Superfluous Pulchritude

A Good Death

2012-02-14T10:17:00.000-06:00

What is a good death anyway? The word in Greek for good is "eu" and the word for death is "thanatos", so in Greek this becomes "euthanasia". But "eu" also means easy - thus, often people think of a good death being synonymous with an easy death. Of course, in our current culture, that word euthanasia is steeped with controversy and moral pull, leaving very little that is easy about the word.

I think for many, the idea of a good death does encompass something about easy; no pain, no suffering, no struggle.

This was not the case for Frank. Although this elderly gentleman had professed a readiness to die when he entered our hospice house, newly diagnosed with cancer, certain clues pointed elsewhere. After about a week of avoiding sleep at all cost, I knew something was amiss. His avoidance of slumber was classic, he refused to get into his bed and spent 24 hrs a day in a recliner. He also, like my own 3 year old at home trying to avoid sleep, would continue to talk even when no one was in the room. The incessant speech was certainly meant to keep his brain from nodding off.

I headed into the room, with a mystery to solve. He had professed no fear in dying, so why did his behavior scream avoidance? I played the normalcy card, speaking of patients in the past who had been afraid to sleep because they assumed they would then die. This struck a nerve, and in my waiting silence he confessed.

"I admit it. I am afraid...." then a long pause, and finished with "afraid of it being too easy." What came next were tears, for the fear wasn't in death, but in a death without struggle. He felt that dying in his sleep would be a disaster, that dying with pain medicine easing his struggle to breath would be cowardly. Then he told a story.

He was a veteran in WWII and had rescued a man who had been burnt, ending up injuring himself in the process. He found himself in a military hospital next to this man he rescued. Charred, with flesh falling off, this man looked Frank in the eye and told him, "You SOB, you better survive and be here in the morning". Frank made the same valiant demand back. The entire night, he heard the moans and groans and cries of the burnt man. As morning dawned the agony filled cries ceased and nurses came, pulling a sheet over the mans face as he took his last breath.

Frank looked at me, and no further words needed to be said. That was a good death to Frank. That was the noble death Frank was looking for.

The story and Frank's personal ideal of what "eu thanatos" was for him, explained a lot of the decisions he'd been making while in our hospice house. He felt very guilty in the revelation. I reminded him that our job isn't necessarily to change who people are, but simply listen so we can understand who they are.

What's your definition of a good death? Is it easy? Is it noble? Is it going out with a fight? Something to ponder.

Art work: The Soldier (1538) from "The Dance of Death" by Hans Holbein

War Baggage

2012-01-10T10:16:00.000-06:00

There have been books and lectures written on veterans and the dying process. I have witnessed a variety of cases. The issue has to do with baggage left unprocessed. These are men and women who pushed down their experiences and suddenly on their death bed, the strength to suppress is gone and the issues come catapulting to the surface. Practically this takes on two forms - either hallucinations and delirium that is out of control, or tears and weeping that won't stop. The former is an attempt to still suppress, the later is the cleansing experience of finally dealing with the memories.

I've been meeting daily with a patient going through this catharsis. He served in WWII, never spoke of his past and prided himself for being a "man's man" and showing no emotion. Suddenly he has found himself crying constantly. Everything out of his mouth comes back to war. He admitted to direct responsibility of the death of men, which has haunted him throughout his life. Today he said something that put in all in context.

My patient was injured in the war and therefor exited active duty by way of a hospital. The General in command of the hospital met with he and 4 others who were also injured to honor them with medals, as well as encourage them. The final words he received from this high ranking official were, "Remember, the first time you ask for help...you've lost"

Through tears at this retelling, my patient said "and I never did ask for help"

Startling to me, this message of strength equated with self reliance. It explains a lot of the man he became and the man who sits now unable to stop the tears.

The message I share with him today is the opposite; that I see strength and courage in his ability to work through his past. That what he is doing now takes more of a "man" than hiding it away. That the tears are the evidence of healing and wholeness. I think the first time you ask for help...you've won!

image from PBS. Copyright © 2007 WETA, Washington, DC and American Lives II Film Project, LLC. All rights reserved

Poignant Timing

2011-06-17T16:30:00.001-05:00

I have a slight fascination with the events leading up to the actual timing of someone's death. Some may call this recall bias, in other words, I simply just remember the one's that are unique giving me a false sense of the reality relating to the timing of death. This is likely true, but I still find certain narrative's inspiring.

In the last several weeks I have had several of these perfectly timed deaths. One family feared their father might die on his daughter's birthday. They had discussed this with him while he was still lucid. The birthday arrived, and he was actively dying. Perhaps he had a choice in the matter, because he hung on until 3 hours past midnight, just making it past the birthday date.

Another patient, an elderly woman known for her vindictive controlling behavior, seemed to be punishing her daughter,who had an overseas trip that had been planned for over a year. The two had the kind of relationship that was tolerant at times but bitter mostly. During an argument, the daughter told her mother, who seemed still to have months left to live, that she was leaving for her trip no matter what. Looking from the outside, it seemed the mother wanted to put this to the test, suddenly taking a turn for the worse and dying on the eve of her daughter's big trip. The daughter kept her word, leaving for the airport, and thus missing her mother's graveside service.

This week I experienced a new one for me. The patient was a young 96, having lived in the same home on her family ranch/farm for the past 71 years. Her only son had adopted the responsibilities of the farm after the death of her husband. I assume it was a combination of a mild stroke and leaving her home that started the slide into a dying state.
The conversation they had went like this:

"I don't think I've got long to live" she whispered to her quiet natured son.
He sat with hat in hand, well worn jeans and work boots. After a moment he spoke up, "Well Mom, I think we're gonna start cutting wheat this week"
She seemed to mull this over and made her deceleration, "I'll wait till the wheat's baled then"
The week came and went and things started to get a bit rough with her transition. I think she was trying to hold on. The wheat cutting then finished, so after some prompting from us, her son let her know the wheat was baled... and she became peaceful and died soon after.

The lesson for me in all this is that while we may not always understand the timing surrounding someone's death, often there seems to be a reason important enough for that individual to either speed things up or slow things down.

An unlikely artist

2011-06-13T16:04:00.002-05:00

When we got the call that Cindy was coming out to the hospice house the warning was, "She's not going to last long." Cindy was in her 50's with end stage COPD. She'd been in the hospital for weeks stuck on a machine called BiPap. They had worked on weaning her off this machine, but weren't successful and didn't feel comfortable using opioids like morphine to help her breath more comfortably. She was frustrated and didn't want to continue to live with a mask forcing air into her lungs, stuck in a bed in a nursing home or hospital, so she decided to come to the hospice house.

Cindy was extremely anxious when I met her, years of smoking had left her thin and much older than her stated age. Her eyes had that scared, wide open look, as someone fighting for each breath. Introducing myself, I asked if she would mind if we tried a new medicine for her breathing and explained how morphine actually would ease the work her body was doing for each breath.

Within days, much to Cindy's disbelief, we had her actually off the BiPap machine and on simple oxygen through a nasal canula. Morphine had reduced the work of her lungs to the degree that she didn't require as much oxygen and wasn't in constant panic mode.

Suddenly she went from a woman who thought she had only a few hours or days left, to someone with months to live. Cindy now had another dilemma; an abundance of time to anticipate her death.

One of the things we offered to not only fill her time, but help her process her dying was art therapy. Cindy admitted she'd never done art, felt clumsy and inadequate. However over the next months, our art therapist worked with her on expressing herself. At one of my visits I happened to mention how fun it would be to put on an art show with everything she'd been working on. The sparkle of pride in her eyes was all I needed to pass the task off to our amazing volunteer coordinator.

This was an art show like none other. The artist sitting, oxygen tubing on, while her room was adorned with her work. We had refreshments, while friends, staff and volunteers flowed in to admire and praise the artist. Cindy beamed, a long time automobile plant worker, I know she was tickled to think of herself as an artist. When I look at her work below, I see more than the pieces; I see Cindy's peaceful face reflecting the respect, praise and love we gave her.

A fortune

2011-02-25T10:55:00.001-06:00

One of things hospice organizations rely on is donations, especially for those of us in the non-profit world. These donations generally come by way of organized fund raisers and memorials.

One particular memorial I will not forget. It had been a very busy day at our hospice house, several admissions and deaths. I had 2 medical students with me as well, so any spare moment was taken up teaching them little pearls of knowledge. Someone from the reception desk suddenly appeared in my periphery and motioned me saying, "Dr. C, would you have a minute to come receive a memorial up at the front".

This in itself was highly unusual, as typically families just sent memorials to us in the mail. I must have looked confused because our receptionist further clarified, "They asked if they could specifically present it to one of our doctors." Now I was getting excited, speculating that this must be quite a donation! I had visions of lottery winners being handed over sized checks, as cameras clicked and hands were shaken.

"Sure" I replied with enthusiasm, having the two medical students come with me so they could be wowed as well. Walking down our long hallway I was trying to speculate who it could be, and feeling just a bit nervous at this unusual request.

As I rounded the corner I encountered 4 people I knew quite well; John a mechanic in his 60's and his 3 adult children. We all hugged, as I began to recall the weeks I had spent caring for John's wife. John teared up a bit when he spoke up, "We just can't say enough about the care Dorothy received here. We wanted to personally present you with this donation so you can continue the good work you all do" His rugged grease stained hands passed me an envelope and he gave one last hug. I smiled then as he waited for me to open up their gift.

The moment I had seen that it was John, I knew that I had been foolish to dream up some giant donation. This was a family who lived in poverty, who spent everything they had on medical bills and Internet "cures" for Dorothy's cancer.

As I opened the envelope and saw the check for $25, and met the eager tear streaked faces of the family, so proud of what they had scraped together, I too cried.

Walking back down the hallway, one of the medical students who had observed this all, including my uncharacteristic display of emotion quipped, "Wow, that must have been a really big donation! How much was it?"

"A fortune" I said, and left it at that.

A Mother's love

2011-02-14T14:00:00.008-06:00

This Valentine's I am remembering Megan and the incredible love she had for her daughter.

When I first met Megan I was extremely skeptical about her ability to care for her newly born daughter Lilly. Megan, 17 and Todd, her boyfriend, also 17 had just brought Lily home from the hospital for the first time. They had no home or apartment of their own, so they were "crashing" with friends. I entered the small apartment just hours after they had been discharged. Four other people were already living in the apartment, which was scantly furnished, yet cluttered and untidy.

My primary interest was in 4 week old Lily, so I squatted down on the floor to meet Lily, as they had no baby furniture/equipment to put her in. She was bundled in blankets on the floor, with an oxygen tube taped to her cheek. Lily had several issues; besides being born with a congenital brain malformation, causing certain parts of her brain not to form, she also was born with a cleft lip and palate. The combination of the brain malformations and the cleft left her with basically a large whole for a mouth and nose and lopsided eyes which she could not see out of. All her nutrition was through a feeding tube. Medically she had severe seizures on a sometimes daily basis, and didn't enjoy being touched and would scream out when being held.

The reason I was seeing Lily was that she had been given a prognosis of only weeks to live, and I distinctly remember thinking that I hoped, for Megan and Todd's sake this was true. They were just too overwhelmed. I left that first night thinking a lot about Megan and Todd, both high school drop outs who had enjoyed playing video games during the day and partying at night. They had unexpectedly become pregnant and decided to do the "right" thing and keep the baby. Now they were being expected to do something super human, and care for a dying child who had a distorted face and didn't like to be cuddled or touched.

Todd didn't handle it long, and left after about a month at home. Lily, surprisingly thrived in Megan's care. At my monthly visits, I watched Megan work like a pro, getting the tube feeds ready, administering seizure medications, etc. Even when she'd been up all night due to Lily's seizures, she spoke to Lily as only a mother could; gently, lovingly, and sweet. The two of them had moved from one friends apartment to another. Although different locations their "home" always looked about the same - always other teenagers at my visits, hanging out playing video games, always evidence of fast food meals, cigarettes and alcohol. But also just as consistent was Megan paying attention to Lily, asking about milestones and telling about little victories in Lily's head strength and cognition. I could tell when Megan looked at Lily she only saw beauty and possibility.

Lily lived just past her 1st birthday.... Her death was tragic, not because she suffered or had pain as she died, but because over the course of the year, Megan had fallen head over heals in love with Lily. The immature teenager I first met had been transformed by love to become a wise responsible woman. Megan embodied the kind of love that "always protects, always trusts, always hopes, always perseveres."

Dilemmas with pain

2010-12-07T11:42:00.000-06:00

I love being able to treat people’s pain without worrying too much about addiction. This benefit of palliative medicine is certainly important especially in the pain phobic, escapist society we live in. My patients usually won’t live long enough and/or have such very real pathology (i.e. cancer) that misuse of medications is quite low.

This, however, doesn't account for patients who have very real addictions and then unfortunately find themselves with a terminal diagnosis on hospice. Suddenly the ease of treating someone’s pain morphs into quite a challenging dilemma.

For instance, one of the tenants of palliative care is to relieve suffering. Thus, ready access to opioids is essential. A regular doctor would have qualms about filling prescriptions early for pain medications or escalating doses rapidly. But in hospice, if a patient is dying, sometimes doses easily escalate in an attempt to provide comfort and relief of suffering.

What to do then, when you suspect inappropriate use? Does someone with a past or even present addiction not “deserve” medications for pain? Can I refuse? Should I set limits? Refusal certainly goes against the grain of a specialty tasked with providing excellent pain control!

We certainly don’t interfere with addictions to other substances – On hospice, smokers generally keep smoking and alcoholics keep drinking…in fact it’s expected that in the last weeks of life people aren't going to change life long habits. Is it different then for other substances?

