Monday, May 28, 2012

Bad news

Breaking bad news to a patient is an experience unlike any other.

It's a necessary part of the job.  Remember - this is internal medicine.  There aren't many fairytale endings here.  It's generally a one-way street that eventually culminates in death.  Feeling chipper today?  Then don't read on.

It sure feels like I blog a lot about this kinda stuff - probably because I do.  I'm really not a pessimistic person by nature - a realist, yes - but not a pessimist.  I'm trying to portray a realistic picture of the work of an internist, which by now you can probably tell isn't full of sunshine and roses.  And yet I still enjoy my work tremendously.  There's something about caring for people in their state of poor health that brings me satisfaction.  But lest you think I am altruism personified, you should also know that I do enjoy the perks of being a doctor.  Recall that I am incredibly human and enjoy the same things that you do.

Back to the topic at hand - bad news.  Part of being an internist is delivering bad news.  And I mean bad news. 

Take Mr H, for example.  He's a 45 year old M who came to the ED this week because of swelling in his legs and abdomen.  He has a history of hypertension but is otherwise pretty healthy.  I can tell right away that he is a bit socially awkward - he tells me he was diagnosed with Asperger's in childhood.  He's incredibly nice and likes to talk.  He lives alone and has a full-time job as a security guard.  He smiles a lot and seems happy with his life.

Before I went to see him for the first time on the medical ward, I looked through his chart.  The ED physician notes bilateral lower extremity swelling, protuberant abdomen that is tense, but nontender.  There is a significant amount of recent weight loss.  He has a notable microcytic anemia - commonly seen in slow gastrointestinal bleeding.  CT scan of the abdomen and pelvis was ordered.  I pull up the scan and on the very first image I see an enlarged liver that is chalk full of metastatic lesions.  There's a large mass in the transverse colon.  Within 2 minutes of starting my chart review I had essentially made the diagnosis of metastatic colon cancer.  Damn. 

With this fatal information in hand, I went to see Mr. H.  It was late afternoon and the sun was going down.  He was alone in his hospital room with the blinds down and the lights off.  The sunlight that made it through the curtain filled the room with a dim, dull yellow color.  I offered to turn the lights on and open the blinds, but he said he had always preferred enclosed, dark places.  Ok, whatever you like.  I'm about to ruin the rest of your life, so you should be as comfortable as you can be. 

He sits up on the side of the bed as I pull up a chair.  It usually isn't a good sign when your doctor pulls up a chair - either you've lucked out and he's got incredible bedside manner, or you're about to get some shitty news.  It's kinda like the casino.  Either you just hit the jackpot or you lost it all. 

I try to keep the chit-chat to a minimum before I break bad news.  There's nothing worse than going from a chipper banter back and forth about something insignificant to telling someone they have a fatal disease.  So I try and avoid that.  But I try not look like the grim reaper either - I've learned that puts off an air of mistrust from the get-go.  I try to take the middle road of being very professional, but not too rigid as to foster mistrust.  If I don't have a patient's trust within two minutes, the conversation generally doesn't go well.

I shake his hand, sit down, and introduce myself.  I ask the usual questions about how he ended up in the ED.  He talks quickly and nervously and doesn't like to make a lot of eye contact.  He smiles and jokes about his abdomen getting bigger - says he's been trying to lose weight and it's coming off his face and arms, but his gut just gets bigger.   

As he talks, I see his mouth moving but I'm not hearing much of what he is saying.  I already know the diagnosis.  So I let him go on until his words have exhausted themselves, nodding as if I'm listening intently.  In the back of my mind, I'm wondering how he is going to take the bad news.  I can see the pain and suffering that he's about to go through.  His days are numbered - this terrible disease will eventually kill him in some horribly unpleasant manner.  Yet I continue to smile and listen to him talk.  For a moment I feel like a complete charlatan, pretending to not know what is going on while listening to him talk. 

