Unintended closure

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

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

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

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

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

Abuse

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

Things to do

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

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

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

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

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

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

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

"Goodbye Doc"

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

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

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

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

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

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

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

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

Cynicism in the ER

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

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

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

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

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

Pain vs Harm

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

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

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

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

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

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

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

OB stories

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

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

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

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

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

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

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

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

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

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