August 31, 2015

good part III

After being transfered to the ICU, the patient never regained consciousness and he passed away. Others on the team were surprised by his passing. They thought he'd regain consciousness. I knew better from the moment I admitted him. You just don't recover from that. And I'm not sure my silent prayer for peace and a good death came to fruition. It's not my first death. Most docs don't forget their first death. But you NEVER forget it when it's your brother as the patient. But I still feel the loss of this patient, nonetheless.

August 29, 2015

loss of an titan

So often with titans in the medical field, there are egos bigger than buildings named after them. Not so with Dr Red Duke. The man was a legend, is a legend. One in a million. All those cliches, except in case they ar a absolutely true. He was larger than life and a model physician for everyone he touched. The patient ALWAYS came first and there was not even the slightest hint of pretentiousness.  He didn't care if it was a CEO, a president of the United States, a med student, or the cafeteria worker or the janitor. He treated everyone the same, and that was with dignity and respect.  He will be sorely missed. The story with videos at the link below are absolutely worth watching. And they are not embellishment. This cowboy, this giant among men was the real deal.

good, part II

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

     Implied is that I did good by correctly assessing the patient and ordering the best test to cut to the chase. But, good? I was off the next night so I did not have the opportunity to speak with patient. And the following shift I was off to take care off my own health problems by getting my bone marrow biopsy. Insert a two day training course on advanced life support for obstetrics and I've missed the patient for days now. I finally come back on only to find out the patient went downhill rapidly and ended up in the ICU.

     A sense of regret washes over me. I only performed HALF of my job. I was there to diagnose the ailment. But I was not there to console the patient. The rule of thumb is that is the job of the day team, not the night team. But not one of them knows pain like I do. And I hope they never do. But I still feel as if I let the patient down. So before it gets too late into the evening, I stroll into the ICU where it is no longer my domain. I stand and watch the patient breathing with a ventilator and say a silent prayer asking for a good death and peace for the patient and the family. The nurse looks at me a bit strangely and asks who I am. So I answer honestly. I admitted the patient and just wanted to do right by the patient by following up, no matter how too late it is.

So, did I do good? I honestly don't know. But I know how I will do it differently next time.

August 25, 2015

affordable care part II

     I lay face down as the tech prepped the area where they would be drilling a hole guided by a CT scanner into my bone to collect a bone marrow sample all in an effort to finally determine whether I have cancer or not.
     "Are you sure you don't want to be sedated?" the tech asks with a slight bit of concern. 
     "Trust me. Neither I nor you want me getting propofol or fentanyl. I'll start vomiting. And I'm talking projectile style. And y'all will have to clean up an awful mess. I'm fine with a small dose of dilaudid and versed."
     "You're the doctor."  Even as a patient, I'm addressed as doctor. I can't help it. It's not that I'm pretentious or want the prestige. It's just who I am. While waiting, a nurse began asking about diabetes drug options so I gave a list of options to bring up the next time they saw their doctor. The patient, sorry I was the patient and they the healthcare worker, walked away armed with far more information than they had before. And it just feels so natural to me. 
     The IV meds are pushed and the metal rod about the size of a good sized Phillips screwdriver is bored into my bone. The interventional radiologist scans me with the CT and then readjusts it. Repeat several times. And I'm not thinking about the physical pain. Acute pain I can handle just fine. It's the chronic one that wears me down. No, I'm wondering why did this take so long? Why did I wait with the potential diagnosis of cancer looming over me? In a word, Money. I had it scheduled before I was to start residency. After all, it was a lot easier to do then with respect to scheduling. But with my "affordable" care act insurance, this procedure was going to cost me $4,000. To quote the infamous Inigo Montoya from The Princess Bride to the government, "I do not think that word means what you think it means." So I had to wait until I started residency and got on a good insurance plan. So here I lay with a rod being shoved back and forth now able to get the necessary test run because I'm fortunate enough to be in the right labor pool. I am grateful for being able to finally get the test but I'm also not naive enough to think that our healthcare problem and it's looming insolvency is moving in the right direction. 