Going deeper philosophically I could even argue that the misuse of opioids generally starts from the ability of those substances to numb an incredible emotional pain… it’s an escape, a postponement of dealing with the hurt, etc. The qualm then is that this desire to escape can happen in very average people who are suddenly struck with a terminal diagnosis. It isn't unusual to treat a 40 year old woman with breast cancer who has what we coin “existential” pain because she can’t deal with leaving her 3 small children. This type of patient often has a pattern of escalating doses of morphine to escape that reality. Is that misuse of opioids? Or is it her way of dealing with dying? I don’t know of any physician who would refuse her medications…. So why then if the escape from pain started earlier and someone got labeled an addict, do we suddenly have issues with treating their long standing existential pain?

It’s certainly a topic worth exploring and one I admit not knowing all the answers for. I suppose for now, I will continue to treat all pain, being aware of addictions and escapism and using the safest medications available, in an attempt to minimize risk of harm

Katie's Choice

2010-11-09T11:38:00.001-06:00

I've seen prolonged dying many times. Usually there is a good explanation, the individual is young or has kids they don't want to leave. Sometimes it's an unresolved conflict or an irrational fear of dying. Regardless of the reason, if a reason, the process becomes extremely tough on the family.

One of the tougher ones for me to explain happened in a young woman I cared for recently named Katie. Although there were young kids involved, they had been removed from the family. Those by Katie's bedside each day were her mother, brother's and sisters. Katie had fought cancer for several years, far outliving her original prognosis.

While I had explained initially to family I supposed this would be long and hard - They and I weren't prepared for the 4 weeks without any food or water that Katie laid in our hospice bed. She was incredibly thin, bones outlining her face and jaw, eyes sunken. She was rarely awake, but when so, in terrible agony, not from physical pain but internal fighting and issues never dealt with.

Her family was devout, cradling her in bed, attending to any sigh or moan, never leaving her side. Each morning they looked at me with strained eyes and weary souls hoping I would tell them she would die that day. But each day Katie's un-readiness allowed her body to somehow exist past the point of human understanding.

Her final week she had stopped making any urine. Her blood pressure, barely palpable stayed around 50/30. Her toes black from no circulation, and the blood pooling we normally see after death called liver mortis was present despite the fact that she hadn't actually died. She was no longer able to move or talk or moan. It was as if her physical body began it's decomposition in lieu of her utter refusal to actually die.

The family became more and more erratic in their exhaustion. Telling her often that it was okay for her to die. In one unbelievable moment, as this living corpse lay with family in tears surrounding her, they began to angrily plead, "Katie, you must go, let go... it's okay, it's time to die...we can't take this any more, won't you please just die!" It was in those moments that a defiantly strong voice suddenly echoed gutturally from the skeletal figure shaking the room to silence, "NO!!!!"

Don't tell me that Katie's prolonged dying wasn't in her control. I am not sure how to envision her intangible will, but it was physically keeping her "here". In medicine we can't measure will or fight or some one's "spirit" but one thing I've come to learn, it can play a huge role in the way we leave this earth.

While her death was prolonged and many would say full of suffering, I must respect that it truly was Katie's choice. And had we interfered medically, shortening her time, like so many had pleaded for us to do, ultimately we would have disrespected that choice. Katie of course finally did die, likely against her will, a few days after her outburst.

Night Visitor

2010-08-24T11:36:00.000-05:00

Blake's mom had been sick since he was born. She was diagnosed with lung cancer right as he came into the world. She went through very aggressive therapy and unfortunately began having strokes as well. Each stroke seemed to take part of her person-hood. Her husband and parents would work tirelessly to help her regain function to undergo more chemo, and then a new stroke would occur.

When I finally met Blake's mom, she had just had her most debilitating stroke. Unable to communicate reliably, her arms and legs were contracted, so that any sips or bites were hand fed to her. She often had a blank stare leaving me to wonder if she was still in there, but the family was determined to keep her living for Blake, her 4 year old son.

She was at our hospice house for many weeks, her husband with her at night, her mom with her in the day.

This particular night Blake had spent time during the day visiting his mom, and was at home with his grandmother. Ready for their nightly routine Blake's grandmother began looking for him, to have him call the hospice house to say goodnight to his Mom.

"Blake" she called, "time to call your mom", repeating this several minutes before Blake finally reappeared. "Blake" she then scolded, "why didn't you coming when I called, you love calling your mom." Blake grinned and told his grandmother "No", leaving her aghast at his indolence.

He then explained, "I don't need to call tonight, because she came to see me, she told me goodnight and that she loves me"

The grandmother was now quite alarmed, calling the hospice house. Her fears realized as she learned her daughter had indeed died just a bit earlier, the husband having not even had time to call yet.

Another unexplainable moment in the world of Hospice and Palliative Care

Failed Admission

2010-08-04T11:31:00.000-05:00

When I walked into Bill's room all I knew was that he had a type of bone cancer diagnosed 3 years ago. He was in his 70's and was not at the end of his disease by any means. Just based on his cancer and functional status, he probably had another year or so to go.

Arriving at our hospice house, I assumed he must be coming for pain control, since his type of cancer is notorious for pain.

He greeted me cheerfully when I entered, introducing me to his wife and 2 children who were visiting from out of state. I noticed the daughter's hand full of crumpled tissues, eyes still moist from tears. They seemed close, hovering near Bill who seemed surprisingly calm and symptom free to have been rushed into the hospice house.

When I finally came around to the, "and what brings you to the hospice house" question, Bill stated in a matter of fact way, "I am getting weaker now, it's harder to take care of myself and I just don't feel I am contributing any longer to society, so I'm hoping you can give me something to help this go quicker"

These types of statements come up from time to time, so I just did as usual, and addressed it openly, naming his suggestion. "Well, Bill, you know we can support any symptoms you have here, pain or anxiety, etc, but I cannot give you anything to hasten your death, it's illegal actually" At this point normally people say they understand and were just joking...

However, this is when the body language changed in the room. The daughter quipped incredulously, "You can't?" while Bill asked, "Well, where in town can I go for that?" I felt everyone bristle with shock, which confused me that they were this serious.

"I am sorry, but again, there is no where in the United States that a doctor can actually administer a medication to make you die, that is euthanasia and it is illegal" I explained.

Then his son blew me away when he addressed his father, "Well Dad, do you just want to go home then? It seems that the reason we came here, to help you die, they won't do...so want to leave?"

I tried to look as if this conversation was normal, however, realizing that this entire family had come in, even flown in from out of state to have some hollywood moment of saying goodbye while I lethally injected their loved one was startling.

He did leave the house, not just because he wanted, but I couldn't justify him staying - there were no symptoms of pain, anxiety, dyspnea or even emotional pain. He was logically just done and actually didn't require any medication while he was with us transitioning back home.

So my first admission for desired euthanasia, was a failed admission. Thankfully, failed

A story for Mother's Day

2010-05-08T11:30:00.001-05:00

The bond between mothers and kids can be strong, but this Mother's Day I'm thinking of a particular bond I witnessed that was excessive.

The patient was nearing 100, and her only son accompanied her to our inpatient facility. I've come to expect tears and displays of emotion in my line of work, so wasn't at first concerned with the overt tears that were constantly adorning the son's face.

But then I began to hear their story. Nearing 70 himself, the son had spent only 2 days apart from his mother in his entire life. They had never vacationed or taken trips, they just stayed, all those years, in the house... together. Well, except for the time in his 30's that he became so depressed with the thought that his mother could die, that he had to spend some time in a hospital on medication.

He'd say things like, "The sound of her breath is what gets me up in the morning, and what lulls me to sleep at night." He was constantly by her bed, holding her hand- even as he and she slept.

I've heard people say before, "I don't know how I'll live when xxx dies". But in this case, I believed it. I'm not sure what else this man had in his life besides his mother? Over the years he'd become enmeshed, and as she lay dying, he seemed to be dying as well.

So this mother's day, be reminded that there may be such a thing as too much....

Suffering

2010-04-09T09:56:00.001-05:00

I think one of the harder things to do is watch someone suffer. I'm not sure if it's because it causes us to suffer ourselves, or if it just brings up fears of ourselves being in that situation.

Recently I had a patient with a complicated cancer. She was at our hospice house for an extended time, but clearly began to lose her fight. In those rough days of her body's transition to dying, she had a lot of symptoms. She was nauseated constantly, with dry heaves frequently, and had pain with any type of movement. Despite all the pills, liquids or IV's that I suggested for her, she wanted nothing.

Nurses began to fret and suggest maybe I could do something about this refusal of medications. "She's just lying in there, suffering..." Suggestions ranged from placing a pain patch, to convincing her of the necessity for a subcutaneous site so that medications could be given, despite her refusal.

While the intentions were good, I had to step back a minute.

Who am I to decide for someone the way they should die? While most would think suffering was indicative of a 'bad' death, the reality is for some, this is exactly the way they want to go. The number one priority for me as a palliative care physician is not to treat someone the way I want to be treated, or the way YOU want them to be treated, but to treat them the way THEY want to be treated.

Although very difficult, I respected my patient enough to not cajole, convince, persuade or trick her into pain medicine. With every frown, moan or grimace I winced, but in allowing her to do things her way, I witnessed an amazing ability she had to stay present, in mind and spirit, till the last moments of her life.

She died smiling. Her journey may not have been my choice, but it needed to be hers.

Artificial flowers

2010-03-08T09:54:00.000-06:00

Walking around work recently I noticed a sudden new addition of plastic flowers in some of the winter lorn gardens. They weren't hard to miss, bright pink and yellow, they were planted in both pots and soil in this one particular area. I thought to myself it was a bit uncharacteristic of our neatly manicured flower beds.

Later that day I met one of the pediatric patients I'm caring for. It's always tough to have a young kid with a terminal disease at the hospice house. I learned however, that this is one incredible kid. He has been able to get up to a wheel chair from time to time and get out of the room. It was on one of these outings that he crossed paths with the patient in the room next door. The adult patient, having been pushed outside in her hospital bed, was heard lamenting that she may not be alive to see spring.

With that perfect sweetness that can come from a child, my little patient whispered to his parents, "We should get some flowers for her, so she'll be happy."

Thus, the fake flowers appeared. I smile at them daily, not just because they are the precursors for spring, but as a reminder of my little patient... though dying himself, he is unselfish enough to think of another's happiness.

Unforgettable

2010-01-23T09:52:00.000-06:00

I had one of those unexplainable moments at work this week.

We had just admitted a little baby. He was born with so many birth defects, that the doctors had told the family there was nothing to be offered. There were problems with his brain, his eyes, his mouth, his heart, his intestines were even formed on the outside of his body. Once the decision to focus on comfort was made, the breathing tube was removed and he was transferred to our hospice house.

Mom got here 1st with him. She was 20 something and overwhelmed. As I was meeting her and the little boy, I noticed some sudden breathing changes. His color was changing to more blue/grey and I realized the worst; this little baby was dying just minutes after getting here.

We gently interrupted our process of admission to see if she wanted to hold her son, trying not to be alarming, but letting her know that her son's breathing was slowing and it looked like he was dying. She cuddled him. I and the nurse hugged her from each side as we sat and cried. The breathing was a pattern of long 40 sec. pauses with just a short little gasp/gulp in between. I listened to his heart which had almost stopped, just an occasional out of sync little beat.

If only his father was here, but he was still enroute. Mom prayed for more time...I prayed for more time, I think all of us were praying for more time.

And then, something I have never seen. That baby boy's color began to pink up. I listened again to the heart, confused at the color change, and as I listened that heart beat began again, strong and fast. Simultaneously the breathing started again, quick and fast.

Just like that, he was back, living and breathing. The nurse and I were flabbergasted. She whispered to his mom, "You're son's spirit must be strong, he wasn't ready to go yet." His mom wept anew, but this time with joy.

A little miracle. I wish I could say he went on living, or that all those malformations were healed. But in truth his heart was much too weak. Instead, his father arrived a little later. The two of them, mom and dad, spent the next hours holding him and loving him, and then just as before, the breathing changed. This time though, they were together as a family. They ushered him out of this world together, peacefully.

Best Christmas ever?

2009-12-18T09:51:00.000-06:00

When I first met Mr. R, who had just been told that his heart was so weak, that he'd likely die within weeks, and asked him who I could contact for a family meeting, he told me "no one". Of his 3 children, he was estranged from them all. I pitied him, he'd clearly chosen a life of solitude. The event that prompted his admission to the hospital was being found by his neighbor on his floor of his home. He was extremely thin, having lost 60lbs of weight this year, he was very weak and he was having a hard time breathing.

I almost left it at that, accepting that there was no one he wanted to contact, but I pressed him a bit to see if there was a glimmer of hope. Finally he teared up and weakly said I could try his daughter on the east coast. I think he was more afraid of rejection than the hope of seeing his kids again.

A few days later his daughter arrived and the tears flowed as the power of forgiveness wafted over each of them. "Can I call Teddy?" his daughter asked, speaking of one of his sons. He bristled as the mood changed and he grunted "No".Well I thought, at least he'd been reconnected with his daughter.

Mr R. left the hospital and I lost track of him until this week, when I started back at the hospice house. When I walked into his room I was surprised to see a room full of people. Such a contrast from the lonely, sad man I had first encountered weeks before. I asked Mr. R to introduce me to everyone. He beamed with pride as he introduced grandchildren he had recently just met and then had to pause as tears started when he came to his son. It had been 20 years since they'd talked.

These are precisely the moments I live for in palliative care. I was a witness to healing; not a physical kind of healing, because Mr. R is still in the process of dying, but a relational healing.

