Monday, November 19, 2012

The doctor gets injured!

It's been a long time since I've needed medical attention.

I've been in for a few visits over the years - all of them regarding funny looking moles that I had taken off.  On one occasion my PCP tried to have me go in for lab work - which I politely refused.  I don't really care about my cholesterol, and I know my bone marrow, kidneys, and liver are fine.  There's no way at my age I'm going to take any medications, so I'd just rather not know at this stage in my life.

Well all that changed over the weekend when I had a traumatic accident that, for the first time in over a decade, made me seek acute medical care.

The mechanism of injury is actually somewhat embarrassing, but for your reading pleasure I will share the humiliating details.

I live on a street that is moderately steep.  Not terribly vertical, but enough to get up to out-of-control running speed in a few strides.  I also like to wear flip-flops.  And my driveway has lots of those annoying little decorative rocks scattered over it - there's just no way to keep those little bastards where they belong.

Anyway, I walked down the street to find my kids for dinner.  After peeling them away from the baby toys they found in a neighbors garage (they are far beyond the infant stage but for some reason found them incredibly entertaining), I challenged them to a race back home.  In hindsight, racing down the sidewalk in sandals wasn't the greatest idea.  But I was hungry and felt like showing them how much faster I am than them.  Plus, as all parents know, a race is a very effective way at getting kids from point A to B quickly.  They fall for it every time!

I give them a little head start to make them think they're actually faster than me.  Just about when we get to the driveway, I cut the corner, put on the speed jets, and make my move.  But damn it all if those stupid little rocks didn't just spoil my plan!  Somehow I stepped right on a little conglomeration of them, and the next think I know I've just face-planted right on the brick driveway.

When I say face-planted, I mean I truly face-planted.  I broke the fall with my hands, but I couldn't stop my large head from slamming straight downward.  It was like my chin was magnetized to the earth - it pulled my butt-chin straight down and dashed it on the bricks.  Before I had time to realize what the hell just happened, my head was lying in a small pool of blood.  The underside of my chin took the brunt of it and I ended up with two deep gashes.

Without a doubt, my pride hurt far worse than my chin.  My kids looked at me with the same face that I give them whenever they do something stupid.  Karma, I suppose.  They also followed my example by not helping me up - rather they ran straight in to the house and I heard my daughter yell, "Mom!  Dad just fell and busted his chin open!"  I suffered alone on that cold, abrasive driveway.

After I got cleaned up, I realized I needed some sutures.  My wife had to leave to teach a class, so I was stuck at home with the kids.  I briefly entertained the idea of going to Urgent Care or the ER to get stitched up.  But with a Health Savings Account that hasn't met the yearly deductible and two young kids that were nearing bedtime, that was clearly out of the question.  My wife jokingly asked me if I was going to suture it myself.  Hah!  Good one honey.  Of course not.  What a ridiculous idea.

My neighbor down the street is an emergency doc.  I gave him a call, but he didn't answer the phone.  I left a shameful message detailing my clumsiness and need for stitches, but didn't hear back from him.  I figured he was working.  Damn.  Now what?

I've always been a very independent person.  It drives my wife crazy.  I refuse to even ask where things are at the grocery store.  I can't stand it.  I'd rather wander around for an hour than ask for help.  Well this was no different.  Am I not a board certified physician?  Do I not have sutures, lidocaine, and needles at my disposal?  Then why should I not just do this myself?  What seemed so silly one hour earlier now sounded like a reasonable option.

For some reason I waited until after the kids were asleep to get to work.  I don't know why.  I'm sure they would have loved to watch it.  I guess I like to work alone.

I put on some gloves and filled a syringe with lidocaine.  I'm not sure why I put on gloves.  It just felt weird not wearing them.  Silly, I know.  I also told myself the risks and benefits of the procedure and signed my own consent - you can't be too careful these days.  

Injecting myself felt a little creepy - kinda like I was doing something illegal.  But I was surprised at how good I was at delivering a painless injection!  Now I know that all my patients that have flinched, cried, and screamed during local injections are full of crap!  I didn't feel a thing.