The strange part about breaking bad news is that I'm not afraid of doing it.  And to be honest, I really don't mind doing it, either.  It sounds strange as I type that, but it's the truth.  I don't enjoy it, but I'm not averse to it.  Some of that is probably selfish - there's nothing that makes you appreciate what you have until you see someone who is about to die.  There's something very sacred in that moment.  All my first world problems disappear and I think about the things that are really important to me.  I drive home with a new resolve to be a better person and appreciate the precious time I have on this earth. 

Unfortunately that profound effect only lasts for a few days.  I'm disgusted at my own ability to remember these moments.  That strong desire that caused me to reevaluate my life the night before instantly flees at the first yelling match between by young kids.  You'd think after having hundreds of these moments that the feeling would just stick.  But it doesn't.  Don't forget - I'm incredibly human.

Back to Mr. H.  His words exhaust themselves and he sits silent, waiting for my next question.  Instead of a question, however, he's going to get some bad news.  Some really bad news.  I've learned to be direct in these conversations.  If you talk too much, patients don't understand.  And once you say the word cancer, it doesn't really matter what you say, because they're not listening.  I take a deep breath and begin.

"Mr. H, I know why your belly and legs are swollen and why you have been losing weight." 

"Ok..." he says, sensing that the conversation was changing for the worse.  His eyes are now fixed on mine and his nervous fidgeting has stopped completely.  He looks scared.

"There's no easy way to say this.  I'm have some very bad news.  You have cancer."  I got goosebumps over my entire body as I said it. 

It's always interesting to see how people respond when confronted with bad news.  Everyone reacts differently.  Mr. H's reply took me by surprise.

"Whoa," he muttered, eyes still fixed on me.  After a few seconds of silence that felt like minutes, he then said rather nonchalantly, "Well, at least I know.  That's cool.  I've always kinda been a fatalist, so I figured something like this would happen sometime." 

He smiled innocently and then asked, "Is it treatable?"

"Treatable, perhaps, but not curable.  Chemotherapy can buy you some time, but it won't cure you of the cancer," I reply.

"Ok...well....let's give it a try," he says with another smile.  "If it doesn't work, that's ok."

That is the part that kills me.  Patients have no idea what to expect, so they try so damn hard to be positive and stay optimistic.  It's admirable.  It gets me every time though.  I'm so impressed with their determination and attitude, but at the same time my gut twists inside of me because I know how much pain they will go through before they die.  I hold back the tears and smile, trying to acknowledge his courage without killing his spirit. 

We talked a little bit more about chemotherapy.  I answered his questions as best I could.   I told him what to expect during the hospitalization and that I'd be by first thing in the morning. 

Breaking away from that conversation is always difficult - mostly because I feel bad about coming in there, dropping some unexpected bad-news bomb, and then just walking out.  I get to go home to my wife and kids and enjoy my life while he is still stuck in the hospital, left to drown in the abyss of bad news that I just threw him in.  I usually end up repeating some cliche phrase to try to cheer them up, which always sounds tacky and trite when it leaves my lips.  Nonetheless I still do it, because it's better than just walking out without saying anything. 

And so Mr. H left the hospital a few days ago with a diagnosis of metastatic colon cancer.  He went his way and I went mine.  I'll probably see him back in the hospital before long, and I would gladly care for him again.  Hopefully next time I won't have any bad news - maybe we'll find something enjoyable to talk about.  And maybe by then I will have learned how to stop forgetting these powerful moments and actually appreciate everything that I have in this world.  I really have no reason to complain, but I probably still will - at least until I have to break some more bad news. 

Stay tuned - exciting picture post about my workplace coming soon!

Thursday, May 17, 2012

Plugging the holes

There isn't a lot of 'curing' that goes on in internal medicine. 

We don't do surgery, which means that we don't get the satisfaction of curing your early-stage cancer by cutting in out.  We don't deliver babies.  We don't prescribe chemotherapy, so we can't cure cancer.  We don't fix broken bones or reattach limbs.  We can't stop bleeding ulcers or put a stent in your clogged arteries.  We can't retrieve the uber-small clot in your brain and cure your stroke.  And however much I wish I could travel to a 3rd world country and fix a child's cleft palate, it's just never going to happen. 

