A Helping Hand

a helping hand by *poivre on deviantART

A couple days ago in the resident's lounge, one of the physicians came in to round with his team (of residents and med students). Because the lounge is rather small, I overheard most of what they said.

They discussed this one patient in his 30s who didn't finish high school, has uncontrolled diabetes, has peripheral neuropathy (numbness & tingling in fingers and toes) as a result, has chronic pain, and is taking narcotic pain meds in order to bear it all. According to the med student and intern taking care of him while in the hospital, they report that he is unpleasant/uncooperative to work with, appears to be "throwing away his life," and just want his pain meds. The physician took this as a moment to ask, "Why?"

This segued into a discussion from the physician about here is a guy who's slipped through the cracks of health care. He takes narcotics for the pain, but narcotics likely make him sleepy and also feel not great, throwing him into an endless loop. His PCP (primary care physician) likely tried to truly help him once, but since he's uneducated and doesn't know how to manage his diabetes, thus his health deteriorated. In his frustration, his PCP likely labeled the patient as "non-compliant," which is technically true - but again, why? It became easier for the PCP to just refill his narcotics and send him on his way. His PCP is also an older physician who's likely jaded from seeing so many of his own patients fall despite his care.

Here, said the physician, was an opportunity for us - med student or intern - to turn the guy's life around. Here, in the hospital, where we have "control" we can say to him, "You need to get your act together and turn your life around." Here we can extend a helping hand and spend the time to give him the education necessary to manage his diabetes. He's a young guy and has a shot of doing well years down the line, why should we also abandon him just because he has a label of "non-compliance?"

I have friends who call their patients "idiots" for smoking and having a BMI of well over 40, and then gets admitted for pneumonia. Or for being alcoholics and developing acute pancreatitis as a result. Sometimes I look at one of my friends, who's overweight and gets winded after going up 2 flights of stairs (how sad . . .), and say "Dude, you get winded after 2 flights of stairs. When was the last time you exercised?" To which his response is, "I've been busy and I just don't feel like it." How dare he call his patients idiots for ballooning up to a BMI of 40+ (FYI, that's more than morbidly obese), for telling them to exercise and eat healthy, when he doesn't do the same and could be in their shoes 10-20 years down the line.

Anyway, righteous indignant rant over. We all, medical and non-medical alike, have an opportunity to turn someone's life around. We all fail from time to time, but that doesn't mean we no longer deserve help. Even so, I'm beginning to feel myself become jaded with adult medicine after just 2 months . . .

Thoughts?

So I read from time to time, as I'm wont to do. Today I came across this article:

No surprise for bisexual men: report indicates they exist

Lol, the title amused me. Of course bisexual men (and women) exist! The only way the title could've been better is if it had the words "Well, duh" somewhere in it. Some may be offended that it took a study like this to "prove" or "validate" our existence, but I'm rather amused. The study does have some limits, as all studies do. It basically assess those who're "perfectly" bisexual rather than people who self-identify as bisexual but may have a skewed attraction towards either men or women.

Thoughts?

Circumcise or don't? Quandary for parents
Fairly balanced article for something that inherently has a lot of bias. A fellow med student friend (at another med school) and I briefly discussed the article/topic. He's of a neutral opinion and would follow whatever medical recommendation would be at the time of his future son's birth (assuming he'll have a son). My opinion is basically the same as any other surgical procedure - if it isn't medically necessary right now or in the near future, then don't do it. 99% of the time, circumcision is not medically warranted (that is, there's something so wrong with the foreskin that circumcision is the only option). I then asked him if, in the future, the medical recommendation is as "neutral" as it is now, then what'd he do? He said that he tends towards conservative treatment, and hence would likely leave his son uncircumcised unless there were some very clear benefits that outweigh the risks (there aren't, as of current medical literature).

Thoughts?