Once sufficiently numb, I loaded a needle on a hemostat and went to work.  Try tying sutures while looking into a mirror if you're up for a challenge some day.  Took a while to get used to, but after the 4th or 5th suture I was on a roll.  In all I put in 6 sutures, 3 in both wounds.  

My wife came home to find me half-naked, leaning over the bathroom counter putting a needle in my face.  I could see the "WTF" bubble caption over her head.  She grabbed the camera and I had to practically beg her not to post anything on Facebook.  

It actually turned out remarkably good.  So good, in fact, that I rationalized that I should get reimbursed for my efforts!  I wrote out a procedure note and submitted a bill to my insurance.  I even charged a facility fee as it was done in my own house - man does that reimburse well!  I had to pay 20% of the bill, but hell, that 80% profit was enough to finally purchase the Xbox I've been meaning to get.

A few days later, however, my 3 year old son decided to karate kick me right in the chin when we were playing cars on the floor.  He got me so good that one of the sutures popped right through, opening up part of the wound.  The initial anger soon turned to glee as I realized that maybe, just maybe I could capitalize off this as well.  If the sutures had been put in correctly, I reasoned, they shouldn't have popped.  Now I may have permanent damage on my chin from a nonhealing wound.  Unacceptable!

I contacted my lawyer, and within the hour we had a lawsuit all drawn up and ready to go.  This was clearly malpractice, and damn it all if I won't get retribution for my pain and suffering.  The next day, an official lawsuit was filed by myself, against myself.  Brilliant, no?  I think I have a strong defense planned, but I'm confident that in the end I'll get a favorable verdict.  As long as I can get an uneducated, sympathetic jury, I'm golden.  I'm planning a countersuit as well - just in case to hedge my bet.  

In the end, this experience taught me a number of things.  First, doctors are no different than you.  We don't like going to the doctor, we don't like paying for healthcare, and sometimes we aren't satisfied with the care we get.  But does this really surprise anyone?  It shouldn't.  Remember, we are as human as you are, subject to the same thoughts and feelings as you are.  Second, no more running downhill in sandals, and third, I'm pretty damn good at suturing.  

So there you have it - the doctor gets injured, fixes himself, rakes in tremendous profit and then wins a landslide decision in his favor.  I plan on retiring now, settling down on a tropical island, and enjoying the rest of my life in peace - far away from my PCP.  

Stay tuned for more wordy nonsense!

Sunday, October 28, 2012

Is it worth it?

I've had a number of people as me if going into medicine is "worth it."  

This is a difficult question for me to answer. I generally waft back and forth with both the pros and cons of the profession, but can't seem to ever answer with a simple "yes" or "no".  

I think the only answer that I feel comfortable with is "it depends."

It depends on a number of variables, some of which you don't appreciate until you've finished training and have the benefit of looking back retrospectively at the whole process.

To keep this particular post from going on too long, I'll direct my thoughts as to whether or not I think it is financially worth it.

For those contemplating going to medical school, I think the biggest obstacle that you need to be fully aware of is the cost.  I've done some back-of-the-envelope math to help you grasp the financial commitment that you're getting yourself into.

Tuition these days generally runs from 30k-60k a year x 4 years = 120-240K.  Tack on modest living expenses for a single adult (add liberally for those of you with families) of about 25K a year x 4 years = 100k.  

Four years of medical school/living expenses will cost you roughly 200-300k.  There will be some outliers both above and below this number, but for the vast majority of people this will be in this range.  Heaven forbid you have a large amount of undergraduate loans in addition to this amount.

Let's assume for simplicity that your 250K in student loans is all federal loans (which is not possible - you're limited to about 30K a year in federal loans, the rest are private loans at a higher rate).  Currently the interest rate is 3.4% and set to increase to 6.8% at the end of this year (you can all thank George Bush for signing the 6.8% into law - and Obama for temporarily lowering it to 3.4% since 2007).  