It's seems backwards to say, with Mr. R on his deathbed, that this will be the best Christmas ever for them - but strangely it is.

No one should...

2009-11-04T09:49:00.001-06:00

I interacted with an incredible kid recently at the House. Innocent and respectful, he was not intimidated by authority and extremely kind to all he encountered. I think this interaction sums it up: when meeting him at hospice with his mom, who was dying with cancer, he interrupted my solemn conversation to ask if we had any microwaves in the room to pop his marsh-mellow topped popcorn that he just couldn’t wait to eat.

As we interacted over the next days, I began to compile a list of things he’d gone through that seemed absolutely unfair.

No kid should have a mom be diagnosed with cancer
No kid should have to stay up all night walking her up and down their stairs at home, at least 20 times, because she’s too restless to know any better.
No kid should have to watch his mom swing at the air and shove people away from delirium
No kid should have to experience telling their mom “I love you” only to hear “I hate you” back with a blank unknowing stare; even if it is the liver failure causing her to be out of her mind.
No kid should have to wake up every hour of the night to look at the clock and wonder if his mother was still alive.
No kid should have to sit at the bedside of his dying mother, wondering why she made strange sounds, why her feet were blue and whether she could still hear him say “don’t go”.

I wish my list ended here. But tragically I must add:

No kid should go through all that, have a mother die, and then 36 hours later have his father die to.

Universal

2009-09-09T09:47:00.000-05:00

There's much debate ongoing in the healthcare-for-all arena these days. I won't weigh in politically, however, I'd like to share this story:

Kathy had a terrible childhood. You'd expect this if you had to watch your mother die of cancer when you were 8 years old. Kathy and her brothers got even more bad news as they grew. The cancer their mom had died with was inherited. Their family had a condition that put them at tremendous risk for getting the same cancer. It wasn't until Kathy's older brother was diagnosed and died at age 25 that the reality of this all sank in for her.

Kathy, a teenager when her brother died, made 2 related vows. She was not going to die of this cancer, and she was not ever going to leave children "motherless" like her own mom did. Still on her father's health insurance Kathy began the suggested annual screens needed to watch for this cancer.

Years went by and many things happened; Kathy got married, had 3 kids and then divorced. In her late 20's she found herself a single mom, working odd jobs to support her family, and no way to pay for her own health insurance. As they, say she was the working poor.

And what stopped? Those annual screens. Unlike clinics that offer free mammograms and blood tests, Kathy needed an invasive screen that no one provides "free".

In her 30's Kathy met Allen. They fell in love, married and quickly got pregnant. Kathy was delighted to again have health insurance through Allen and quickly made arrangements to begin the screening.

You will already know where this is headed. I can't imagine being told that I had cancer. For Kathy it was even more gut wrenching, she knew she would probably get it, and yet hadn't had the means to catch it early and possibly cure it. The vows she had made as a teenager would all be broken, and although Kathy fought through chemo and surgeries for 2 years, she did not win the fight. At the young age of 36, her life was over.

I met the new generation, the 11 year old, the 9 year old, the 6 year old who had her birthday 3 days before her mom died, and the little 2 year old. I wonder if they will be making vows themselves, and I wonder if they will live in a society with insurance that will allow them to put and end to their cancer cycle.

Borderline

2009-09-01T09:43:00.001-05:00

If you have borderline personality disorder, please try really hard not to get an aggressive cancer. The combination of the love/hate, push/pull personality doesn't do well with the rapid changes that come from say, ovarian cancer or pancreas cancer.

I recently took care of a woman in this situation. She'd opted not to pursue chemotherapy for her advanced cancer, but also seemed determined to feel good despite not wanting any medications. Our daily conversations went something like this:

"Ms. Fraz, how are you this morning?"

"Miserable. Horrible. Awful", she’d say with her disheveled hair, eyes half open, and wrinkles cemented on her face from constant frowning.

"Oh?" Feigning surprise, though this was the 4th day in a row she'd said this, "What specifically is bothering you?"

"I'm vomiting, I'm in pain, and I'm so tired" were her general complaints.

To this I reminded her, "You know, Ms. Fraz, you haven't allowed us to give you any medication to help"

Her reply in full whine now, "But I don't like how medicine makes me feel" pause, "What are you going to do to fix me?"

And this is the crux of such a personality. She wanted someone else to fix her and to bare responsibility for her misfortune.

What makes borderline’s even more difficult in terminal illness is that they usually don’t have a lot of healthy relational support.

Ms. Fraz, in fact, had only one single person as her friend. No family…no other human relation. More tragic, the one friend she did have, Bill, was adamantly apposed to her decision not to pursue chemotherapy. He would tell her daily that she would be going to Hell for not trying to cure herself. “It’s like suicide to not try for a cure”. He’d badger and bemoan her and she’d cry and get distressed. She’d demand he leave, and then call him back for more.

She was aware that when she lost the ability to make decisions herself, he would be in charge. She had given him that power legally, even acknowledging that he would probably choose things she didn’t want.

And so she spent her time dying of cancer, wanting to feel better, but refusing the help we offered. It was in this pitiful state of inertia that she continued to pull Bill in, to listen to his rants about her mistakes and damnation until finally she weakened and he won. Back to the hospital she went from hospice, to spend her last days hooked up to machines and IV’s, getting poked and prodded, pushed and pulled. A perfect borderline personality metaphor; dying in the same way she lived.

Birthdays and Anniversaries

2009-08-24T09:41:00.000-05:00

When anniversaries or birthdays approach someone who is dying, the tension in the room grows. It's often one of the first things family members tell me, "You know her birthday is this Tuesday, you don't think she'll make it till then do you?" or "His son's birthday is in a week, I hope he can make it past then" The sense is, the death date is so etched into memory, even more than birthdays, and no one wants to share this date with the dying.

Of course, statistically it is very rare for someone to actually die on their birthday or anniversary. In fact the odds are less than half a percent. But this last week I had two people die on their anniversaries. Both approached it with that same dread. One was a young mother who'd been married 17 years. When the day arrived her blood pressure had dropped to 60/30. All of us, along with her family tried willing her to survive the day, but she didn't.

The other woman was older. It was her 25th wedding anniversary. Her husband had wrung his hands and paced as the days grew closer. Against the odds, she too, looked to be actively dying the morning of her big day. The day went on and family gathered, but I knew with certainty she'd not make it.

At 3:27pm her heart stopped and she took her last breath as her husband kissed her for the last time. The chaplain came to comfort him, and as they talked the chaplain asked, "At what time of day were you married?" The husband stopped, looking at the clock, "Our wedding began at 3:00pm" and then as if reality of the events finally struck him, tears began to fall and he continued, "Our wedding was only 25 mins long, and 25 years ago to this moment, I was kissing my bride for the very first time as her husband"

She had promised him days before that she wouldn't die before their anniversary. She was right to a degree. But what are the odds that she died not only on the day, but at the moment of her first married kiss?

Anything more frightening?

2009-07-04T09:40:00.002-05:00

It's hard to imagine a worse reality. She had contracted some sort of encephalitis. Absolutely regular 23 year old, living life fully, when suddenly she became ill with headache, sleepiness and fevers. By the time she was admitted to the hospital, most of her organs were failing. Her kidneys shut down, requiring dialysis and her liver began to fail.

Much more troubling than these major organ problems however, was the damage occurring in her brain. After the onslaught to her body was over, she was blind and hearing impaired. Even the typical sensations of touch seemed to be misinterpreted now by her brain.

She was in the hospital for months. Nothing improved.

Can you imagine what reality was to her? I try, and it's horrifying; To not be able to communicate with anyone... to be in constant darkness and if sound does filter in, the brain can't understand what the sound means!

It was in this condition that I met her. Sitting in her room at the hospice house, she'd all of sudden cry out, "Is anyone there? Can you hear me? Help me, please! I'm here, I'm here..." But none of my words or even touch seemed to register. She was in complete isolation. I wasn't surprised then when the crying out turned to, "If no one's out there, I wish I could just have a gun, and let this be over"

I had no gun. But mercifully the family had, after months of this crying out, opted not to continue dialysis or treat new infections. It was only a matter of time then before her wish to no longer be living in such a frightening reality would be over.

For the record: If I am ever blind and deaf and trapped in my brain, please don't try to keep me alive

Choices

2009-06-13T09:39:00.001-05:00

It was a bittersweet moment. She received her acceptance letter to medical school the same week her pregnancy test read "positive". If there hadn't been 2 previous miscarriages, perhaps there would have been no real decision. But, knowing that motherhood was in her blood, she boldly declined her spot.

As the years went by, her three healthy children granted her an indescribable joy. However, there was always that nagging thought, "Could I have done both?". Her husband heard the regret often and tried his best to encourage her, but it seemed to eat into everything she did. She was convinced she'd made the wrong choice.

Then the unthinkable; she was diagnosed with an incurable cancer. Bravely she fought through the vomiting, weight loss and fatigue. Ironically, it was in the stillness of her illness that she was able to finally announce to her family resolutely, "I did make the right choice".

The Change

2009-05-12T20:28:00.000-05:00

I wonder when things change? At what age do we start using pills for pain? Oh sure, even with little ones we dose out tylenol occasionally- but that's usually for fevers and not primarily pain. When I child whimpers from a fall, or even cries out loudly with an "owie" we reach out our arms naturally to draw them to us. Who hasn't fixed a minor scrape with a magic kiss? For those middle of the night terrors, we snuggle and bring them close. When they get anxious about trying something new, we give them a hug and gently encourage. Always though, we touch, grab them and pull them close.

Somewhere a long the way it changes. We stop touching and start medicating. Here's a pill for the pain, a tablet for your worries... No more hugs, no more snuggles. Wouldn't it be interesting if doctors treated patients like infants? Drew people in, instead of pushing them away with medicines. I wonder if there would be more success treating pain and anxiety if our initial response was to reach out in embrace?

The system

2009-04-07T20:26:00.000-05:00

The "system" always gets flak. But sometimes, like today, it actually does good.

Candice is here dying of ovarian cancer. Her one and only beloved son has been behind bars for much of her illness. When Candice came to stay with us, and we knew her time was limited, a letter was sent asking permission for a last visit by her son.

And the "system" consented.

Today, dressed in orange, shackles around his wrists, and accompanied by 2 guards, the son arrived for his 2 hour visit. His mother, who has lain with eyes half open in a blank stare without a single word for the last 2 days and blood pressure readings hovering on nonexistent, became suddenly alive when he entered her room. His hand cuffs were removed and he hovered at her bedside holding her hand as she mustered up the strength to say "I love you, I forgive you" all in one breath.

The visit was mostly silent, he crying...she hovering between here and beyond. But he made it, and she waited....just for him, so she could say goodbye. Thank goodness the "system" allowed it to happen.

Back to work: a reminder

2009-03-16T20:24:00.000-05:00

The chaplain was just finishing his prayer for the woman who had died. The family was huddled around the bed. Curled up in bed with her was the woman's husband, staring at her face and mouth, reminding me of the way a new mother takes in every detail of her newborn from only inches away. My eyes drifted back to closed as the prayer neared its end, when suddenly a loud moan started. The moan, coming from her husband, quickly escalated to a panicked scream as he began to yell "She's not breathing...she's not breathing", His eyes saucer wide drilling holes into her half open mouth. Although she'd passed away 20 minutes before, the reality was just hitting him.

The room erupted into emotion as someone near the husband grabbed him in a bear hug whispering to "let her go". He seemed in a trance, having an emotional seizure of sorts. Even though I already had tears running down my face it wasn't until he then embraced her saying out loud, "One more, let me hold you one more time" that I lost it. Something cracked in my self-made wall of distance and for a moment I realized what it might feel like to have your very last embrace with someone you love.

Another hard reminder on my first week back to work, how precious our time is with those around us.

Confession

2008-12-15T20:23:00.000-06:00

I wish I could always claim altruism when taking care of dying patients. But the truth is, there are times other priorities in my life try to stake a claim in my work.

This happened last week at work. I had met with a lovely family to discuss our plan for their loved one who was on a ventilator, not responding, and likely permanently stuck like this. He'd had the most aggressive care possible, but it seemed brain damage was irreversible. In the family meeting they told stories of his great accomplishments and were very clear that living a life on a vent with artificial nutrition through a feeding tube in his stomach, in a nursing home somewhere, was not something he would have wanted.

The decision was made then to withdraw the aggressive measures in place. We'd remove the ventilator and antibiotics and support him as his body transitioned to a dying process. We always warn families the process is unpredictable in terms of time frame. He may live minutes or days, something I wouldn't really know until he was off machines.

It was a very peaceful process. The family was all in the room. We removed the breathing tube. Took off all the other tubes and wires, beeps and buzzes, and let them just be with him. It was evident he'd been very sick, because he really made no effort to breath on his own. I prepared the family it would be more in the minutes range and left them to be with him.

Sometimes the monitors out in the nurses station still record the electrical telemetry from the heat. I'm not as used to this, as usually everything is turned off, but in this case I could look at a little computer monitor to see his heart still beating.

Here's the confession. With my husband out of town this month, I'm the one to pick up our daughter from daycare. I'd already stayed in the hospital longer than I usually do, and was keenly aware as I watched the blip of this mans heart, that each blip was time getting later and later. As it began to get slower and slower, I found myself mentally coaxing the heart to stop. "'c'mon, let that be the last beat. I've got to go!"

I know, how callous! When I realized what I was doing I was immediately disappointed in myself. This bleep on the screen signified a person's life...by hoping it would stop soon, I was essentially wishing this man dead. Not for some noble reason, like to end his suffering, but so that I could pick up my daughter on time from day care.