August 23, 2015

good part I

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     It took less than two weeks. I pull a stool up to the bedside in the ER to get the patient's story. I cinch the curtains shut to try to get as much privacy as possible but they remain impotent against the constant noise of controlled chaos that is a tertiary level ER. It becomes readily apparent after listening for five minutes that this story will not have a happy ending. I explain to the patient what general tests I am going to order, how the process of being admitted to the hospital works, and always end by telling the patient that I am here all night so if they need anything, just have the nurse give me a call. And I genuinely mean that last part. No matter how tired or what time of the night it is, I always answer the phone with a pleasant voice saying, "family medicine, this is Dr Isaac."
     I quickly enter in the admission orders along with a battery of tests to rule out some common things. But I know the most important one - a CT scan - and order it without hesitation. By this point, I have earned the trust of the third year resident so that he had deemed me competent enough to plan my own orders. He will review them to make sure I didn't forget anything but the point of being a doctor is learning to think on your own.
     A couple of hours later, I go home and hurry up and sleep. I only have a limited number of hours to eat and sleep before turning around and coming right back to the hospital. When I wake up, I check my phone for any texts or calls that I missed while sleeping. Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

August 17, 2015

the physical form

Working long and odd hours, I often get the gym to myself. I looked in the mirror and thought, though this physique is no Adonis, I wondered, does this body yet have cancer? I still do not know. Another consequence of working long and odd hours is that it's difficult to take care of yourself. I'd rather be asleep than waiting in a doctor's office. But the bone marrow biopsy is a day away and that shall reveal all.

August 15, 2015

Every morning I come home from work strung out on adrenaline and caffeine thinking to myself, it's astounding how much I can learn in just one night. And every evening I drag myself back to the hospital and a different patient comes along that makes me think to myself, I don't know jack shit.

August 7, 2015

vampire test

     I have been accused, justly I might add, of having a bit of an Eeyore personality.  My wife is my opposite and so at times will needle me initially to try to get me to smile, but failing that, then just to get any reaction out of me.  So it was the other day when I was stressed about not knowing whether I had cancer or not, my back pain was flaring up, and I had some work issues causing some stress.  So she poked, prodded and finally gave me a love bite, really more of a hickey than a bite, on my forearm which I admit did cause me to crack a smile at the absurdity of her action until I saw my forearm.  We both looked down.  On top of my skin resided a thin film of what medically would be called serosanginous fluid but in reality is blood with a bit of other fluid.
     Now, she didn't actually bite me.  She didn't bruise me.  But the capillaries in my skin are so congested with the excess red blood cells that they are easily ruptured.  Really easily, apparently.  I asked my wife if she tasted the salt of blood, to which she answered yes.  She then of course found it to be the funniest thing in the world at that moment that I'm oozing blood while I'm just thinking to myself, "This. Isn't. Normal."
     So the day before my next scheduled blood draw I'm curious what my red count is running so I just hand my forearm to my wife.  Yup, still elevated.  The results the next day confirm it.  Time to lower the dose of my medication again.

Disclaimer: The vampire test should only be performed under the supervision of a trained physician.

August 4, 2015

affordable care part I

Out-of-Pocket Costs More Stressful Than Cancer in Texas

Nick Mulcahy
July 31, 2015
In a finding that points to the overwhelming impact of out-of-pocket expenses in American cancer care, more than 30% of patients with advanced cancer rated their financial distress to be more severe than their physical, family, and emotional distress, according to a new study from Texas.
Of the 149 study participants, 72 received treatment for advanced cancer at a general public hospital in Houston and 77 received treatment at a private comprehensive cancer center.
Not surprisingly, the poor folks at the public hospital were a lot worse off.
In fact, a novel self-reported survey revealed that the average "intensity" of financial distress in the public hospital patients, measured in a 10-point scale, was more than twice that of private center patients (8 vs 4; P = .0003).
But some degree of financial distress was present in just about all public and private patients (90% vs 86%).
Financial distress was calculated as the percentage of a patient's total family income spent on out-of-pocket cancer costs in the previous month and the related subjective stress.
Median monthly income of the public patients was lower than that of the private patients ($940 vs $3000).
The overall findings are "concerning" because physicians lack the tools to uncover financial distress, according to the study authors, led by Marvin Delgado-Guay, MD, from the University of Texas M.D. Anderson Cancer Center in Houston.
"The vast majority of the instruments aimed at determining symptom distress and quality of life do not include a financial distress item," they write.
Their study was published online July 23 in the Oncologist.
Financial distress was also associated with anxiety, depression, and poor quality of life.
"I am not surprised that such a large proportion of patients consider financial distress to be more unbearable than other forms of distress," said Yousuf Zafar, MD, from the Duke Cancer Institute in Durham, North Carolina, who, along with his colleague Amy Abernethy, MD, coined the phrase "financial toxicity," as reported by Medscape Medical News.
Patients are at risk of suffering in silence.
Dr Zafar said that patients are ill-prepared for the treatment-related financial burden and do not know where to go for help. "As a result, patients are at risk of suffering in silence," he said.
Dr Delgado-Guay's team and Dr Zafar agree that of all stressors a cancer patient faces, financial distress receives the least attention.
What can clinicians do? Perhaps use the Comprehensive Score for Financial Toxicity (COST) — a questionnaire developed at the University of Chicago, as reported by Medscape Medical News — to help "identify possible interventions to ease patient suffering," the study authors say.
The 30% Explained
In their study, patients had breast, colon, lung, or prostate cancers that were recurrent/refractory (treated with more than two lines of chemo), locally advanced, or metastatic.
In addition to the COST questionnaire, which is not a validated tool, patients completed validated questionnaires to assess symptoms, psychosocial distress, and quality of life/functioning.
To assess the relation between money stress and other cancer-related stressors, the study participants responded to a series of statements made by the investigators, such as "I have more financial distress than physical distress."
Financial distress was reported to be more severe/stressful than physical symptom distress by 45 patients (30%), than distress about physical functioning by 46 patients (31%), than social/family distress by 64 patients (43%), and than emotional distress by 55 patients (37%).
All responses were significantly worse for patients treated at a public hospital than at a private center (P < .05).
When patients consistently report a high level of physical, spiritual, and emotional distress, clinicians should explore the possible presence of financial woes. In other words, when ongoing high levels of distress of any kind are present, expect that financial distress is also present, say the authors.
However, they caution against generalizing their findings because only two institutions were involved.
The authors and Dr have disclosed no relevant financial relationships.
Oncologist. Published online July 23, 2015. Abstract