By the time you finish 4 years of medical school and  3 years of residency, your 250K in loans, with 6.8% interest and assuming no payments have been made during school or residency, will have ballooned to 361K.

So you finish residency and get your first job making $160,000 year (avg starting salary for primary care these days).   Uncle Sam will come by and swipe 30% off the top, and your state tax will be about 5%, leaving you with about $100,000 left.  

That gives you about $8300/month to live off, which seems pretty good.  And that would be good if you didn't have that huge ass debt strapped to your back.

At 361K in debt at 6.8% over 10 years, your monthly loan payment will be $4150.  

That leaves you with $4250/month to live off...for the next 10 years.  That's the equivalent of a $50,000 salary.  

If you stretch that out to a 20 year repayment, you're looking at monthly payment of  $2750/month - FOR 20 FREAKING YEARS.

So back to the question - is it worth it?  It depends.  If you don't mind being a primary care doctor in your early 40's, still living off the equivalent of a $50,000/yr salary, then yes, it's probably worth it.  Your net worth will eventually improve to ZERO during your 40's (ie out of negative territory), after which your significant investment will pay off once you have finally slayed the debt beast and payed off all your loans.  If you continue to work into your 60's, you'll be fine.  

Now, lest you forget, we live in a time of declining reimbursement to physicians while the cost of medical school rises every year.  The time will soon come that unless you have a way other than student loans to finance your debt (scholarships, loan repayment plans, etc), you will be working your entire career to pay off your loans - all the while living off of a very average salary.

Again, if you don't mind living like this, then by all means, follow your dreams.  But if you have any financial sense, you'll quickly realize that this may be financial suicide.

Now hopefully it's obvious why some people out there have such a hard time finding a primary care physician these days.  It's daunting to choose this path when you will be living in indentured servitude for the next 1-2 decades of your life.

But doctor, I love primary care and I don't care what it costs - I want to follow my dream and be a PCP!  By all means, go right ahead.  But realize that this amazing amount of debt with crush your altruism within months, at which time you'll remember my words of wisdom and weep with regret!

If you have your heart set on primary care (which, as an internist, I applaud), I strongly implore you to look into loan repayment options.  This is really the only way that you can temper the crushing debt that will try to ruin your life and still do what you love to do.  There are plenty of programs out there, and while temporarily inconvenient, they may save your financial life.

For those of you going into sub specialties, you'll be much better off financially for the time being, but beware lest you think the current level of reimbursement won't decline in the next few decades.  You have a financial target on your head, and Medicare is dialing in the sights.

So the moral of this post is simple - think long and hard about the financial implications of your decision.  Don't fall into the trap of telling yourself that the level of debt doesn't matter, that you'll be a doctor and somehow things will work out financially.  That's like running out into the street and then looking both ways.  Odds are you'll get creamed.

Take it for what it's worth.  I wish there was an easier way, but it is what it is and it isn't going to change anytime soon.  

Stay tuned - next time I'll look at the other aspects of medicine and tell you if I think it is worth it.

Wednesday, September 12, 2012

A different perspective

My service lately has been dominated by patients with serious wound issues.  

I think the general public would be horrified if they saw some of the chronic, non-healing wounds that people live with on a daily basis.  Hell, I see them on a frequent basis and even I'm horrified by them.  I just can't seem to get used to large, rotting, pus-filled wounds with visible chunks of muscle and occasionally bone.  

As an internist, thankfully I don't really have to actually be the one to deal with the wound.  I look at it once and then consult the wound care nurses.  If need be I call the surgeon to debride the wound.  But I rarely have to touch the wounds.  Frankly I don't really have anything to offer.  I'm not trained in wound care and I don't do surgery.  

Right now I have one patient who lost all of the skin on his lower leg from necrotizing fasciitis, one with a large abdominal surgical wound that has an enterocutaneous fistula that constantly oozes intestinal juices, and an extremely purulent non-healing skin wound from a skin cancer excision.  These are all pretty nasty, but they don't compare to the wounds of two patients I call 'the twins.'

