Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, June 09, 2004
    Twenty-One Gun Salute

    My secretary brought in a tiny black-and-white TV today and I've been watching the funeral procession all afternoon. It is remarkable to see how many people turned out to see Reagan, both in Simi Valley at the library and now in Washington.

    I'm getting eerie echoes of the past here; I was born four days after Kennedy's assassination, and my parents have often told me of the weekend my mother spent in the hospital prior to my birth (she was at bedrest for pre-eclampsia). My father managed to bring in a small TV and get it hooked up. My mother said the nurses were in and out of her room constantly to watch the news (this was well before it was standard procedure to have televisions in hospital rooms). The Kennedy funeral was the blueprint for the Reagan funeral arrangements, so it gives me an idea of what my parents saw that weekend.

    I'd also like to leave you with this quote:

    [Reagan] was put on earth to do two things: kick butt and chew gum, and he ran out of gum around 1962.

    That pretty much sums it up.

    Thursday, June 03, 2004
    Well, That Was Fast

    The gentleman I told you about yesterday died at five o'clock this morning.

    It's probably the best way it could have happened.

    In This Bridal Season...

    I can't do better than to direct you to this weblog. It's written by a caterer who calls herself a Food Whore and it's hysterical. The descriptions of the weddings are priceless, particularly this one ("I Won't Even Get Out of Bed For $5").
    (via Very Good Cooking)

    Wednesday, June 02, 2004
    You Never Know

    So I've got another dying patient. We seem to go through cycles of this kind of thing (what V. calls "the thinning of the herd"). This fellow is in his nineties, has severe heart failure and kidney problems, and peripheral vascular disease (translation: his foot is turning blue due to lack of blood). He has lived at home with a caretaker and close attention from his daughter, but in recent months has become weaker, had multiple visits to the hospital, and has had two episodes of pneumonia in the last year. This time when he went to the nursing home for rehab he was too weak to participate in the therapy sessions, and he's stayed there ever since, more or less bedridden. The ulcer developed two weeks ago. The vascular studies I ordered confirmed that he needed surgery (you know it's not good when the report says "critical ischemia").

    So I reviewed the report and thought: OK. This man would likely not survive surgery. He'd never consent to an amputation, and a vascular bypass on his leg would require an angiogram to see if he had operable disease; the dye used in the angiogram would likely wipe out his kidneys (which are hanging by a thread). After discussing all this with his daughter, she agreed with me and I referred him to hospice care. We're going to focus on pain control and comfort care.

    When cases like this stick in your head, it's usually not the disease process that you're thinking of, it's the patient. So it is here. The case I just described is not unusual for internal medicine - a bundle of disease processes, each playing off against the other, forcing the doctor to choose a treatment strategy. Not that this isn't interesting - it has a lot to do with why I enjoy my job - but I'm remembering something else.

    I picked this patient up about two years ago when his previous doctor left the group. His chart was the size of the phone book, and I was too busy keeping up with his meds and his various illnesses to go much into his past history. About two months ago, with the worsening of his illness, the patient became more depressed and I decided to get a psych consultation to see if medication would help. When I saw the consult note, this is what I read:

    Patient is a Holocaust survivor. His first family (wife and children) died in the camps. After the war, patient remarried. His daughter Ms. X [who is the one who stays in touch with me] is a product of his second marriage.

    Holy crap. I didn't know.

    I keep thinking of this man who fought so hard to survive, whose body is now betraying him and falling apart. He has his daughter, and his caregiver, so I suppose things could be worse; but I can't do much now except ensure him a comfortable death.

    I will do that. I promised his daughter.

    Go Ray Bradbury

    In 1953 Ray Bradbury wrote a sci-fi classic called Fahrenheit 451. Michael Moore "borrowed" this title for his documentary, Fahrenheit 9/11. How does Bradbury feel about this?

    He's not happy.

    (via Tim Blair)

    Tuesday, June 01, 2004
    Old Guard Vs. New Guard

    A couple weeks ago The Firm held one of its quarterly partners' meetings. These meetings are generally long and dull, as I suppose the meetings of most businesses are. They are enlivened in the first half hour by the serving of dinner ("Pollo Loco again?")and by the chance to chat with one's fellow MDs. The Firm is pretty big, and our members are spread among four or five different offices, so in many cases we only get the chance to talk in person at one of these meetings.

    At this particular meeting an issue came up which illustrated - to me, anyway - the changes taking place in medical culture. The topic at hand was partnership. To be more specific, a doctor who has been with us for two years (the traditional length of time before a member qualifies) was under discussion for possible partnership. She works hard, is respected by all the MD's in her office, and is committed to the group. The problem is, she works part-time (though more than 50%) and no one in the history of The Firm has ever been admitted to partnership without working full-time for at least two years. We have several doctors who work part-time, mind you, but all of them worked full-time for years before switching. Thus the debate: could anyone not working full-time even be considered for partnership? Forget prorating benefits, forget her skills or commitment. Would The Firm even be willing to consider a part-timer as a partner?

    Three of the senior docs (all male) immediately voted no. They gave various reasons but they all boiled down to a variant on "Can we rely on anyone who isn't willing to commit fully to the group? Do you realize this means that someone working part-time might then qualify to be a member of the board of directors?" (because any partner can run for the board).