Nothing we do (at work) is very sexy.  And if you don't do anything sexy, you don't make as much money.  Insurance just doesn't reimburse for brains.

What we are very good at, however, is managing chronic disease.  You know the type of people who can keep an old car running waaaaay longer than it should?   We are the medical equivalent of a crafty mechanic.  Although we can't cure many patients of their ailments, we can keep them alive for much longer than they would ever be expected to live. 

Keeping chronically ill patients alive can isn't as easy as you might think.  Take one of my patients that I'm currently caring for in the hospital.

Mr. K is 67 year old living in a body that is physiologically much closer to 87 than it is 67.  He is a musician by trade.  At age 62 he went on disability - and unlike many of my patients, he actually has a good reason to be on disability.  His problem list looks something like this:

Uncontrolled diabetes
Chronic renal failure on dialysis
Peripheral neuropathy
Coronary artery disease
Previous myocardial infarction
Congestive heart failure

Treating a patient like this is similar to plugging holes in a dike.  Once you have one plugged, it's only a matter of time until another hole starts to leak.  It's usually manageable - at least until you run out of fingers.  And I've just about run out of fingers with Mr. K.

He was brought to the hospital 2 weeks ago by his family because he had severe pain in his tailbone and was acting strange.   Xrays were negative.  He was acting strange because he family had been loading him up with opioids to try and control his pain.  I admitted him to observation with the thought that I'd just hold his pain meds and he'd wake up enough to discharge him home the next day.  He's still in the hospital 2 weeks later.

After his mental status cleared, I was able to get more history.  He tells me he's been falling for the past 3 months.  Hmm.   Why is he falling?  He has double vision.  On exam I see that his eyes don't move back and forth like they should - he has a bilateral cranial nerve palsy (this is very abnormal).  I don't have a good explanation for it, so I consult neurology.  We get a battery of tests and imaging that all come back normal.  Hmm.

Meanwhile, Mr. K is seen by physical therapy for evaluation and refuses to work with them.  Why?  Because his tailbone hurts too much.  Hmm.  But his xrays were negative - shouldn't the pain be getting better by now?  He has to lay flat in bed because any movement causes him pain.  So I order an MRI.  Next day I get a call from the radiologist (never a good sign).  Turns out Mr. K has a completely fractured sacrum - the worst he has ever seen.  It was displaced so much that he couldn't really flex or extend his feet because the broken fragment was pressing on his spinal nerves. 

After consultation with neurosurgery and orthopedics, I was told that there was nothing surgically that could be done to fix this.  It would have to heal on its own.  

The next day, he went into atrial fibrillation, a heart arrhythmia that can cause blood clots in the heart that can then lead to a stroke.  I started him on a blood thinner.

2 days later I get a call from a frantic nurse to come to his bedside stat.  I lift up his sheet and see a huuuuuuuuuge pile of blood clots coming from his rectum.  I dig through the mountain of clots and find bright red blood pouring from his rectum.    Hmm.

I transfer him to the ICU and GI comes to scope him.  They find an arterial bleed in the colon - and there's nothing they can do to stop it.  I call surgery.  They come and say that he is too unstable for surgery and proceed to stuff his rectum with a large wad of packing.  He required six units of blood (thank you anonymous donor), a lot of fluids, and vasopressors to keep his blood pressure up.  Fortunately the bleeding stops and the next day he is out of ICU.

Then I get a call back from the radiologist (even worse sign).  After reviewing his back MRI, he notices that there may be osteomyelitis of his spine (infection in the vertebrae).  I consult infectious disease.  He doesn't know if this is infection and requests a bone biopsy.  I talked to interventional radiology, who politely declined the biopsy as they couldn't reach the area in question with a needle.  

Meanwhile, his rectal packing falls out when he has a bowel movement and he starts to bleed again.  More packing is inserted, and bleeding stops.

By this point he has now been in the hospital for 10 days.  Prior to coming here, he was essentially bedridden for 3 weeks, making it more than one month that he hasn't been out of bed.  He's incredibly weak.  He's malnourished because he has no appetite.  And he can't get out of bed because of the pain in his sacrum.