The twins are not biologic twins, but rather twins of circumstance who happen to be the same ethnicity, have the same terrible wounds for the same terrible reason and ended up in being admitted to the hospital on the the same day.  They both ended up on my service and somehow they ended up in rooms right next to each other.  They don't share the room, and thus don't even know of each other's existence.  

Both were injured in motor vehicle accidents in their 20's.  Both have spinal cord injuries.  They both have stage 4 sacral decubitus ulcers with infections that have spread to the bone.  

One of the twins has probably the worse decubitus ulcer I've ever seen.  He has no skin over his entire sacrum, buttocks, or perineum.  All you can see is muscle and bone.  He got this from years of neglect - both by himself and his family caregivers.  He has a suprapubic urinary catheter that doesn't quite function properly - urine leaks around the catheter straight into the into the wound.  And when he defecates - you guessed it - stool inadvertently seeps into the wound as well.  

You wonder how anyone in this situation could go on living.  Both are partial quadriplegics and are primarily bed-bound.  Neither have a lot of money or family support and are thus limited in the quality of services that they can afford.  They don't get out much, if at all.  They aren't married and don't have children.  My heart goes out to them every time I see them, and deep down inside I feel guilty for having a body that works so well.  I wonder if they get jealous when they see me stroll in and out of their room.  I wonder if they secretly harbor anger towards those who have it better than them.

But I've noticed a curious thing about spinal cord patients.  Despite how terrible of a life I imagine them to have, they always seem quite content with their situation.  Decubitus ulcers and all, I've never heard one complain about being paralyzed.  

They are incredibly patient and take everything in stride.  Large infected decubitus ulcer?  No big deal, it's happened before.  UTI from chronic indwelling catheter?  Happens all the time.  Prolonged hospital or nursing home stay?  No problem.  They just go with the flow.  

I suppose you just get used to things and learn to deal with them.  

I've thought about the twins a lot this week.  Seeing them take their unbelievable misfortunes in stride is impressive.  They are much stronger that I would ever be in their situation.  Even in their misfortunes they have a better attitude about life than I do at times.

One of the selfish reasons that I like being an internist is because I get frequent reminders how fortunate I really am.  And yet at times the daily reminders still aren't enough to really make me appreciate what I have.  

Someone once told me that no matter how bad you think you have things, there is always someone who has it worse.  I think that's accurate.  

And thus after seeing the twins every day this week, I've recommitted (again) to being grateful for what I have.  I'm not hopeful that this feeling will last long, however, because it never does.  But that's okay, because fortunately for me there will always be another unfortunate patient on my list to remind me whenever I do forget.  I just hope I don't have to see his chronic wound.

Stay tuned.

Tuesday, August 28, 2012

The Great Enabler

This post is coming to you live from 3:30am.  I'm pulling a night shift at the hospital and have some rare downtime.  Instead of sleeping (which I desparately need), I have chosen to blog.  Why?  I don't know.  It makes no sense for me to blog when I could be sleeping.  But I am.

I've chosen to share my thoughts on perhaps one of the most misunderstood and, in my opinion, one of the most abused pieces of medical equipment currently available.  

They say a picture is worth a thousand words, so here you go:

I recently had an experience that made wonder about these beloved pieces of expensive medical equipment. 

A few months back I peered out into the waiting room of the clinic and noticed a woman similar to the one above, who also happened to be sitting in a scooter nearly identical to this one.  Joining her at her visit was her husband, equally as large and with an equally nice scooter that even matched hers!  How nice.  They blissfully held hands as they waited.

I've never really had an issue with these things until I saw this couple.  What started out as a mere curiosity soon turned into a bit of an anger provoking moment as the husband pulled out a large bag of Lays potato chips and handed them to his wife.  As she began to chow down, he produced an extra large Snickers bar and wasted no time polishing it off.  Of course these yummy treats tend to make you thirsty as we all know.  But this couple got an A+ for preparation - each had a jug of soda in their basket that was less than half an arms length away!