That's my confession. And my apology to this man's soul, who's heart did stop. And to his family, who weeped at his bedside and hugged me in gratitude for helping him die peacefully, not realizing my hidden selfishness.

Toddlers at work

2008-12-08T20:21:00.001-06:00

I lead a lot of family meetings for my job. This week, I felt like I was mediating a bunch of toddlers at one such meeting. The sad thing is the fighting had little to do with the actual health of my patient.

The background: Mr Jones, 60's, came into the hospital with bad emphysema. The woman with him identified herself as his wife. She then became the primary contact for decisions as he got sicker. "Shall we do this surgery Mrs Jones?" and she directed the doctors on what he'd want. It got to a point that he was on the ventilator and required neurosurgery for extra fluid on his brain. At this time, she decided to call the rest of the family who lives out of town to tell them their loved one was in the ICU and critical.

Chaos ensued. A son flew into town. Two sisters drove in. All entering the ICU with steam whistling through their ears. The family was angry. There was no "Mrs. Jones", they said. This woman had been married to the patient 20 years before for only 4 months. After a restraining order and a loss of a great deal of money they divorced. She arrived at his door a few months ago, needing a place to live, with a certificate showing she was a licensed caregiver, which the patient needed. So she moved in with him.

It was in the fireworks of these two parties meeting that we were asked to intervene. The good news was that the patient was doing better, and able to get off the vent, so I could speak directly to him about his medical decisions. He could also designate who he wanted to be his decision maker in case he got ill again.

The family and ex wife still needed some help and as I met with them, I realized that true issue was not the patient and his wishes but the house he was living in. He was renting it from his out of town sisters. When they arrived in town they found the ex-wife had changed the locks and barred them ,with police force, from entering. I guess because the patient was renting it, he had to give permission for the "landlords" (his family) to enter, and being on the vent his "wife" had that power.

Sadly for this fake wife, as the patient awoke, he was able to give that permission to his family, and her scheming began to crumble. As she began to realize the situation she emotionally started to unravel, pleading with the patient, newly off the vent and still in the ICU, to change his mind. She hysterically begged me to convince him otherwise as she'd soon be homeless. The family, not helping the situation, antagonized the woman, with threats of calling the police.

I tried, in vain, to help them talk as adults, but as they bickered and threw insults and waved different legal documents in front of each other, I began to see them as two-year-olds struggling to both play with the same toy. My reasoning doesn't help with my own two-year-old, so why would it help now. Like with toddlers I finally said, "Enough! Time for both parties to leave. Your fighting is hindering our care of the patient." They did need a bit more coaxing from the hospital security before they finally left.

It's interesting what brings out the worst in people. In this case it was a house. Never mind our sweet patient who almost died, who will need good care at home once he leaves the hospital, and who emotionally is sickened to find that someone he really loved was trying once again to swindle him

Jabba the Hutt

2008-11-22T20:18:00.000-06:00

One of my favorite lecture series all year is the "mystery and awe in medicine" talk. Very informally we sit around telling stories about the things we daily encounter that we can't explain.

It is very common for people to see deceased relatives in the last hours and days of life. Usually a comfort to families and patients it is unknown what this phenomenon is. Some say it has to do with cultural expectations, and that it's natural for someone close to death to talk about their mother or someone who has gone on. Could it be possible that someone is actually there? How would we prove it?

One of our great social workers told the story of Eddy. He was young and at our house dying of cancer. The day before he died he began to tell others that he'd been visited by his deceased grandmother in the company of a stranger. He told our social worker, "It was great to see my grandmother, but that other one was a bit scary. I don't know who grannie was with, but it looked almost like Jabba the Hutt".

This surely would point to the theory that these visions are delusional; made up dreams in our minds. And this is precisely what our social worker thought as she kindly listened to him tell again about his "visitors".

The next day Eddy was unconscious and no longer able to communicate. Eddy's mom sat by his side when our social worker visited. Eddy's mom had missed the stories of the day before, and our social worker gently retold Eddy's vision, including this account of "jabba the hutt". Instead of chuckling or smiling as our social worker expected, her face turned white and her mouth dropped.

"I don't believe it" she gasped. She went on to tell our social worker that Eddy's grandmother had a dear sister who died years before Eddy was born. The two older woman had been inseparable. This great aunt of Eddy's always struck people for her overweight, bald-headed, eyes larger than life look about her. Though she'd never considered it before, she looked exactly like Jabba the Hutt.

Eddy then was seeing someone he'd never met, not even seen pictures of, and absolutely didn't recognize. Now explain that one

Gum Drops

2008-10-15T20:17:00.000-05:00

Every day she has bowls of candy in her room at the hospice place. There is always one filled with gum drops, but today there was one with pumpkin candies too. She's not the typical hospice patient, although she came to us 2 months ago appearing to be on death's door, she clearly is not. She's in her 80's, uses a walker to get around, but looks like she's got at least another 6 months to go.

She offers me a gum drop and then says, "I'm trying to cut back, limiting myself to just 3 gumdrops a day. One in the morning, one at lunch and one before bed, 4 a day was just too much" She is very serious but it's hard not to smile. "How did you know 4 was too much?" I ask. "Well" she hesitates "it was the noises my body was making, and someone told me once the noise was from eating too much sugar." I certainly wasn't going to challenge her logic. "You know" she continues, "When I first got here, I really let myself go, eating a couple gumdrops at a time...I should have known better. Life is good now that I'm down to 3" And with that we move on to talk about other things.

Part of me wants to convince her to let loose, eat what she wants, she's on hospice for goodness sake! But I also recognize her joy in self-restraint. Perhaps it is in limiting herself that she relishes the tiny sugar covered jelly candy all the more? When I left the room, I took with me her gift of one gum drop. More as a reminder to me that life's not always about how much more I CAN have, but how much is enough for me. Maybe just 3 gumdrops a day is enough : )

Christmas in September

2008-09-22T20:16:00.000-05:00

Not everything is always a perfect ending. One of our patients this last week is a single mom of 3. She was diagnosed with cancer last year, having just turned 40 it was very unwelcome news. The doctors were never able to say where the cancer came from. It was squamous cell, but because it had already spread so far when it was found, it couldn't be called "lung" cancer or "skin" cancer. What they did know was it was in her bones and brain and abdomen and it couldn't be cured.

As a mom, her one wish has been to make it to Christmas. However, everyone at the "house" knew that wasn't going to be likely. Although she was still getting around, eating meals, the chance of her making it 3 more months seemed impossible. Always trying to be creative, we just decided to have Christmas early. An email was sent out to all the volunteers and staff on Friday for a call to arms. There was to be a Christmas tree and lights, presents for all the kids...Christmas music and goodies and even a Santa Claus visiting.

In just 2 days, the office here at the house began to fill up with food and gifts in anticipation for Monday's Christmas in September celebration.

I was surprised then when I entered the office this morning to find people in tears. In a seemingly unfair turn of events, our patient had died overnight, on our "Christmas Eve".

What awful timing. All these good intentions by so many caring people, left now to wonder why? And 3 children who were already dealing with a dying mom, not just wondering, but now screaming, WHY?

Finger Nails

2008-08-17T19:51:00.002-05:00

You really can't take the mom out of anyone. I saw an example of this very clearly this week. We have a woman in her 30's here with cervical cancer. It's been one of the tougher things for me to come in each day and visit with her about her cancer and about her girls. Ellie is 7 and Zoey is 2. There are pictures plastered all over the walls here at the "house". Sometimes in the afternoons, I hear the girls running around in the halls, being admonished by grandparents to keep quiet.

Kindra, my patient, has really been in and out of it, asleep most of the time. Part of this is to escape the hard reality of dying so young. She talked to me earlier this week in one of her more awake times about the girls. "Zoey isn't going to miss me, I mean she'll miss me in the way people miss the idea of things, the idea of a mother, but not really me. It's Ellie I really worry about. I know she'll miss me so much. I worry their dad will take his grief out on them, won't be patient with them." I thought, as I was scrunched on the corner of her bed listening, how unthinkably hard this must be. What must be harder... knowing your child won't remember you or knowing your child will?

After that talk she spent the next several days in a deep sleep, enough to make everyone concerned that she was getting close to dying. That is until today. Suddenly out of a deep coma she arose, sat up and wanted to spend time with her girls. She got up to a wheelchair and was pushed around for a few minutes. And then, like only a mother could do, she wanted to clip her girls fingernails.

There in her wheel chair, pale with dark circles around her eyes she sat, almost skin and bones. Each girl one at a time climbed into her lap so mom could clip those nails and get them clean. Such a little thing, but spoke volumes.

She went back to sleep later, maybe not to awake again. But for a time, she mustered up her strength to take care of unfinished business. Isn't it those little things moms do each day that make them moms? There's not a more symbolic gesture as that...

Bathing

2008-08-15T20:14:00.001-05:00

I'm constantly in awe of the little things hospice does to help families cope.

Madame Olga was a true diva. A life long voice teacher, her two daughters' sole purpose in life was to cater to their mother's ego. Madame Olga was well known and spent her life dedicated to her craft. She was still giving voice lessons at 97, a week before her stroke. It was obvious to the family that any physical impairment, let alone loosing the ability to sing, would be impossible to live with. She came to the "house" to spend her final days. Although mostly unresponsive, completely unable to communicate, every time the daughters would play their mother's music, her eyes would open and a tear would fall.

After she passed away, the nurse did what she always does; offered the daughters a chance to help the nurse bathe the body. Hesitatingly, both daughters consented.

The experience was life changing. They both later told how that symbolic act of cleaning their mother's body, helped both of them let go. The eldest, Gertrude, though in her late 60's had spent her whole life taking care of her mother, to the neglect of her own life. As she bathed the lifeless body before her, she wept and verbally forgave her mother. The bathing ritual was a way to cleanse her own soul of the harbored resentment at the larger-than-life mother who was never good at being "mom". As both daughters cleaned her wrinkled strong hands, and washed her crooked feet, they were also able to reminisce and say a final good bye.

Cleaning, bathing and preparing a body after death has been a part of cultures for ages. It is only in our modern death denying culture that we've delegated the task to others. It's refreshing for me to hear that hospice at least offers the option. For some, like the daughters I met, it was one of the most meaningful experiences of their lives.

Too much to handle

2008-07-24T20:09:00.000-05:00

Sometimes it's better not knowing.

I stumbled across an article in the paper today. What caught my eye was the picture of the 20ish person. "I know that face" I thought. As I began to skim, reading about the youthful adventures and work life of this person my brain began to make the connection.

A few months prior I'd taken care of a lovely 50ish woman with pancreatic cancer. She'd come to us with intractable vomiting, thought to be partly of an emotional nature. The trend is all to common; someone young , often a parent, who just isn't ready to die is vomiting uncontrollably. Instead of processing through the reality, the struggle can become symptomatic. In other words, the emotional pain manifests itself in pain or vomiting.

My patient had reason for emotional struggle. A mother of 2, one of her kids was killed right before her diagnosis. The loss of her child in addition to the loss of her health became overwhelming.

While I took care of her I worked with medications to help, but I always felt the fear and resistance to dying. The remaining child was doting, caring and supportive and the bond between the two was extremely close.

I moved on to other places to work, and wasn't around for the mother's death, in fact had forgotten about this young family until I saw the picture in the paper.

What I was reading was an obituary. An obituary of this young person, the child of my patient. The paper said the cause of death was unknown. But isn't it known? This poor young one had already had too much loss. Perhaps the prospect of life alone seemed too overwhelming.

I'm shocked still as I write this. I'm used to the process of a body shutting down, through disease or old age. The sudden snuffing out of life, in the midst of health and potential is depressing. Couldn't something have been done?

Therapeutic Privilege

2008-06-30T20:06:00.000-05:00

There is a phrase sometimes used in ethical discussions about patient's rights called "Therapeutic Privilege". The connotations aren't always positive. In fact, when I hear the word this is what I think of "I (the doctor or family) know more than you, therefore I have the privilege of deciding what you should know or not know"

This story illustrates the problems with this concept:

Annette is in her 20's. She was diagnosed late in life, at age 13, with a genetic condition that effects her digestion and absorption of food. Over the years she's gotten to the point that she can only stay alive with nutrition given to her through her veins, called TPN. This seems like an easy solution, accept anything in our body (like an IV line) over time has a tendency to get infected. Annette ends up being in our hospital every few months with a bad infection from her TPN line. In fact, she's had so many infections that she is loosing veins that can be used for her nutrition. The line she has in now, is actually the last vein. If it gets damaged or scarred, there will not be another way to feed her.

When Annette is not in the hospital she lives in a nursing home. A life of poor nutrition does a lot of things to the body. She has thin bones and cannot walk, she has had many dislocations so it's hard to use her hands, her growth is also stunted. She has been chronically ill for over a decade, and the psychological ramifications of this have made a definite impact on her social skills, as well as her developmental growth. To me she seems like a 13 year old, ironically the age of her diagnosis.

This most recent admission to the hospital was again for infection of her TPN line. The one line she has left! Her family struggled with watching her so ill, and wondered if there was anything to do. Her regular doctor mentioned palliative care, and talked to the family about the options of hospice and comfort measures. The one big difference is that the doctors, based on the family's wishes, did not include Annette in on this talk. The family cried and worried about Annette's overall health and decided they wanted to stop the TPN, as a way of ending the never ending cycle of infections/hospital stays/pain, etc. The problem- they didn't want any of the doctors to tell Annette... "She wouldn't be able to handle it" they cried, "She'd panic and it would be worse, it's better if she didn't know she was dying" This then is the concept of Therapeutic Privilege. We think that the truth (stopping your food) would actually hurt you, therefore we withhold information.