    You could feel the atmosphere change in the room. Every woman sat a little straighter. All the part-time doctors in the group are female, and they all have kids - this is of course their whole rationale behind working part-time. Hands started going up. "How are we supposed to attract women physicians if we aren't willing to take part-time MDs as partners? You know the demand for female physicians these days, and let's face it, most of them are going to have kids. We've got to do this."

    I'll spare you the rest of the debate. Suffice to say that the Old Guard was voted down in a landslide. They looked somewhat taken aback but accepted the situation with good grace. There are lots of details still to be thrashed out, but it looks as if the old mindset of "Forget about your family, Medicine comes first" is changing.

    The following week I was chatting with V. and told her about the events of the partners' meeting (she'd missed it, being on vacation). Specifically, I told her about Dr. X, one of the old-timers who'd led the Old Guard in arguing against granting part-time docs partnership. Her response was succinct:

    "Who raised his kids?"

    Monday, May 24, 2004
    The Treatment Is Worse Than the Disease

    Man sues guru over raw frog cure

    Friday, May 21, 2004
    The Code

    I was sitting in my office one day last week writing referrals, when I suddenly heard words you don't normally hear in a doctor's office: "Somebody get the oxygen. And where's the crash cart?"

    Driven by curiosity, I leapt up and headed down the hall toward a tight knot of ancillary staff clustered around the door to an exam room, their stares focused on an elderly woman slumping in her wheelchair. Actually, "slumping" is an understatement; she looked like she was trying to pour right out onto the floor. J, my partner, was trying to get her out of the chair with help from one of the nurses: "She isn't breathing," I overheard. I grabbed the phone and called 911 (I've only had to do this three or four times in the course of my eight years here, and it always makes me feel somewhat phony, like I'm an actor on ER).

    "What's the patient's age?" asked the operator.
    "Uh, she looks to be in her eighties." ("Ninety-four," prompted her relative, standing in the hallway looking freaked out.) "Strike that, she's ninety-four."
    "Does she have a pulse?"
    "No pulse." ("She has a pulse, she's just not breathing!" yelled J.)
    "Sorry, yes, she has a pulse but she's in respiratory arrest," I stammered.
    "And you're a health care provider?" (Was it paranoia, or did I hear a note of incredulity in her voice?)
    "Yes, but I'm not the patient's provider. Her provider is in there with her on the floor," I fired back.
    "Okay, fine, the paramedics will be there shortly."

    I hung up with relief, snagged a radiology tech student and assigned her to go downstairs to direct the paramedics to us when they arrived. Then I joined J on the floor. By this time the oxygen and crash cart were in the room. I uncoiled the nasal tubing for the oxygen and passed it to him, then grabbed her arm and felt for a pulse. The patient's eyes were open and staring at the ceiling - at first glance I was convinced she was dead - but the pulse was nice, regular and strong.

    "Can you find any Narcan?" asked J. The patient was on pain meds for a fracture, and his theory was that she might be narcotized and therefore not breathing. I fumbled around looking for the drug, then gave up long enough to grab the bag-and-mask mechanism off the cart and toss it to him so that he could ventilate her. Within seconds her previously open eyes started to blink and focus. By the time I found the Narcan and got it into the syringe, she was doing well enough that we didn't need to use it.

    I heaved myself up off the floor and listened to the distant siren. The patient's niece was sniffling into a Kleenex. I asked her gently, "Do you know if she was using more pain meds than usual?" The answer was no. She'd felt unwell, the family had brought her for evaluation and then she passed out. When elderly people in wheelchairs drop their pressure and pass out, it's usually bad news. The chair holds them upright and they can't get flat, which means the brain is being deprived of oxygen since it isn't being perfused with blood (that's why people faint in the first place. It's a safety mechanism to get blood to the brain when your pressure drops). If the person cannot be placed in a supine (horizontal) position, they may develop a watershed stroke due to decreased perfusion in the brain. In this case, she was densely unconscious to the point that she wasn't breathing. The good news is that if you can get them flat and ventilate, they'll wake up as soon as blood gets to the brain, as happened here.

    That's really the end of the story; the paramedics showed up, loaded the patient onto a stretcher and took her across the street to the hospital. We later found out that her sodium was low, but that still doesn't explain why she reacted the way she did. We got our reminder that day that it's much easier to manage emergencies in the hospital than it is in the outpatient setting, even with a crash cart and oxygen.

    Confound It, Ernie, Where Do You Find This Stuff?

    My milkshake bringeth all ye gentlefolk to the yard, and they're like,
    verily, it's better than thine...

    Oh and while we're on the subject of rap: "Hassle the Hoff" is coming out with his first album, produced by Ice-T. This oughta be the most exciting album since Pat Boone went heavy metal.

    Thursday, May 20, 2004
    Where Have You Been?

    Via Mental Office Girl, here's a map of the places I've visited:

    create your own visited country map

    Sunday, May 16, 2004

    Have you ever been in a library and seen one of those cool posters? The ones showing a celebrity with a book, and the caption "READ"? I've often wondered if they were for sale to the general public...

    Well, they are. The American Library Association sells them online. They've got everyone from Alec Baldwin to Shaquille O'Neal to Weird Al Yankovic (pictured with A Brief History of Time). Might be the perfect graduation gift for a friend's kid.