August 1, 2015

it's official

     While I have filled the shoes of a doctor multiple times over with my family, I have now officially performed my first formal act as a doctor while working nights this month. Prescribing tylenol. Nice way to ease back into things. Real slowly. Fortunately, I'm not as dumb as the intern on Scrubs and had no need to page anyone on the dose.

membership has its privileges

     I am down in the medical center to sign some more forms for work.  But I figure why not kill a couple of more birds with one stone.  Or, a coat in this case.  I'm supposed to come back down the next day for another blood draw.  But I really do not want to drive 60 miles round trip just for a blood draw when I could do it today.  I also need to get in to see a pain management specialist to see about doing something different for my back.  So when I get out of my car, I throw on my white coat that, contrary to my wife's opinion that the md should be lowercase until I complete residency, has the capitalized MD after my name.
     I sign my forms and head over to my oncologist's office.  It's quicker to walk outside but it's flirting with triple digits which is why I hate wearing the white coat in the first place.  Who would want to put on an extra layer of clothing in this climate?  But I'm realizing how much of a status symbol it really is.  So I stay inside and take the longer but air conditioned cross walk over to the office.  Instead of going through the 10 layers of bureaucracy to sign in, I simply casually walk back to the phlebotomists.  They like me because I can tell funny stories about their favorite doctors from when I was in med school.  I ask, and I must add nicely not just because I treat nurses special but because I treat all (or try to) human beings as I'd want to be treated, if they could at all possible squeeze me in.  One look at my coat's insignia and she puts her arm on me and warmly says, "we got you" with a smile.
     Five minutes after the blood collection, I'm walking from the oncology office to the neuroscience center (I'm a walking disaster).  I find out that they finally got an in house pain management specialist.  So I walk to her office suite.  It's near the end of the day so no patients are left in the waiting room.  I briefly introduce myself to the person at the desk and less than five minutes later the doc's medical assistant walks out.  I briefly explain what's wrong with me, what their spinal neurosurgeon colleague upstairs said about me (for free), and that she'd like me to try spinal injections to get some sort of relief from the chronic pain.  And I will never forget her answer because it was so kind and couldn't have been more appreciated.  "Well, we don't want to waste your time so do you want to come in for the visit and get the injection the same day?  We can make you the last case of the day since you're working nights and you can get some sleep.  We can squeeze you in next week.  Will that work?"
     I wanted to hug her.  The previous pain doc's office I tried to call first didn't answer, second time put me on hold and third time told me they were booked until September because the doctor has been on vacation and is going again.  So getting this royal treatment felt wonderful.  I'd like to think they treat all their patients this way and maybe they do.  But I also know it's because I'm a doctor for the same institution, albeit a resident.  But I figure I more than paid my dues with earning that MD under the circumstances I did so I felt a little less guilty about getting special treatment.  I've lived enough catastrophes the last 5 years that I'll take a little grace and privilege whenever I can get it.
     By the time I'm walking back to my car, I'm checking my phone and some of my blood results are already back in.  It's looking less and less like cancer and much more like a bizarre reaction to a medication.  With that sigh of relief, any feelings of guilt for getting special privilege melt away.