It did not feel right to me. I pictured Annette getting weaker and weaker without food, wondering why, with doctors and family members in fake smiles reassuring her nothing was wrong. That's not comfort. That's not good medicine.

Needless to say, this is not what we did. Despite the family's wishes we began including Annette in the discussions. We had to be simple, but she could still decide for herself what she wanted. And ultimately, despite being stuck in bed, in constant pain, with no hope for getting better, she chooses to at least try; to keep coming back to the hospital, to even wind up on machines if need be, anything to keep her going.

You can see why therapeutic privilege is a slippery slope. Who decides what information someone can or cannot handle? Had we let the family decide, Annette would not be alive today. Had we even let some of the doctors decide, they'd have looked at her life and thought, "not worth it" and she'd not be alive today. Luckily, we threw therapeutic privilege out the door, and asked our patient...who is alive today.

Guppy Breathing

2008-04-28T19:57:00.003-05:00

There’s a type of breathing when people die called agonal respirations. The best way to describe this is a deep, regular breathing that often involves movement of the jaw and shoulders. The jaw movement is what I almost always notice. If you think of it, normally when we breathe your jaw doesn’t move at all. This forward thrust of the jaw is an ominous sign, and usually means death is minutes to hours away. Another name for this type of breathing is guppy breathing, named I suppose for the movement fish make when trying to get air out of water. We have pamphlets in all the rooms explaining these things for families,so they can also recognize the signs of the dying process.

All this is background for a funny story. We had a lady here at the house that was very curious about the dying process. She decided to read the pamphlet too, so she could be prepared for these changes in her body. That’s understandable, but she went even a step further. The nurse went in her room one morning and found the patient sitting in bed holding a mirror up to her face. She had put on her brightest lipstick, a deep red that was in shocking contrast to her pale skin. There she sat with her cheeks sucked in, making a fish pucker face,moving her lips up and down. “Mrs.Rose, what are doing there making that face?” the nurse asked in bewilderment. “OH, I’m just practicing” she said matter-of-factly. “Practicing what?” the nurse wondered. “Well, this book here talked about guppy breathing as you die, so I thought I should practice it to see how it looked…I want to do it well.”

The nurse could hardly contain her laughter at this misguided attempt. If she only knew how different the fish pucker face was from actual agonal breathing…and how strange it would be if that’s the face we all made when we died!

Irish Lament

2008-04-21T19:53:00.001-05:00

People express emotions in so many different ways. I've met a very facinating person this week at the house. He's in his 80's and is the husband of one of our patients. The two of them had been living at home alone, never having had children. She had been getting jaundiced but neither one of them seemed to notice until a cousin stopped by and called 911.

She was subsequently diagnosed with cholangiocarcinoma, a type of cancer in the bile duct and given just days to live. That's when she came to the house for her end of life care.

Her husband is the one who impressed me. What I first took to be dementia, I soon realized was actually misplaced brilliance. He was an electrical and mechanical engineer and worked on the Apollo space missions in the 60's and 70's. His way of thinking was in a plane so different than mine, that he had a hard time grasping why his wife was dying.

Everyday I'd see him walking down the hall, hunched over with time, a blue and yellow knit stocking cap on to match his green polyester pants, blue knit sweater and stripped shirt. Never once in the week he was here did he change clothes. And everyday he'd carry his violin, to and fro, having been a concert violinist as well.

For all that he could do in explaining how valves of her biliary drain worked, and remembering every blood pressure reading she'd had in the course of the week, he lacked in emotionality. I could sense that he loved his wife of 60 years, but never once did he sit by her side to tell her so, never once did he whisper he'd miss her. It was all numbers and mechanics.

She died today. As peacefully as she could. He had been in the room with her all morning, knowing it was getting close. As she took her last breath he picked up his violin and played "Irish Lament", the music piercing the silence of the room. I realized then, that was how he was saying goodbye. Unable to put his feelings into words, the music was his way to do it. A few tears dropped as he played, causing all of us in the room to cry. A brilliant man saying goodbye in the only way he knew how.

Who has the say?

2008-03-10T18:46:00.001-05:00

What do you do?

She’s in her 20’s. She’s battled sickle cell disease all her life, with a list of hospital stays that would fill a notebook. In fact, she even had a baby while in the ICU. That’s right, hooked up to a vent, on blood pressure medicines; they did an emergency c-section last year in the unit! They told her family at that time, they didn’t think she’d make it out of the hospital.

But she did. She was even able to get off the trach (breathing hole in her neck). So when she came in this time with pain, and called her sister from the ER in a panic saying, “Tell everyone I love them, I think this is it”, no one really believed her. She even told her sister whatever happened she wouldn't want to wind up stuck on machines.

But she is. This time in the hospital she had an arrhythmia and her brain had some time without the proper amount of oxygen. She not only wound up on the ventilator, this time she didn’t wake up. All the scans and tests show severe brain damage.

We sat down with the family- a confusing mix of people. A biological mom who gave up custody, a foster parent whom the patient verbally said she wanted making decisions, and 2 sisters who are now raising our patient’s child. We gave them the bad news about her brain injury. We let them know the neurologist thinks she has only a 5% chance of getting any better. We painted the bleak picture of putting in another trach, of placing a feeding tube into her stomach and of moving her to a nursing home for people in vegetative states.

We reminded them of what she told the sister, about the premonition of dying and not wanting to be stuck on machines. Still, the family said, proceed with all the things that will keep her stuck.

What to do. They are making decisions, but maybe not the decisions the patient wanted them to make. Yet, who are we to take away that hope they have, that 5% chance of her improving from the blank stare, body rigid, hooked up to machines existence that she’s currently in.

What to do?

A Challenge

2008-02-11T18:43:00.001-06:00

There's just something about feeding and children that is inseparable. Or maybe it's feeding and motherhood? Regardless I had a case recently that's been one of my more challenging ones personally.

Max was born with a brain condition that didn't allow him to interact with others. He was blind and deaf, so as you may imagine, touch was not a comforting thing, but an intrusion to his dark silent world. The part of his brain that thinks, remembers, or feels was not formed. Basically he was living, but not experiencing.

Max's mom did an amazing job raising him. He ate and slept and cried. He never smiled and always screamed when being held. He never spoke and his eyes were always closed. His little body grew until one day at age 3 he quit being able to eat.

His mother took him to a children's hospital where test after test was run to determine why max couldn't swallow anymore. The doctors finally told her, "his body has just outgrown his little brain." The choice was now hers, should she have the doctors put in a feeding tube or let him live out the rest of his natural life as he was able without medical intervention?

Bravely she decided not to intervene with his disease course. So he came into our hospice care for the last weeks of his life.

Everyday when I visited Max I had to do a lot of internal work. Emotionally I'd see a little child with an otherwise healthy body asleep, with little thin arms and a dry little mouth. A part within me said "FEED THIS CHILD" and I'd have the urge to find a bottle and at least try to let him eat. I'd watch his heart beat through his shirt and smooth his hair and pray that we weren't causing him pain. Logically I'd have to tell myself over and over again that even the smallest amount of milk would cause him to choke and cough and have more discomfort. I also had to force myself to remember his condition. This wasn't my daughter that I was starving to death, this was a little boy who had lived his life in the dark, in silence, with an occasional intrusion of touch that frightened him. A boy who's brain had reached it's limit on what it could support.

I can tell you that the longer he lived without food or water, the harder each visit became. In total, he lived nearly 3 weeks with us.

3 weeks that I tried to figure out why I felt so torn about his eating, when almost every disease process we can get, ends with days and weeks of not eating. Everyday I treat people dying of cancer, of liver disease, of dementia or heart disease, who all quit eating. It's natural. So, was it his 3 year old age or the inner mom in me that found it difficult? Still trying to sort it out....

Visions

2008-01-20T18:40:00.001-06:00

I'm always intrigued at the things people talk about and "see" as they get closer to death. Especially the things that are unexpected. For instance:

There's a sweet elderly Jewish lady at the "house" with colon cancer. She's still very coherent, but isn't eating much anymore, and can't get out of bed. This week when I sat down for one of our regular talks she said, "Last night I went to Heaven and was told to put my arms around the 2 that loved me most" I encouraged more by asking who those people were. "Jesus" she said matter of fact like, "He suffered so much, you know?". I waited a while and she continued, "God was there too." I asked if he said anything and she broke into such a wide and peaceful smile, "that I was well loved"

Of course people of the Jewish faith believe in Jesus as a wise teacher, but I didn't expect him to be held as one of those who loved her the most. It gives more credibility to her vision because it's not what you'd expect. I'm looking forward to Monday, to see if she's had any more visits to Heaven.

Impossible odds

2008-01-09T16:33:00.001-06:00

Manuel was born 12 weeks early to first time parents of a small town in my state. The trauma from needing a ventilator with such underdeveloped lungs led to permanent lung damage that required a tracheotomy to be placed. A ventilator is hooked up to this small hole in his neck at all times. He also was so young, part of his throat hadn't formed right, necessitating that a feeding tube be placed for him to eat. One complication after another, until an entire year passed in the children's hospital I'm rounding at this month. A year in the same crib, same room, same nurses.

Manuel's mother came to this hospital when Manuel did, and hasn't been back to her home since. She spends each day with him, and each night at a Ronald McDonald home for parents with sick kids. Her husband, to keep his job, lives hours away, only able to visit every few months.

As Manuel's 1st birthday approached everyone was in good spirits, because it looked like he could finally go home. He'd still be on the breathing and feeding machine, with visiting nurses everyday to their home, but it would be home. Manuel's mother, who spoke no English when Manuel was born, now conversed with the nurses with ease about her delight to finally get out of the hospital.

They had to just do one more CT scan.

The CT scan showed the unthinkable, some spots on his liver that came back as liver cancer. Completely unrelated to his other medical problems, this child was unlucky enough to have a very rare cancer as well. You can imagine what a hard conversation it was to sit Manuel's mother down and tell her the news.

The nurses tell me that she took the news stoically as the doctor talked about options for chemotherapy that may cure the cancer, if his little body can survive the treatment. The cancer is rare enough that someone as sick as Manuel has never been treated. As soon as the doctor left though, her tears flowed strong and bitterly.

Manuel is due to start the chemo tomorrow. His parents decided to give it a shot. I watched Manuel today chewing on a plastic cap of his feeding tube, laying on his back in his crib, having never sat up, or put weight on his legs, having never said "da da" or even cooed. And now, despite all those setbacks, he has to battle cancer. Doesn't seem fair.

Hard to bear

2007-12-24T16:30:00.000-06:00

I’ve been doing pediatric hospice visits this last week. I knew, as a mother, this would be more difficult than the adult hospice population. Each newborn I’ve seen with chromosomal abnormalities so life altering, that they won’t survive past a year of age, have pulled at my heart as I imagine what the parents must be feeling, struggling each day. What has surprised me this week, is not the tough medical conditions, or my own emotions as I relate to being a parent, but it’s the social situations that have caught me off guard.

It seems that each child has come from strained social circumstances as well. Little Marcus is 8 months old now, but has a rare disorder with his brain. Instead of splitting into two halves, only one large brain formed. This causes serious mental problems: he can’t coordinate swallowing, so is fed by a tube in his stomach, he has problems breathing and needs oxygen, he is blind and probably deaf, and has seizures everyday of his life. His mom is just 18, pregnant in her last year of high school, she wasn’t prepared for this form of mother hood. Her boyfriend has stepped up and is helping out, but they weren’t planning on marrying, or being together after high school. Life looks so much different now.

Jamie is only 2 weeks old, born with a similar problem as Marcus, but worse. She also didn’t form a nose, so there’s a gap from her nose buds to the mouth, a very severe cleft palate. She also has all the problems Marcus has. Her young parents had dropped out of high school and were newly dating. They were shocked when they became pregnant, and even more when they learned of all of jamie’s disabilities. When I visited this young family they were living with friends. The tiny apartment housed 2 families, 3 boys ages 2, 2 ½ and 3 and now Jamie and her parents. It was chaotic as the 3 boys ran around asking about the feeding tubes in jamie’s belly and why there was a whole in her face. No one in the entire apartment was older than 20.

More than coping with taking care of a child with such complex medical needs, I wonder how the experience of the children dying will affect them. Each of these children will likely not make it to a year of age. To be 16 and mom is hard, to be 16 and have to watch your child seize 3-4 times a day, up to 2 hours each time seems unbearable, but then to be 16 and live through bonding and loving that baby and watching them die in a year, seems almost a breaking point.

The key incident

2007-12-17T16:28:00.000-06:00

Before embarking on Friday’s home visit’s I reviewed the info I had on each patient. The first home I was to visit had a note from the nurses on it: “Patient share’s duplex with drug dealers, always take security with you if going after dark”. I was going in the day, but it did make me a little more cautious as I made my drive.

As luck would have it, in my nervousness to hide my computer, iPod, etc in my car when I arrived at the patient’s house, I jumped out and habitually pressed lock on the car door and saw my keys still sitting in the console.

My heart sank. Of all places to get locked out of my car, I’m in some dangerous crime filled neighborhood! There was nothing more to do just looking into my car, full of regrets, so I made my way to my patient’s half of the duplex.

As I knocked I had the thought- had I left all my valuables in plane sight, maybe someone would try to break in, and then I’d get my keys!!

I met my patient for the first time, in one breath introducing my self and lamenting about my car key situation. She’s a young woman, 48, with colon cancer who’s husband died last February of the same disease. She has a 9 year old and a 30 year old, but no kids in between.