The next night he spiked a fever to 102 degrees.  I order a urine sample.  The nurse brings me a specimen cup filled with something that resembles thick almond milk.  No thanks, I prefer cow's milk.  And I'm really not hungry or thirsty anymore.  I start him on antibiotics for a UTI.  

Believe it or not he has weathered the storm and is doing well.  Now we're trying to get things arranged for him to go back home.  He kindly refused rehab placement - he just want's to go home.  He understands that if he goes home, he may never get up enough strength to get out of bed on his own.  But he's tired, he tells me, and doesn't have the energy to keep fighting.  He just want's to go home.  I don't blame him.

Fortunately there were enough fingers to plug all the holes this time.  Actually I really shouldn't say that yet, because he's still in the hospital.  There are still plenty of things that can still go wrong.  But assuming that he gets back home, then I've done my job.  His quality of life will be worse, he'll still have pain, but he's alive.  That's what I do.  I keep that old, broken car alive for one more ride.  

Sometimes I wonder if I'm fooling myself by thinking I've done a good job by keeping someone alive.  Personally I'd never want to go through much of what I put my patients through.  But there's something about living with chronic illness that I guess you can't quite understand until you've had to live with it.  Even when faced with death, many chronically ill patients will choose to keep fighting right up until the end.  When death is the alternative option, I suppose living in a nursing home doesn't seem that bad to a lot of people.  

So as long as there are chronically ill people who want to keep fighting, I'll be around.  My job isn't sexy and I'll never be regarded as highly as the subspecialist.  I probably won't cure you of anything, but I'll try my best to keep you alive.  And odds are, I'll be successful.  Your engine may still sputter and smoke, your lights may be dim and your tires may be worn, but I may be able to keep you together long enough to enjoy a few more rides.

Have a great day, and stay tuned.

Wednesday, May 2, 2012

No heart, or no brain?


It's been a while - things have been busy lately.

I'm in an economic frame of mind today, so I'll share an experience I had last month.  I'd be interested to hear your thoughts on this particular situation.  Medicine is so saturated with absurd economic policy that it's my default when I don't know what else to write about.

I had a 40 year old M who presented to the ED two months ago because he didn't feel well.  Why didn't he go to his PCP first?  Because he didn't have one.  Why didn't he have one?  Because he didn't have insurance.  Why didn't he have insurance?  Because he was in the country illegally.  Very common dilemma across the US these days.

Routine blood works reveals a BUN of 90 and serum creatinine of 10.  In English - he had kidney failure.  Further workup told us that this was not an acute problem, but one that had been slowly brewing for years without him knowing it.  Thorough investigation failed to uncover the cause of renal failure - could have been one of a bazillion things.  He was discharged home as there was no indication for starting dialysis at the time.  He was given a list of clinics to follow up at, but failed to do so.   His medical insight was very poor and he felt that dialysis would kill him.

So he presents again to the ED one month after discharge - still not feeling well.  Not unexpected - you can imagine that living without a major organ system might cause some discomfort.  But by this time his renal function had worsened even more - now he was overtly uremic (fancy medical word for his brain now being affected by years of toxins that have been slowly accumulating in his body).  

Once you hit uremia-ville, you're pretty much screwed unless you either start on dialysis or get a kidney transplant.  Transplant takes about 5 years to get on average and is limited to those with insurance, good social support system, and a whole host of other factors.  This gentleman obvious wasn't going to get a new bean.

That leaves dialysis.  Sounds simple enough, right?  Not so fast.  It's incredibly expensive.  

I have no clue how much it really costs to dialyze someone for a year.  I'm not sure anyone really does - the cost can vary tremendously.  A quick google search led me to an article from 2002 that approximated the cost at $66,000 per year.  That was 10 years ago.  Tack on a few extra K and we're probably around $75,000 now.  

Back to the case.  With a clear need for dialysis and without insurance, the hospital is forced to eat the initial cost of his hospitalization (I can hear the administrators groaning).  Since he isn't a citizen, there's no federal insurance that will cover his dialysis (virtually all dialysis patients are covered under Medicare regardless of age, btw).  Likewise, he won't qualify for Medicaid because he isn't a citizen.  