Why medicine actively and legally stifles innovation
This was a particularly interesting article. The author certainly utilized a unique health care delivery model. Definitely worth a read. I find the idea of such innovation to kind of operate outside "the system" refreshing. It's a funny thing - they tell us (the med students) to think about every possible diagnosis in the differential for a patient's disease. Then the physicians proceed to systematically dismantle almost every suggestion we come up with except the most likely/obvious ones. I can't say they're wrong in doing so because if you keep asking a med student for something "outside the box," you're going to eventually hear ridiculously rare diseases that very few people ever get and very few physicians ever see. I don't question their knowledge and clinical judgment over mine, because it's obvious that they know far more than I do (almost more than I can possibly imagine myself ever knowing!). What I do question is the system at large that seems to repeatedly fail patients and ends up producing jaded physicians. There must be some way to rectify the system and this article was one step in that direction.

Thoughts?

Less Person, More Intervention

A couple days ago I was at an advisor's apartment to welcome students of the incoming M1 class. His wife, who has acute myeloid leukemia, was also present. By any statistic you can quote she has beaten the odds more than once. She's a tough one and still fighting on.

Almost 3 years ago when she first greeted me and others as freshly minted M1s, she was lively, warm, and motherly. Now, bald and weak from chemo, tanned as if her skin had been baking under a desert sun, and also on dialysis, she appeared so frail and mortal. I've seen this before - the frailties of the body, broken by disease and worn from treatment and intervention. But also peering through are the embers of a once-strong soul. I could tell through her heavy-lidded eyes that she wanted to be healthy enough to interact and engage with all of us, instead of lying on the living room couch. I could tell that behind her wearied smiles that she's fighting off her own suffering.

I read a blog article the other day by a doctor who experienced what it was like to be a patient. What he wrote seems to mirror some of the patient's I've seen. Being a patient in the hospital must be one of the most frustrating things in the world. You rarely fully know what's going on with you, nurses are poking you every 15 minutes to 4 hours, and doctors order things to be done on/to you as you lay helplessly. We just need to remind ourselves that, at the end of the day, we can go home. Our patients often can't.

It's easy to correct an electrolyte imbalance. It's easy chase a blood culture. It's easy to track labs. But it gets harder and harder to see patients as people and not a "bag of symptoms." You look at someone and you don't see a mother, a sister, a father, a brother. You look at someone and you don't see a baker, a chef, a nurse's assistant, a student. No, instead you see an alcoholic, a morbidly obese individual, a body part, an organ, a pulmonary embolism, a cancer. All of which is true, one can't objectively deny any of it.

But in the ICU (intensive care unit), I've seen people become less and less person and more and more medical intervention until all that's left is a body on a ventilator with an NG tube, a Foley catheter, an arterial line, a central line, and a telemetry attached. In that state the soul has probably fled and all that's left is a shell of a person kept alive, not for the patient's sake, but for someone else's (whether it's the family or the medical personnel).

A woman was brought in to the ICU today. Full code, meaning CPR and the whole deal. She should have been left to die in peace. As my senior resident said, "This is a special place of Hell that people are forced to suffer through when someone calls the code."

That said . . . people occasionally do get well enough to regain their humanity and go home.

Pandora's Hope

I've witnessed Pandora's Hope with my own eyes,
staring at its immortal form behind its mortal guise.
A blessing, a curse; making us toil long after the day is done,
pushing us harder through a battle that can't be won.
I can only guess at its motives and its reason
since its release from its God-wrought prison.

I have seen it visit you on the edge of death
as you lay gasping with each labored breath.
With your eyes tightly shut in silent pain,
Pandora's Hope burrows deep into your vein,
snaking its way from your arm to your heart
and leaving its eternal mark within your chart.

Defeated, futilely struggling, there you lay.
Can you even hear us and what we say?
Our words of strength reach not your ears,
in your unconscious darkness of pain and fears.
Lifeless are your feeble and atrophied limbs,
your vessel subject to Hope's every whim.

It's not your pain - your suffering - that Hope allays,
but rather our fears and insecurities that It keeps at bay.
And before we realized, before we even knew,
Hope, and Artifice, have crept their way into you.
Hollowed out, Pandora's Hope has made you its shell,
And all for us It traps you - here you dwell.

A Good Death

My last patient died yesterday when I was post-call (aka, I wasn't in to the hospital).

This morning when I logged on the EMR (electronic medical records), I thought it was odd that it listed him as "discharged." I thought to myself, "Why would anyone discharge him? He's far from being stable enough to go home!" Later during rounds, the attending told me and the intern taking care of him that he died Sunday night.