Although tired, and in bed, she immediately went to work on my problem. I tried to dissuade her to not worry, that I was there to see her, but she wouldn’t have it. She began calling her landlord and neighbors. “I’m sure one of these young men around here can break into your car” she muttered. I’d hear her ask for so and so’s son, then take ownership as if it was her car, “Dewon, I locked my keys in my car, you think you can come get them out?” They’d talk a bit, but everyone probably saw my car parked outside and declined to come try.

Later, my husband agreed to get off work and come and unlock it. I ended up spending 2 1/2 hours with this patient. We didn’t discuss anything too profound; I tried practicing what I’ve heard of as the ministry of presence. Not wanting to exhaust her, I’d often remain silent, letting her rest. Then we’d talk for a little bit about her life.

In those silent moments I thought a lot about my key incident. I know that had I not been so nervous I wouldn’t have made the mistake. I’d now spent an afternoon here, and was embarrassed at myself for the prejudices I had when I had pulled up into this neighborhood.

When I left, we hugged as friends, and I was glad the day had turned out as it did.

Tension

2007-12-12T16:26:00.001-06:00

I had a hour long drive to go visit a new home hospice patient. She lives with her family in a very small town. I passed many farm fields covered with ice and snow to get to the town. I found her street and recognized her home easily. I had already heard that this little town had surprised she and her family by building them a new home.

Jackie was diagnosed with lymphoma last year, and has had the most aggressive therapy available for this aggressive form. She and her husband had bought an old farm house and were in the process of fixing it up when she was diagnosed. While gone for 3 months, away from her kids, getting a bone marrow transplant, the town had volunteered and built a magnificent home.

I walked up to the front, passing bikes strewn in the snow and rubber balls hidden behind bushes. I felt myself growing sad just walking to the door.

Jackie is my age, with 5 children, ages 2 1/2 up to 12. MY AGE and dying.

Jackie's husband welcomed me in, to more Christmas chaos with decorations and wrapping paper around. Jackie was able to walk out to greet me for just a few minutes before retiring to bed from exhaustion and nausea. Her hair short, having just started to grow back after chemo. Face thin, having lost 50 lbs.

It was a hard visit. For the first time, I sensed tremendous distrust in me as a young hospice physician. Perhaps it was anger on her part at my life, or just the weariness of fighting so hard to beat something impossible to beat. Regardless, there was a lot of tension in that house.

It's so different when I work with young patients vs. older one's. Young patients often keep hoping for miracles. Comments her husband made led me to believe that they both are still expecting she'll be cured, even with all medicines now stopped. There's often more escapism in young people as well. When it gets so hard to face the reality of being a mother of 5 and dying, it becomes easier to take medicines to go to sleep. She's avoiding the pain, with drugs, but meanwhile loosing the precious time she has left with her family living.

Usually I leave visits feeling good, but not this day. Passing the bikes again, I had a heavy heart.

Prayer for compassion

2007-12-08T16:22:00.003-06:00

My impression from my initial visit 2 months ago was the Mr. J had led a very hard life, had been in jail, had been homeless at one point and had extensive alcohol and drug use in the past. He now had metastatic lung cancer to his brain and I was making a follow up visit. He’d been drinking 24 ounce beers all day, so my initial expectations for the visit were very low.

I went through the usual stuff, asking about pain, constipation, appetite, sleeping, etc. He was sober enough to answer through the questions, but at times would start to drift off again. I’d watch him light a cigarette, take a puff then forget it was in his hand. It’d continue to smoke up the room and my lungs, and he’d drift back to sleep. “Mr. J, you need to be careful when you’re this sleepy and smoking, I’d hate to see this house catch on fire.” He’d wake up, the cigarette now burned to a little nubbin and puff once more before lighting another.

I really wanted to finish up. It was the last visit on Friday afternoon and I was queasy from the smoke. I, however, forced myself to be patient. “Anything else on you mind?”

Mr. J then surprised me. For the next 15 minutes he began to talk about God. He spoke of how sad he’s been. How at first when he was diagnosed he questioned God, “why me, why my family?” He voluntarily said that he’s come to an acceptance now. He still prays that God will heal him, but he is at peace with his disease. He said the hardest thing now is that his mom and aunt haven’t accepted it. He then fell asleep again and even with another question to follow up on his statement, he kept sleeping. I sensed he had reached his end point.

I went up to him to say goodbye, again having to shake him awake. I asked if there was anything else we could do and he said “just pray for me”. I went deeper, “How should I pray for you?” He asked for strength, and then just as I was turning to go he chimed in, “one more thing to pray for, pray that I have compassion.”

I was actually moved by his simple requests. A man, dying of cancer, who has had problems sleeping, problems with pain and anxiety, a man who has struggled with things he’s not been proud of in his life. The two things he wants most are strength and compassion.

When I had word that Mr. J was drunk and emotional, my own prejudices imagined he’d either be riled up, flirtatious or weeping with self-pity. I was shocked to find his emotionality was appropriate. He’s doing the work people are supposed to do, as they get ready for death. In fact, Mr. J, with his cigarettes and alcohol, his stab wound scars and tattoos, was doing a better job coping than many of my other patients. More surprising to me than even the work he was doing on death, was that he’s been able to move beyond ego centrism. When he asks for compassion, he’s thinking about others, and how he acts towards others. Death and disease are often so inward, focused solely on self and how to feel better, that I rarely find people wanting to improve themselves for the sake of others.

I had to think, when was the last time I asked for compassion?

More Drama

2007-11-15T16:21:00.001-06:00

I had a dramatic family meeting last night. My patient, Yvonne, a young 40ish woman with metastatic breast cancer has been in our facility for pain management. She's getting ready to transition either back home or to a nursing home for the last weeks/months of her life.

She's had a tough time, her 3 teenage kids don't seem to be accepting of her decline. Since she's been gone from home, 2 of them have dropped out of school. She can't be around to encourage them to go, to take care of them, to help them keep their paths straight.

I met with her kids separately, to make sure they understood how serious their mom's cancer was. Also, to give them a chance to ask questions. We then went back for a larger meeting. All of the patients brother's and sisters and cousins came. About 25 people all circled around the room. I knelt on the floor next to my patient. I spoke to her, but for the benefit of everyone. I explained where we were at in her disease, and what the options were for next. All of the family voiced the desire to take care of her at home, ready to pitch in. As I wrapped up I said something like, "Now is the time as a family to be saying the things that need to be said".

One of her brothers spoke up, "I just want to say, sis, I love you... and doc, thanks for everything". Another sister started to tear up, "I have something to say too," I was really amazed, I hadn't meant THIS moment was the time to say everything, but hey, the mood was there. The sister kept choking up, "If ever we needed to be a family, it's now" People were amening and crying. The sister was visibly having a hard time speaking, "What I have to say is.... our niece, kiki has died" At this, screams erupted. People jumped up wailing, saying "What!, Why are you saying this? How can you say this in front of Yvonne" Pandemonium, as people ran down the hall crying, shouting, moaning and angry. Yvonne sat, tears streaming, looking weak and shocked. The sister making the announcement said to me, "Yvonne raised Kiki, she was a 4th child to her. Kiki was only 12, she had cerebral palsy from birth, and her death had been sudden."

What a way to make an announcement! You'd think there was a more subtle way to let someone know their child had died. After comforting my patient, I got up to leave... that meeting was defiantly over, with a big black exclamation point.

Ignorance Bliss?

2007-11-05T16:19:00.000-06:00

Something to ponder.

As science advances, one of the things that will occur is the linking of cancers to choices. We know now all about the links of smoking, obesity, etc. But, what if we're able to pinpoint all cancer to a specific behavior?
So what?

Well, think of this. Is it comforting to be able to assume the cancer you're dying from is just happenstance? Perhaps it allows you to blame God? Or at least be able to blame circumstance. The responsibility is at least not yours to have to sit with, hour after hour, as your body withers. Will science take that away? We are searching for reasons, aren't we? But what if all the reason's just point to ourselves? We can't then be mad at God or even chuck it up to LIFE... it becomes our own grief at bad choices.

What I'm not sure of is if our new information and causations will be helpful or harmful. I see a lot of guilt with certain cancers, which seems to get in the way of the dying process. At the same time, I see a lot of blaming God for things that don't make sense that also hinders the closure process.

Be prepared: by the time you die, you may know exactly what food you ate too much of, or what behavior you did that will be the ultimate cause of your death. It will be interesting to know if it changes anything.

Rituals

2007-10-30T16:18:00.000-05:00

I heard a great story today that I'd like to retell:

An elderly gentleman with dementia, living at a nursing hom e, started exhibiting some disturbing behavior. Before going to bed at night he'd shuffle up and down through the halls of the nursing home. This particular place had pictures of all the residents outside each room, to help them all find which room was theirs. AT each room this elderly man would pause, and then kiss the picture of the elderly resident. He'd wander up and down the halls doing this until the staff would loose patience and force him to bed. What at first seemed cute, really began to disturb everyone working there, and even some of the other residents. The head nurse called this man's family to discuss the situation. The daughter listened to the story and then said, "I know exactly what to do to fix the problem, and I'm sorry I forgot about it". The next morning she arrived, a picture frame in her hand. As she placed a picture of a young boy next to her father's bed she explained, "This is his oldest boy, who died tragically at the age of 8. All our lives, dad would kiss our brother's picture before turning out the lights to go to bed. I think he's been wandering the halls looking for his son's picture, to kiss goodnight" Sure enough, with that picture beside his bed, he never wandered the halls again.

Story board

2007-10-26T16:15:00.000-05:00

Finishing up a week at the "house". As I sit getting ready to leave for the weekend, I wonder who will still be here Monday. Each room has such a unique story, with vibrant characters.

Room 1. 80 year old woman dying of heart failure. Her well dressed husband is hard of hearing, a "talker" with a scruffy voice like Louie Armstrong. "I guess I'm the biggest fool here at this place, not wanting to leave her side. From the moment I left the Navy, walked off the boat and saw her, I've never been the same. I just can't be away. My kids told me I should go get some rest, but I woke up at 4 this morning with her on my mind. She's not opening her eyes anymore, but I think she knows I'm here" His booming voice echo's through the house. He pats her hand, his eyes well up, "I don't know how I'm going to make it with out her"

Room 17. 50 year old man dying of liver failure. He is a skeleton with a sheet covering him. Eyes sunk back, mouth open, eyes glazed over. Soft classic rock is playing in the background. He was a drummer for a band and his friends say he lived a rough life: drugs, alcohol, you name it. He's alone now. He can't let go, afraid of what awaits him. He had 40,000mg of morphine yesterday and is still not comfortable. Fighting demons we can't imagine.

Room 20. 70 year old woman dying of breast cancer. She's a big woman, Italian, still in her flower patterned night gown. Her three daughters are now all in town. Big women, with big hair, each a different bouffant style. Their loud boisterous voices and personalities seem to match their appearance. The youngest daughter tells me "When I arrived, Mama's spark came back, her color's so much better..." The middle one at the same time, "She's really plateaued don't you think, doesn't have that same rattle when she breathes..." While the oldest chimes is, "Mama's going to surprise us yet, why, her temp's down to 101 from 103" and then all three ask me, "What do you think, do you see the same improvements?" While all the facts they stated are true, I have to still remind them that she's dying. There loud chatter and banter with each other follow me out of the room.

People may think my job is boring- the outcome already known - Death. But each room is such a colorful story that I get to enter into briefly, how could it be boring!?

Dying at home

2007-10-15T16:09:00.000-05:00

Another one for the books. When I was on call this past weekend I was involved in an extubation of a younger guy; 23 years old and a gun shot wound in the back of his head. He'd been at our hospital for 3 weeks on a breathing machine, waiting to see if he'd become brain dead. This is a case you'd say, unfortunately he didn't progress to brain death. He was trapped- not brain dead, but in a persistent vegetative state. Enough damage had been done from the bullet, that he was guaranteed never to wake up. Ironically, his 14 year old cousin had died at our hospital 6 months earlier with a gun shot wound. Having watched the ordeal his cousin went though, our patient was very vocal to family and friends that he'd never want to be alive if it was hooked to machines.

After 3 weeks in the ICU, it was time for the family to honor his wishes and take out the breathing tube. Over 30 people assembled after church sunday to meet one last time with us and give the final okay. We extubated him a little later, and not surprisingly, he began to breath on his own. As healthy and young as he was, it became clear that it would be days before his body actually shut down. His fiance', with 2 kids at home, was adamant she wanted to take him home to care for him these last days. We reluctantly made arrangements for this, and things started getting messy.

Police began calling. Evidently, there was suspicion that a family member was involved with his shooting. In fact, the bullet was still lodged in his brain, and would need to be extracted at autopsy for evidence. There was worry that the family wanted to take him home to die, to avoid the autopsy. (Destroy the body to protect the family?) We even had to have a last minute meeting with our lawyers on the legality of sending him home. Then this patient's fiance' started asking questions about sperm donation, wondering if it was possible to somehow extract some sperm for later use. (The answer legally is no, because he can't give consent). Just when we finally had everything arranged, the hospice home team started to fuss. It was too late in the day, they said, to go to this fiancé's neighborhood to meet him on his transfer from the hospital. The nurses worried, they'd be the next gun shot victim in our hospital.

What can I say? Isn't helping people die at home supposed to be easier?

Evil

2007-10-08T16:07:00.000-05:00

Tell me if this isn't just evil.

We have a 50ish patient with ALS (Lou Gehrig's) disease. As his muscle's have weakened with the disease, he's been left unable to talk or move. He's a brilliant mind trapped in a body that doesn't work. His wife, however, is the one with the real problems. We learned soon after he was admitted to our hospital, having now lost the ability to swallow food, that his wife was abusive. She'd often leave him at home, alone, not able to call for help or even move.