I couldn't believe my eyes.

I bet these folks are loving their scooters.  They hit the jackpot.  They no longer have to exert themselves at all.  I'm sure whoever prescribed these is a hero in their eyes.  They love him to death.  It wasn't me, by the way.

In medicine, things tend to come in bunches.  You'll go a few months without seeing something, and then in one week you'll see it three times.  Not more than a few days after seeing that hideous sight in the waiting room, I had a patient come and visit me to request a scooter.  He was middle-aged and had no real health problems.  

This is gonna be good.  Can't wait to see what he says.

Turns out he has pain in his feet from a rash.  Does he have pain when he walks around his house?  No.  But when he goes to the store and has to walk around a lot, the rash starts to hurt. Why can't he use the ones at the store?  Because he just wants his own, and saw on TV that Medicare would cover it.

It turns out that Medicare has been paying for too many of these little gems lately.  Check out this quote from an article in USA Today from 2011:

  • A report released last week by Medicare's inspector general also showed that 61% of the motorized wheelchairs provided to Medicare recipients in the first half of 2007 went to people who didn't qualify for them. The inspector general found that Medicare is billed an average of $4,018 for a motorized wheelchair that normally sells for $1,048.
I love it when I can find objective data to back up my opinions.  It's quite validating.

My gut instinct was correct - the majority of people who use these things have no freaking reason to be using them.  They are abusing a wonderful piece of technology (at the taxpayer's expense) that actually does help a lot of people who actually need them.

If we keep this crap up, it won't be long before the movie WALL-E becomes a reality.  Get used to seeing this!

And thus on a macro level, scooters are doing our nation more harm than good.  They are, perhaps, the greatest enabling piece of equipment out there on the market.  

Since 61% of people are using them when they really shouldn't, perhaps someone should make a list of reasons NOT to ask your doctor for one.  I couldn't find such a list on the web, so I've taken the liberty to publish my own list.  Let there be no more confusion!

The Doctor's List of Unacceptable Reasons to Request a Medical Scooter
  1. Obesity.  No exceptions.
  2. Complications related to obesity.
  3. Laziness.
  4. Fibromyalgia.
  5. Rashes (any location).
  6. Chronic fatigue syndrome.
  7. Inability to hold all of your junk food.
  8. Lack of automobile.
  9. Dislike of public transport.
  10. Because Medicare will pay for one.
There, I feel better now.  Will anything change?  Probably not.  But at least I feel better.

Stay tuned.

Sunday, June 24, 2012


Ok, it's been a while.  Sorry for the delay.  Hopefully my blog won't go the way of 99% of blogs in cyberspace with time in between posts gradually lengthening until they eventually stop - only to pick up again at some random point months down the road (the blogging Wenckebach effect).  Sadly it probably will.  

But for now I'm here, bursting with blogging energy and eagerly wanting to share with you more adventures of my life as an internist (yawn).

I thought today would be a good day to share some photos of my amazing workplace.  But before we jump right to the good stuff, you have to endure my thoughts on hospitals.

In general, I see hospitals as a necessary evil.  They are actually very dirty and dangerous places.  Check out  this article on the estimated number of in-hospital deaths due to medical errors.  I secretly wonder how many of those I've unknowingly caused.  Any of you doctors out there think you've killed a patient?  Dr. Cox of Scrubs would have you think otherwise!

But hospitals continue to exist because they have a net positive effect.  In other words, we save many more people than we kill.  How reassuring!

You should feel somewhat reassured that hospitals, physicians, and nurses are continually trying to improve.  Improvement can be slow, but at least we're trying to move the in right direction.  Remember - all of us in healthcare are human and make mistakes just like everyone else.  

Fortunately I've been part of hospitals that take patient satisfaction and patient safety very seriously.  I have the photos to prove it.  So with that in mind, let's take a look around at my second home.  