I wasn't surprised (he was in really really bad shape with zero hope for recovery) but it still shocked me a little. The family had decided to declare him DNR (do not resuscitate). Within 24 hours of his death, most/all of his family had flown in from all over the US to be with him in his final hours. He was put on palliative care right away, but since the palliative team doesn't work on the weekends (wtf is up with that?), my attending began standard administration of morphine to ease the pain. His breathing rate was high and the morphine actually brought it back down to normal. He died some time later.

I almost cried a little but it wasn't the time and place. I had only known him for about 3 days and we did everything right by him. As the senior resident later remarked, "I'd rather be dead than live on through that." His rights were respected (his son had the power of attorney) and by all accounts, he died a good death - quick, and not drawn out like with cancer.

What do you think? Is there such a thing as "a good death" and if so, what is it to you?

Suck is My Life

Well that was a bust of sorts. Such is my life. :-/

Was supposed to get together with Dan today. When I got there, he had some of his (gay) friends present. They were kinda amusing, lol. He was trying to fix one of their computers, unsuccessfully. Then because we were all there and bored, we decided to go to the giant mall complex near his place. I never got to say what I wanted to.

Oh well. At least I bought some jasmine oolong tea (we went to a tea shop and I had been wanting to buy jasmine tea for a couple days now, what a coincidence, lol). And two of his gay friends play the cello, that's always a plus in my book, lol.

The Good Life vs. the Long Life

A couple days ago a fellow JMS (junior medical student) and I were conversing. Yes, I am aware that my posts have all lately become medically-oriented; heck, who're we kidding, it's been this way for most of the last couple years, lol. Anyway, we were conversing about the kind of doctor we want to be - one who helps patients live a longer life, or one who helps patients live a better life (as in, better quality of life).

If you had to choose one, would you choose a good life or a long life? Of course ideally we'd want both and patients often demand both. But try as hard as they can, they're only human and in the short run will almost always sacrifice a potentially long life for a good life. This got into a discussion of medical philosophies. In medicine we can do many things to prolong life but often at some cost of a good life. In some surgical specialties, such as orthopedics, they work on getting people back to their normal baseline or in some cases improve upon that - that is, an increase in their quality of life.

It's not easy being a patient. Some of my friends simply don't understand that. You can't just tell a patient to take xyz drugs for their health problems and expect them to be even 67% compliant. It's not easy taking 5+ different medications every day, each of them taken at different times and some with certain conditions/restrictions. It's easy to forget which ones you've already taken and which ones you forgot to take. On top of that, you have to maintain a more restricted diet and have a exercise regimen at all. Because, as we all know, medications only gets us so far; the rest of the way is all on our own. And with each pill we have patients take, with each side effect they may present, we decrease a patient's quality of life in order to increase their lifespan. One could argue that we increase quality of life over the long term too, but in the short term it still kinda sucks.

So is there some way to have one's cake and eat it too? Yes. In pediatrics, the general rule is that kids are usually healthy. The goal (in primary care peds) is to keep kids as healthy for as long as possible, and hopefully transition them into healthy adults. The other JMS who's on the same service as I am this month currently has a patient who's about my height but weighs 198kg . . . That's over 400lbs!! This morning I just looked at her (the patient) and thought, "If I hollowed you out, I could fit about 3 of me inside of you."

This woman also has some young kids, all of whom are normal-sized for their age. The other JMS recounts to me, "Did you see her kids? They're all normal. No kid starts out life that fat. What's the difference between them turning into her? Oh yeah, 18 years."

So if I truly desire to go into peds, I have about 18-21 years to prevent my patients from turning into their parents and developing the same health problems their parents either have or will have. It's possible. It won't be easy, but it's possible. I don't think we honestly try hard enough to counsel patients on preventative medicine - eating right, exercising, not smoking, cutting back on drinking, safe sex, etc. It's difficult in primary care, I know, what with the 15-20 min office visits. That's practically impossible! But we must still try.

Perhaps I'm being too idealistic. I wonder if it'll all crush me.

---TANGENT---
I'm meeting Drew for coffee tomorrow. Perhaps this time I'll dredge up the courage to tell him how I truly feel about him. Hmm . . .

I'll let you all know how it goes, maybe . . . lol.
---END TANGENT---