But the worst thing happened not long ago. Upset for some reason, she started yelling at our patient. Telling him how he'd ruined her life and such. In fact, there was no point living any more. She grabbed a gun and shouted " I'm going to kill myself". I can imagine his eyes widened with horror, but he couldn't do a thing- couldn't grab a phone, or yell to stop her. She left his room and the next thing he heard was a gunshot. Then silence.

She then sneaked out of the house, so he'd not know that she really was alive. She left him in despair, thinking she lay in the next room dead, with no one to help. She didn't re-appear till the following day, with a sneer on her face for what she'd put him through.

I can't fathom that type of emotional pain that he's experienced. It's hard enough to cope with being trapped in a body that is loosing it's ability to work, let alone having the psychological torture he's had to endure.

He's moving to the hospice house tomorrow, with only days of life left, we'll try to ease his suffering the best we can.

Timing is everything

2007-09-04T16:05:00.000-05:00

An interesting labor day weekend, as I worked all three days. Yesterday was one of those, "can't believe this is happening" days.

I worked in the hospice house and was taking care of a 70ish g entleman who had just been admitted the night before. He had metastatic prostate cancer and had been deteriorating rapidly at home. The family all arrived in the morning, and were surprised to see how much closer to death he was. He wasn't opening his eyes or talking, he had that sound with each breath of a rattle of fluid stuck in his throat. His wife of 50 years was having the hardest time, saying things with a tinge of anger because of how quick this was all happening. I had spent time with the family talking about all that was happening, and let them know we were expecting him to go in hours to a day at most.

I was out working on other charts when a family member from this room came running up shouting, "My mom has just passed out, come quick" I entered the room to find the pt's wife slumped in a chair, looking very pale, having just come to. Everyone appropriately swooned over her. Her blood pressure was elevated at 220/100 and one of the nurses told her, "You need to go to the ER, with your blood pressure so high, you could have a stroke". The family started echoing this advice and all were a bit panicky.

I was standing by the husband's bed watching as everyone forgot about the him and hovered now by the wife. I glanced down at my patient, and noticed his breathing had changed, a long long pause and then a very shallow breath. He was dying, right then, and everyone had forgotten about him. They were all debating about taking the wife to the ER, and she kept shouting, "No, I want to stay here!" I finally interrupted, "Mrs B, I think you should stay, you should also take your husband's hand now, because it won't be long". Everyone's head's whipped around and had that wide-eyed look. A daughter looked at me, then at her father, "You mean he's dying?" I nodded my head and the swarm moved back around the patient's bed. The stress and emotions of having their mother just pass out, and now moments later having their father dying was too much. Loud wailing and sobs filled the room as I watched him take his last breath.

How ironic for his wife to have passed out, literally minutes before he died, as if his soul leaving somehow sapped some of hers away. And they had almost missed it. He almost slipped away with everyone in the room, and yet not one person's eye's on him. Maybe that's what he had wanted.

Prisoner of the home

2007-08-28T16:00:00.000-05:00

I've started home visits this month. A little different pace than working in the hospital. I like getting to come into people's space. Their homes tell so much about them. A little glimpse that most doctors don't get into their patient's lives.

One of my encounters yesterday stands out, not because of the appearance of the patient's home, but the appearance of the patient himself. He's had squamous cell carcinoma of his sinus for 2 years. The cancer has literally eaten away his face.

When you see him, he has something like a curtain hanging over his right cheek. Some pads are taped up to his eye brow, and then hang down over the area of destruction so you can't see. He's developed a nervous tick over these 2 years, his right hand taps the tape, while his hand conveniently covers the dressing. I assume it started whenever the first lesion appeared, kind of hiding it from people without them noticing. Now this habit is a full blown tick, he can't stop the motion.

I was amazed when the dressing came off. The perspective was something I've never seen. From below his eyebrow down to his lower lip is a large cavern. NO longer any eye, cheekbone, top lip. It's uneven and oozing, as if some creature just took a giant bite out of him. He wears dentures still to help him drink fluid (since his lip is gone). Thus peering down at him, I could see the top of the upper dentures; as he moved his jaw, they moved. The hole is the size of a grape fruit- his nose only half there. He can't take any solid food, and even fluid pours out of the right side, so that only a few ounces get in.

It must be hard for him on many levels. One, he's a prisoner of his house, to embarrassed to leave, even with the dressing, people would stare. He hasn't been out in over a year. The other hard thing is the visibility of the cancer. If there's a blessing in most cancers, it's that it's on the inside...so we don't see it's destruction. To have to feel, watch, and experience the eating away of your body must be torture.

Communication

2007-08-22T15:58:00.001-05:00

You never know what direction a palliative care consult may take. Our team got involved with a 40ish man with a rare condition. He had Berger's disease, which is a disease of blood vessels that can be very painful. In fact his fingertips had auto amputated- basically died- leaving just the nail sticking out by itself. Another problem with this disease can be forming clots. He came in the hospital needing surgery for some clots in the vessels in his legs and ended up having multiple strokes, leaving him in a coma state, unable to wake up, talk, etc. That's when we came on board.

What makes this story unique is the family. We had a family meeting and the patient's son and extended family decided to move to comfort measures- meaning we'd stop all the extra meds we were using to prolong this poor man's life, and let him die naturally. They all talked about how miserable he'd been with this berger's disease- always in pain, and getting worse and worse. They new he'd never recover from these massive strokes, so the best thing was to make him comfortable.

As extraordinary as it might seem, this same son attempted suicide last night at 8 o'clock, and unbeknownst to him, his father died an hour later. Just as his father was leaving our care, the son was being admitted to the very same ICU unit his father was leaving. The ICU team and even the psychiatrist that came to see the son all avoided the news about his father...who wants to tell a suicidal person someone they love just died? That's when I got a page.

"We were wondering if you'd be the one to tell him his dad died...after all you did meet him at the family meeting, and no one else wants to do it"

I guess when you're in a specialty that specialized in communication, people want you to do their dirty work. So at 3 in the afternoon, 18 hours after his dad died, I knocked on his glass ICU door, took a deep breath and jumped in. He actually took it okay, was upset and sad, but had expected it... I think he was just happy someone told him. It might seem unwise to tell a suicidal person about their father's death, but better now while he's safe, being watched like a hawk then finding out later on his own.

The Narrative

2007-08-18T15:54:00.000-05:00

Narrative in medicine is a huge part of the human struggle with disease. Another way to say this is, our stories help us cope.

A 70 ish hardworking farmer had a stroke at home and collapsed hitting his head and causing a bleed in his brain. He was rushed to our hospital and placed on life support. The neuro intensivist spent days trying to fix him. He had a drain from his brain to help relieve the pressure, he was on medicines and fluids to correct any imbalances in his electrolytes. Our team came on board to support the family and honor his wishes. They were giving him time to wake up, as sometimes can happen with stokes in the few days after the event. They spoke of his humor, and daily laughter. They said he always told them if he couldn't laugh and be at home he'd rather die. It became clear that the best case scenario would be him living in a skilled hospital on an breathing machine forever. The family made the hard decision to take the breathing tube out, which would mean he would pass away.

The day this was decided, I was in charge of the process. The family didn't want to be in the room when we took the tube out. He was breathing well enough, we assumed he'd probably do okay for a day or two off the machine. The family went to lunch and we got everything ready and pulled out the tube and the drain in the brain. I watched him like a hawk, looking for signs that he was struggling, so I could give medicine to take away the struggle. In minutes from the tube coming out he was making changes that indicated he would not last days, but likely die in minutes. I panicked- THE FAMILY WAS AT LUNCH!

I quickly began paging their names overhead in the hospital, and calling cell phone numbers. Doing this I kept peeking at him in his room, watching his breathing space further apart. Finally I spotted the family down the hall, seeing in their movements they had no idea of the urgency to get here. I met them, and calmly tried to prepare them for the sudden changes, that he was close to death. They now rushed into the room. I could see he had already died. They hovered around him, stroking his face and hands all saying their I love you's. His wife of 60 years bent close to his ear and whispered to him. I knew this was important so I just waited several minutes and then gently said I needed to check him.

I was sure they all knew he had died, but as I put my stethoscope to his chest to confirm it, and then solemnly nodded that he was gone, a new burst of tears issued forth. They hadn't known. Then in the moments of tears and hugs I heard a daughter say, "At least we were here by his side when he died, he needed us to let go, it turned out so perfectly" I had been thinking how unfortunate it was they had missed it, but now I saw they believed they had made it. I kept my mouth shut with the correction and heard other members now voice similar sentiments on the timing.

I realized now that this narrative would be a part of this family's life long story. And the story of being there, saying goodbye and ushering him into the afterlife was more crucial than the actual facts. Some may say truth is more important, but for them, the perception offers more healing.

Chance to say goodbye?

2007-08-11T15:51:00.001-05:00

We had a very messy family situation on Friday. A 40 something man with HIV, Hep C causing liver failure and lymphoma in his brain had come into the hospital very sick. For years he's told his family that he wouldn't want to be kept alive on machines. He was so sick when he arrived that the ICU team needed to decide quickly whether to intubate him or let him die comfortably. The patient was too confused to give and answer, and the plan was to honor his previous wishes and not put him on machines. However, his youngest son, 17 was panicking and demanded his dad be intubated. It's hard in those situations to know what to do. Usually it's better to intubate and then withdraw care later, as you can't really change once he dies.

We got involved the next day to help the family sort out what to do, now that their dad was where he never wanted to be- living on machines. I went to the ICU to see the patient first. He was the color of a sunflower, his skin full of fluid making him puffy. His feet and hands were already turning blue, like they do when someone's dying. It was clear to me after seeing him, that he was going to die despite all the medical intervention.

We sat down with the family- an ex wife, 3 kids with from different moms, and family friends. We talked about him and his wishes and how sick he was. The family finally grasped the situation and one daughter said, "I guess the only question then is when do we stop the machines, because we also don't know what to do about his other son..." AT this moment she chokes up and everyone in the circle starts crying more. We ask if the other son is out of town? "No, he's here at the hospital" We learn that this 23 year old son was in a car accident the night before, and broke his neck, and looks like he might be paralyzed. He was in the neuro ICU and didn't know his dad was even at our hospital. His mom, different from the ex we were talking to, had told everyone to keep the news from him, as he would be too stressed. Although he'd been asking about his dad since the accident, everyone was lying to him.

We were of course aghast at this. The immediate question was should they tell him about his dad? And the answer was an emphatic YES. The long term ramifications of being lied to about someone dying can be devastating. While done out of protection, the family wasn't thinking about days from now when they'd have to tell the truth. The second question was equally important, could we arrange a way for the son to say goodbye to his dad if possible? I went to work calling the neurosurgeons and trauma surgeons for their input. They all cleared him to go by hospital bed. The hospital is pretty big, so he'd actually be wheeled from one building to another. The ICU room where his father was dying was big enough to accommodate another bed, however because of the son's neck injury he wouldn't be able to turn his head to see his dad. We'd need to lift the head of the bed to almost sitting for him to say goodbye.

All the planning looks to be in vain. We talked with the son's mom, frazzled by having a son who is likely a paraplegic and an ex husband dying on a ventilator, all at the same time. She is angry at the world right now and has decided she won't tell her son about his father. She's in protection mode, and to her, having him even just be told that his father was dying could make him give up on his own recovery. She says she'll think about it, but I believe that while "thinking" the dad will probably die.

This is the hard part about all of medicine. We can give information and have opinions, but ultimately people make their own choices. In this case, I'm glad I won't be around to be a part of the the truth telling later. I can only guess at the son's sense of betrayal and regret for a moment that was possible, but gone forever.

Visitors

2007-08-03T15:50:00.000-05:00

There are unexplainable things that happen near death. Here's a story from this past week. A 40ish female had been in hospice dying of lung cancer. I've had a chance to talk with her everyday, and watch the slow process of dying. She made it clear in the beginning that she didn't believe in God, and thought death was either final or perhaps we'd be reincarnated...but she definitely didn't ascribe to any heavenly afterlife beliefs.

She started making some rapid changes indicating that things were getting closer. Hadn't had any fluids in days, was mostly sleeping, having spells when her breathing would stop for 20 secs. I went in one morning and sat on her bed, as was custom. "How are you doing today Sally?"

With all the energy she had she'd half lift her eyes to see me and then close them to talk. "I'm doing okay" She said weakly. I just waited in silence for her to talk. She started up, "However, there's this man that keeps coming in here." I was surprised, "oh really?" because no one else had been in to see her that day. She continued with a frown, "Yes, he keeps asking me to come with him, to come to the other side" She didn't see my eyes get big. She took a break and then went on, "I just wish he'd answer all the questions I have". "Who sally?" I asked still wondering about this man that was visiting her. Then she really shocked me when she said, "The Lord".

How to explain this medically? I think there is no way. Sally died shortly after that, perhaps finally deciding to go with that man to a better place.

Oscar

2007-07-26T15:48:00.000-05:00

Did anyone hear about Oscar the cat on NPR this am?
LINK: (http://www.npr.org/templates/story/story.php?storyId=12249387)

There's an article in the New England Journal of Medicine that came out today about this cat with uncanny abilities. He has lived since a kitten in the a nursing home in Rhode Island. He interacts with the residents and staff, but when he enters a room and jumps up on the bed to sleep with an elderly patient, the nurses usually rush to a phone to call family in. That's because Oscar somehow senses when people are close to death- usually within hours the nursing home patient dies. He's been at 25 deaths, and is viewed as one the most accurate predictors of someone being about ready to die. Doctors aren't even that good- we'll get down to 24-48 hours, but rarely to the 3-4 hour mark. It makes you wonder what he senses? They say he kind of sniffs the air as he wanders in and out of rooms. Is there a smell of dying? If so I haven't whiffed it yet!!!