One thing that I love about my hospital is how focused they are on preventing the spread of dangerous bacteria.  Most hospitals have hand sanitizer within arm's reach at all times.  But I recently found out that we have taken hygiene to a whole new level.  As I went into the bathroom the other day to micturate, I found this nice surprise when I lifted up the seat:

What the hell does this mean?  Perhaps it secretly sterilizes the outermost portions of your ass cheeks and creates an antimicrobial 'fire break'.  If you can't get doctors to wash their hands, go right to the source!  Brilliant!

You should also know that we are also a very evidence-based institution.  Nothing in this hospital happens without some type of exhaustive literature search to find scholarly articles to support the proposed change in protocol.  Apparently no one researched the magical toilet seat prior to installation, because the bathroom protocol had soon changed.  Perhaps administration saw the rate of hospital acquired infections creeping up and decided to take a more drastic approach to ensure proper sanitation.  Not two weeks later, I found this on the door to my favorite bathroom (come on now, you all have your favorites too).

If hand washing and antimicrobial ass rings aren't effective, then clearly the next step is to close the bathrooms.  It has been shown to be 100% effective for preventing the spread of physician-acquired infections!  

Well I'll be damned if that small sign on the door was going to keep me away from my favorite commode!  I was not prepared to disrupt my daily schedule for the infection control committee.  

I guess I'm not as stealthy as I thought - check out the same door the very next day:  

Never!  How dare you!  No one ever asks for my input around here.  Actually this was enough to keep me away.  But apparently there are people who are either blind or illiterate that work here, because this is the same door not 24 hours later:

What you can't see are the armed guards stationed to either side of the door.  This made me laugh out loud.  As if the big sign, writing on the door itself, and the big red arrow weren't enough, now we have ourselves a crime scene.  Just between you and me - on my night shift I opened the door, took a few steps back, and dove head first between the top of the lower X and the crime scene tape just to get to my beloved throne.  Unfortunately the tie on my scrub bottoms tripped the laser as they were falling to my ankles and I was forced to escape through a small vent in the ceiling.  That was close.

The next day I finally gave up the bathroom fight and went to the one 'around the corner' as suggested by the writing and big red arrow on the door.  Guess what I found on that bathroom?

No freaking joke.  I gave up the fight and found a new fortress of solitude.

Enough about bathrooms.  How about this handy sign that I found posted on the back of the elevator wall:

WTF?  Why no love for the medical patients?  Hey you, Mrs. 95 year old, oxygen-using, blind, mostly deaf terminal cancer patient, I'm sorry but you need to step out and let the strapping 25 year old man with the inguinal hernia on the elevator.  The stairs to the 6th floor are on the other side of the hospital, right behind the morgue.  Thank you for your understanding!

On to the cafeteria.  Believe it or not, our hospital's food selection isn't all that bad.  Every once in a while, however, I see something that reminds me that it's still a hospital.  Check out this bowl of yummy goodness - couldn't pass this one up.

It brought back such fond memories of Mrs H, a pleasant 85 year old grandmother of 27 who greeted me with a blue bowl full of similar material the morning after being admitted for a small bowel obstruction.  

Our beverage selection is also top-notch.  We do our best to unknowingly sanitize your GI tract with a 'rare black tea'.  

Tazo is actually short for tazobactam, an anti-betalactamase compound that is combined with the fourth generation penicillin drug named piperacillin (piperacillin-tazobactam), also known by medical personnel as pip-tazo.  I guess the 'pip' doesn't taste so hot, but damn, that tazo is amazing!

Hopefully you now have a better idea about the wonderful place that serves as my second home - actually it probably qualifies as my primary residence given the amount of time I've spent there over the years.  I poke fun of it only because I like it.  Sure it has it's drawbacks, but on the whole it's been a great place to work and I have countless memories/stories that will be with me for the rest of my life.  Hopefully I've done more good than harm, although I suppose I'll never know for certain.

Stay tuned - post on one of my least favorite medical devices coming soon!

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.