first solo code like situation. Throughout training I think it's the thing you dread most. Unlike most situations in medicine, your processes are catapulted into mach speed. There is no time to dwindle, pondering the effects of your decision. It's now or never.

The situation was a young sickle cell guy. I'd been the one to admit him 5 days earlier when his Hemoglobin was down to 3.9 (recall normal is 13-15). I hadn't heard much about him on my night time calls. The call came at 12:07 from someone on the floor "the nurse needs you up here quickly, something is wrong with Mr. R -he's just not acting right" I noted vitals and rushed up. What could be wrong- the guy is 27 - surely not a heart attack. Blood clot? Too much pain meds? Stroke? Seizure? I was silently pleading for God to grant me wisdom.

It always produces anxiety when there are groups of people around your patient's bed- the room was full already with nurses and respiratory therapists- I felt their tension lift as I entered. AS if, 'whew the doctor's here we can relax.' BUT my tension had hit the roof. Okay, start with information and assessment. He was obtunded, breathing hard, but if you squeezed his hand he'd respond. GOOD. Glance to the tele' monitor with the vitals- BP 250/120 UH, not good. Pulse 130's, not good. Oxygen 99% on the 2 liters they had strapped on his nose. That was good. Now I realize they( being everyone in the room) are looking at me -directly into my eyes. Can they see my fear? Can they see I am child, that I'm just dressed up in my dad's doctor coat and stethoscope, not really a doctor?

I push out my calm in control voice- "let's order some things- CBC, CHem 12, mag, phos, d-dimer, Abg, Chest xray" next "Let's do something about that blood pressure" And I order some quick IV meds. All this is intermixed with questions "what happened today?, anything new? what meds did he last have? Any changes? What were this morning's labs?" All the nurse knew was that he was okay when she came to work at 7pm- he was alert, not in pain, even refused his pain meds. All was okay until his alarm went off that monitors heart rate and blood pressure. He was FINE- and now all had changed. I was encouraged that he was awake enough to move all hands and legs- but something was definitely wrong.

Although things were serious, they were stable enough to keep gathering info - the nurses were helping sit him up a bit when one of them let out a loud shock like gasp. I glanced over. She was carrying something she'd found by his neck. There in her hand were about 3 teeth from a set of dentures- obviously broken, chomped right a part. Light bulb goes off in my head- "He had a seizure" I shout- "let's get some ativan on board." As the nurse went to get it- it happened- another seizure. His whole body started to convulse, as saliva and froth spewed from his mouth- she gave the push of ativan as his body, a minute later relaxed. During the seizure I was watching his oxygen rate- they suctioned, he seized and his 02 dropped to 50% - His seizure over, I stood saying out loud "go up, go up" The numbers crept -55, 60, 65, 70, 80" Then stopped- 80%. Not good enough- he wasn't maintaining his airway.

Game up. That's what I thought- no more playing for me -time for help. I gave the order that everyone had been waiting for, wondering when I'd say it - "let's call rapid response, get him up to the ICU" The ICU team swept in, didn't need to intubate, or put a tube in, but wanted to watch him upstairs in the ICU. In minutes he was gone. Now the empty room, and all the extra nurses and people who had stepped in to help. Suddenly it really did feel like some sporting game- nurses coming up patting me "great job" "way to go" "that was good" And i doing the same "you all were wonderful". "Good thing you found those teeth!"

So, another first. Not too many big 1st's left in medicine. But the "first crashing patient in the middle of the night" can be crossed off the list.

Tumors in the Bible

I am working nights these 2 weeks.  It's been tough adjusting to living at night and sleeping in the day.  BUT the good thing is that there is more free time in the wee hours of the night.  Time to read and watch movies sometimes.

I'm always surprised, when I pick up the bible and start reading it like a novel; what stories i find!  There are some really funny and dramatic things in there that have no profound spiritual insight AT ALL.  I thought I'd share this one story that pertains to medicine. 

So in Samuel, there's this big fight between the philistines (bad guys) and Israelites. This is when God lived in and around the famous ARK of the covenant.  You can guess- the philistines win and steal GOD (well, the ark).  What happens next is predictable- wherever the ark is- people get sick- they get tumors.  Towns keep passing the ark to other philistine towns- which get the tumors too.  Now the weird part:  They finally GET it, that the ark is GOD and GOD is cursing them- so they decide to send the ark back to the Israelites.  BUT they want to include a guilt offering with it.  Guess what they make?!  Golden rats.  Okay, strange, but still believable. BUT they also make golden tumors...  I laughed out loud reading this.  Golden Tumors?  Blobs of Gold like marshmallows packed together? I'm sure GOD loved that...what combined with golden rats- it's what all Gods want as a gift.