Works Vs Faith

2007-07-24T15:46:00.001-05:00

The chaplain that works at the House told me when I started that he can always tell when patients are brought up under a works based or faith based belief system. I started paying attention to this myself, and noticed the trend. Often when patients think that what happens to them after they breathe their last breath is based on what they've DONE in life, hey start getting nervous. They question if it was enough, they have bad dreams, they get agitated when awake and often fight dying right to the last moment. It's hard to feel secure if the only thing that counts was your actions in life. In contrast, those who believe they are loved despite what they've done are always calm. They sleep peacefully, spend time sharing memories instead of questioning the past, and they die gently. It seems oversimplified, but the pattern is present everyday that I work.

The Cruise

2007-07-15T15:42:00.000-05:00

This is not the way you'd like the end to be. A sweet elderly man with cancer had been living with his wife at home. She managed to arrange for him to be admitted to a rehab facility. This in itself is silly- because rehabs are for people who have things you rehab from- like car accidents, strokes, heart attacks. When cancer is riveting your body, doing physical therapy 3 hours a day isn't going to help you get better.

The real reason for the rehab soon was evident- because the day she dropped her dying husband off, she left town for a cruise with friends. Didn't call anyone while she was gone, never checked in with her husband. It was if she skipped town. The poor man was heart broken, like an old dog someone leaves at the pound. He declined very rapidly in the rehab place. The rest of the family had to step up to decide what to do next. That's when they opted for the "house". I met him when he arrived. He doesn't have long to go, but this sudden abandonment is weighing on his mind. Though he hasn't said a word, he's restless and sits, leaning forward with his head in his hands. Occasionally he slaps his fist against his other hand. He's struggling, and fighting his thoughts. He's angry and devastated, and dying with things unsaid.

The wife is due back in town today. The family wonders if she'll even try to find him. It might be good if she does come, perhaps giving him a way to let go of his anger. It's his only hope to go peacefully.

Unquiet mind

2007-07-11T16:06:00.000-05:00

I've never been so close to an unraveling human brain. A 70ish man had collapsed after having a bleed in his brain. He'd had other complications in the hospital including a seizure and respiratory failure. We met him when he was already on the breathing machine. Unfortunately, even with no medicines to make him sleepy, he was still not responding, even when we caused him pain. This is a very ominous sign.

This man had a wife and a severely mentally challenged son. His wife and son would come visit every day at the same time. The son was in his 30s, with debilities in seeing and cognition. He was a gifted pianist and always had headphones on listening to music to keep him calm.

A helpful thing in this case, was that the patient had an advance directive that spelled out exactly what he'd want and not want in this situation. It was explicit that he'd not want to be on the breathing machine, or have dialysis or even tube feedings. Our team had begun the slow process of helping support his wife and walking her through the process of letting go.

Unlike any other person I'd ever met, his wife had this unnatural ability to control our meetings by not letting anyone else talk. She'd open her mouth and talk non stop for an hour. It was if she couldn't stop her brain. You could tell she didn't trust herself, so if she kept talking, she'd not have to hear the bad news we were telling her, and she'd not have to make any decisions on what to do next.

My last day I met with her for 2 1/2 hours. I was just trying to clarify her wishes, to either keep him on the machines even though he never wanted it or to change our approach. I remember listening to her talk, fascinated by her thought process. I didn't realize then, it really was unwinding. Think of someone on the brink of insanity, with thoughts popping in their mind, but the filter gone. She seemed to not be able to control the direction of what she was saying, and actually realized she was on the cliff of insanity. At one point I had been able to get in a sentence about her husband and she panicked. "Don't say another word" she half screamed as she grabbed my hands. "Okay" I said and was shocked as she reached out and literally grabbed my mouth to close it. "I told you, not another word...oh look what you're making me do, I didn't want to think about this today, I can't do this" Her eyes looked frantic, as she kept talking...it was as if I, by speaking, was some how stealing what little control she had on her brain. I stepped back worried if I did utter another sound she'd really attack me.

She managed to get it back together and we left the meeting calmly after another hour. Amazingly, she decided to withdraw care a few days later. Then, her fragile mind did collapse- she had a true psychotic break and is currently admitted to a psychiatric ward.

How strange to witness a brain unraveling. All the safety mechanisms gone, verbally I was witnessed what it was like to be in her brain as it spun out of control... In someways I'm lucky all she did was grab my mouth and hands, you can never predict what truly psychotic people may do!

Prognostication

2007-07-08T15:41:00.000-05:00

There's a word in palliative medicine we talked about this 1st week of orientation called prognostication. It's especially important in this field. Doctor's make prognoses all the time- we tell people in clinic when we expect their infection will respond to antibiotic treatment, or when their rash will leave. We guess when broken bones will heal and when pain from a muscle injury should dissipate. However, when it comes to the time of death, doctor's are a bit more nervous. The thing is, just like all other things in life- most people WANT to know what we think. Knowing helps with the preparation, and with coping. It helps not just the patient, but the family too. The problem is historically doctors haven't done a good job of giving our prognosis on time of death. This has to do with several things- from not wanting to communicate bad news, to not wanting to be wrong when guessing.

In my field of medicine, when everyday I am seeing people who are actively dying- it's important to become good at prognostication. It will be one of many uncomfortable things I'll do this year. I'm to continually work on getting more accurate in predicting the time of people's death. The deep question then becomes 'is there such thing as becoming too accurate?' Hypothetically if doctor's could develop a system with computers and genetics, etc that had no error rate- 100% correct, all the time, at telling people when they would die - - - should we?

Eve of fellowship

2007-07-01T15:39:00.001-05:00

Well, I guess it's time to be a little more regular at this- And perfect timing, as I start my new training tomorrow. That's right, I am officially done with residency. I survived what most would say are the roughest years of a doctor's career. Does it feel good to be done? Absolutely. In fact, as I am at the eve of my next life change, I recognize a different feeling within. Instead of the typical anxious, dreadful, excitement that accompanies life changes (I.E. high school, college, med school, residency). I finally only have excitement. The anxiety and dread of something new and challenging is gone.

That's for 1 huge reason- I'm going to be doing something I love. My fellowship is in palliative medicine, so I begin a career helping people and families through the process of suffering and death. I'm careful when I talk to people about this upcoming year- I try not to say "I'm looking forward to a good year", because that seems kind of glib. But I do say, "I'm looking forward to a meaningful year". And perhaps because I am someone who relishes meaning, that's why I'm truly excited about this start.

So, on to a life of endings- but a huge new beginning for me -

Nature and Nurture

2007-05-06T15:37:00.000-05:00

I love psychology - but it's frightening what we parents can DO to those in our charge! Last week I got to observe a counseling session. The session itself was pretty boring, but the background was fascinating. This 50 year old woman was the eldest child in her family. When she was 5 or 6 her parents realized that her 4 year old sister was mentally challenged. Not knowing how to be "fair" to both girls, they decided to just treat them both as if they were mentally handicapped!

For her whole life, this intelligent woman had all of her decisions made for her as if she was incapable of making choices. A smart woman, avid reader, good at math, etc -she is socially a mess. She's 50 and has lived 20 years in the same apartment- that was after moving from her parents house. She has never dated, EVER. Why? because her parents told her not too. In the session it was fascinating to see that she still can't make decisions, she has been trained to ask her mom and dad (now in their 70's). She has no depth whatsoever, was never trained to THINK.

2 lessons then: 1)Just because you are given the capability, I.E. "IQ", if the right environmental cues aren't available you can still be "dumb"ed down. 2)Seeing the consequences, I don't recommend this form of "fairness" in parenting!

First Intubation

2007-04-20T15:32:00.000-05:00

Another fun first. Some would say it’s a little late for this first, as I am 2 months shy of finishing residency.

I was doing an ER shift last Friday the 13th. I had heard the ambulance tuner go off, and minutes later the paramedics came rushing in with a woman in her 50’s. I heard them saying she’d been found on her couch, unresponsive. The ER doc looked at her and then said loudly, “this would be a good one for a resident to intubate”

It was the moment of truth. I could easily stay where I was and pretend I didn’t hear his statement. Surely someone else would love to practice putting a small tube down a dying woman’s airway? The thing was I had done precisely this for the last 3 years; let others practice this last scary skill of medicine. I knew it was my time. I took a deep breath and put on my confidant actor self.

“Dr. Wood, I’d like the practice” I said as I s tepped into the chaotic room with the code in process.

He handed me the laryngoscope and tube and said “Go for it” , then asked, “how many of these have you done?”

I think the 8 nurses busy putting in IV’s, drawing blood and bagging the patient all stopped at once to hear my response. “Uh, none, this is my first.” I definitely heard some chuckles.

“When you’re ready doctor” the nurse to my left said. I said okay and they took off the mask that had been pushing air into her. I moved her tongue, but the blade and light in and lifted her chin towards the ceiling. I then hoped the tiny black hole I saw deep down her throat was her wind pipe/trachea. I grabbed the tube and I heard someone say “It’s a good sign, she has the one eyed wink” To see better my left eye was scrunched together tightly. With a little fumbling with the tube, I finally slid it in and prayed I hadn’t picked the wrong hole leading to the stomach. A few moments later all the confirmatory signs showed I was in. “Great job” I heard with a small applause.

It wasn’t until I was out of the room I started shaking. Now I'm a doctor, right. Intubating is some understood right of passage of residency. And now I can’t think of any other milestones left to cross!

Happiness?

2007-03-28T15:30:00.000-05:00

I read an interesting article about happiness this week. Ever thought about what happiness is? This article talked about it being more satisfaction than pleasure. I think society tends to pursue pleasure assuming it will make them happy- when really it's more about being satisfied. They did this interesting survey- what would you pick--- You could make $50,000 dollars a year and everyone else you know would make $25,000. OR you could make $100,000 dollars a year and everyone else would make $200,000. What's your choice?

Most people in the survey chose to make less money- to make $50,000. Because to them it was more important to be better off than their neighbors than to actually have more income. Interesting huh? If only we could learn to be satisfied with what we have, without looking outward for a sense of meaning...I think that is when real happiness and/ or even contentedness occurs.

Denial

2007-03-27T15:27:00.000-05:00

In psychology we learn about all of the ways people cope - sublimation, rationalization, reaction formation, etc. I think the biggest one I see in clinic is denial.

I am working with a surgeon this month who does a lot of breast biopsies and mastectomies. He'd shown me a mammogram earlier of a woman with certain cancer- the shaggy white edges of the dense mass on the film was ugly looking, as most cancer is. He purposely scheduled her biopsy for a day I was in clinic. The woman was a spunky young 73 year old who had never had surgery and was on no medications. She had also missed several years of mamm's because she felt so healthy.

We used the US machine to find the big mass and then using a fancy biopsy gun took several small pieces that looked like 1/2 inch long spaghetti noodles. Unlike breast tissue, these noodles of tissue where very hard and firm like cancer. The surgeon said nonchalantly "well, we'll let you know in a few days, but this is undoubtedly cancer"

The woman didn't even blink an eye, and even smiled when she said "oh, now doctor, you don't know that! I'm trusting in THE LORD, I have a lot of people praying for me, it's not cancer".

She looked at me for validation, but I couldn't give it. This was cancer and she was displaying denial. It's not like we were saying "we'll let you know IF...but we'll let you know what KIND" I smiled back trying to convey the seriousness of the world she was getting ready to enter. I just hope her absolute confidence in God won't shatter when we tell her the pathology results... because, the results came back today, and it is invasive ductal cancer.

Intro to Palliative Medicine

2006-10-30T15:15:00.001-06:00

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

2006-10-17T15:13:00.000-05:00

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

2006-09-20T15:11:00.000-05:00

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

2006-08-20T15:06:00.002-05:00

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

2006-07-23T15:02:00.001-05:00

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

2006-07-22T15:45:00.000-05:00

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

2006-07-18T14:58:00.000-05:00

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"

2006-06-19T14:54:00.000-05:00

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

2006-06-10T14:50:00.000-05:00

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

2006-05-31T14:46:00.002-05:00

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

2006-05-20T14:43:00.000-05:00

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

2006-05-06T14:41:00.000-05:00

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

2006-04-20T14:35:00.003-05:00

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

2006-04-10T14:33:00.000-05:00

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

2006-04-04T14:26:00.000-05:00

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

2006-03-27T13:23:00.000-06:00

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

2006-03-22T20:40:00.000-06:00

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

2006-03-20T20:37:00.001-06:00

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

2006-03-15T20:34:00.001-06:00

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

2006-03-12T20:28:00.000-06:00

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

2006-03-07T20:23:00.001-06:00

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

2006-03-05T20:21:00.000-06:00

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

2006-03-02T20:19:00.001-06:00

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

2006-03-01T20:17:00.000-06:00

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

2006-02-26T20:13:00.001-06:00

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

2006-02-20T20:11:00.001-06:00

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

2006-02-18T20:09:00.000-06:00

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

2006-02-15T20:05:00.001-06:00

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

2006-02-12T20:01:00.000-06:00

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

2006-02-08T16:19:00.000-06:00

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

2006-02-06T16:15:00.000-06:00

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

2006-02-02T16:12:00.001-06:00

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

2006-01-28T16:08:00.001-06:00

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

2006-01-25T16:03:00.000-06:00

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

2006-01-11T15:57:00.001-06:00

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.