So now he has a dialysis catheter and clearly needs dialysis three times per week for the rest of his life.  There is no other option to keep him alive.  But no dialysis center will accept him as a patient because they are all for-profit, private companies.  Many of them are public companies whose stock is traded on Wall Street.  Accepting charity patients would be financial suicide.


Now what?  The first solution to pop into your head is the same that came to me - sir, it's time for you to go back to your country of origin.  Maybe they can help you.

But with a wife and kids that have grown up in the states, he was hesitant to even consider the option.  And besides, there's no work back home, and he's not sure he'll get any treatment at all.

Sounds like we need a social worker - anyone want to step up to the plate?

This is where it gets interesting.  Unbeknownst to me, there is apparently a federal emergency insurance program that will provide insurance to certain illegal immigrants.  What?  You're kidding, right?  Nope.  I don't know much about it, but there is some program out there that, with the assistance of the social worker, he applied for.  Apparently it takes a while to get approved, so unfortunately I'm going to leave you hanging because I don't know the rest of the story.

In the meantime, the patient was instructed to return to the emergency department three times per week to get dialysis.  Tack it on his bill - he doesn't care.  He'll never be able to afford 1/100th of it.  Whichever hospital he chooses to go to gets stuck eating the bill - potentially three times per week for the rest of his life.  And recall it's not cheap - somewhere in the ballpark of $75K per year (probably more when done at the hospital).  

I'm a bit conflicted on this emergency insurance program that he may or may not qualify for.  If this really exists (and I'm told it really does), I'm not sure how I feel about it.  Am I glad that this relatively young, poor, hardworking man who happens to have been born in another country is able remain alive?  Absolutely.  Am I happy that there are 45 million Americans without insurance in this country who get passed over in order to fund this guy?  Not at all.  

It seems a bit ironic to cover foreign nationals when American citizens without insurance declare bankruptcy every day.  It's the leading cause of bankruptcy in America.  I have idea if this is accurate, but I like the graphic.

10 Leading Causes of Bankruptcy

If this example isn't enough to get you thinking, I've got more.

Ever thought about prisoners?  They are provided healthcare at your expense for the entire duration of their incarceration.  But when they get released from jail, their coverage stops, right?  Not in my state - I learned this year (courtesy of a colleague of mine who had a patient that was just released from prison) that we provide care for one freaking year after they are released!  I can't provide any credible source of information regarding this, but I'm using it anyway to prove my point!

And how about terrorists?  I know that I shouldn't use Michael Moore as a source for, well, anything, but I was a bit shocked to find out that we provide full medical service to prisoners housed at Guantanamo Bay.  Wtf?  Again, I'm all about being humane, but really?  Shouldn't they have to work for it like everyone else?

Let me get this straight.  We let 45 million people in this country go without insurance while providing coverage for illegal immigrants and prisoners.  I understand that even we stopped providing this coverage that we still wouldn't have enough money to cover the 45 million uninsured, but it's at least a start.

Then again, many of these undocumented citizens work much harder than many of us in this country and contribute in a very positive way to our society.  Any who disagrees with this is blinded by his myopic partisan view of the world.  My experience has been that they work hard and want what we all of do - a peaceful, successful life.  

This case has caused me to think a lot about these issues over the past month.  I still don't know where I stand.  

It reminds me of a quote often attributed to Winston Churchill.  "Show me a young Conservative," he said, "and I'll show you someone with no heart. Show me an old Liberal and I'll show you someone with no brains."

I guess those in the middle are entitled to waft a bit on these things.  And that's exactly what I do.  I wish I had an answer, but I clearly don't.  Even if I did, I'm not sure it would change anything.  We've proven to be a fiscally reactionary nation that waits until impending disaster before anything gets changed.  I'd rather enjoy my life than waste it ramming my head against a wall.

I guess I'll continue to sit back in the peanut gallery and watch how these things play out.  And in the meantime I'll continue to try to do the right thing - whatever that really means.