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.