Update

Eight days later my dad was finally discharged from the hospital to go home. The clincher was when his neutrophil counts finally got into a safe range with plenty of wiggle room. He's lost quite a lot of weight over the past two weeks so he's got quite a lot of rehabbing to look forward to in order to gain back strength and lost muscle.

things I've learned

     Most anybody will admit our healthcare system has some severe flaws.  Very few, though, will see through the political posturing to the inherent and deeper flaws.  So far, I've yet to see one meaningful policy idea put forth seriously.  Take for example the now Supreme Court validated Affordable Care Act.  It has both its defenders and detractors.  I've yet to hear anyone, though, address and propose a solution to one of its fatal flaws.  There are simply not enough doctors to address the increase in the number of patients that will have insurance.  Period.  Math is not on this law's side.  And it's going to get worse because it takes a good decade to train new doctors.  It's not like they can be cranked out in respone to an increased need in short order.
     There is a rule of thumb that for each decade of life, that represents one chronic or serious health problem.  So a 44 year old will typically have 4 problems and a 72 will probably have 7.  There is also a rule of thumb that an office visit should take between 15 and 20 minutes.  So when a 60 year old patient comes into the office with 6 problems, which problem am I supposed to ignore?  Their prior cancer history?  Their osteoarthritis?  Their hypertension?  Their diabetes?  Their high cholesterol?  Their bladder control problems?  I don't ignore any of them and end up spending a good 50 minutes with the patient.  That means the next 2.5 patient encounters are now backed up.  This happens daily.  How are physicians going to handle an increase in the number of patients?  That which cannot go on indefinitely, will not.

discharged?

     We had already signed the papers, packed my dad's bags and walked out the room. Discharged.  I left my dad in the front lobby of Mdacc while I trekked back over to school to get my car. He was ready for some uninterrupted sleep in his own bed (hospitals are the worst place to get rest). In the ten minutes it took to get my car and drive back, they called my dad. One of the cultures did end up coming back positive.
     Parainfluenza 2. You know the coughing snot nosed kids runny around schools and day cares? This is one of the viruses responsible for that. It is usually not a big deal but in a stem cell transplant it's a very big deal. Significantly bad things can happen to stem cell patients infected with this virus. So we are back in the room waiting to hear what they want to treat him with (viral treatments are rather limited) and whether to do it as an inpatient or outpatient. The waiting game again...

associations

     That smell. That smell on my hands. It's not an unpleasant odor but the emotions that go with the smell are another matter. It's the distinctive smell of the hand sanitizer at MD Anderson's hospital. The source today is the emergency room. The last time I was here was the day of my brother's funeral. The time before was my brother's death.  In both instances my dad ended up there with neutropenic fever. Today we ended up there again - same shit, different day. While the circumstances where nowhere near as dire nor as urgent for my dad, the feeling of failure was strong. Weren't we done with this? Why was he spiking a fever?
     My dad had been fighting on his own a presumably viral infection for the past 7 days, but today it took a turn for the worse. His fever jumped up to 38.1 C (100.5) which to anyone else would simply mean a day home from work. For him, it's an automatic stay at the hospital with the full work up. The IV antibiotics have begun. The cultures have been drawn. The chest x-ray was normal so no pneumonia (I guess my lung listening skills have become honed because I had told my parents no pneumonia that I could tell). Now the waiting game begins...

it's never about hypertension

     At the top of each chart there is always a Chief Complaint (or CC).  It's what the patient is here about today.  Or, at least what they told the nurse when they came in.  The problem is it's NEVER about the chief complaint.  Sure, a patient may have diagnosed hypertension.  Their CC may state "follow up for hypertension".  And they may in fact not have very well controlled hypertension (chances are they don't).  But that's rarely why the patient came in.  Inevitably, there is something else going on in their life which prompted the visit.  Some new ache.  Some old pain.  Some new symptom.  Some newly observed finding on their elbow.  Some completely fabricated symptom.  The uncontrolled hypertension is what is most likely going to cut their life short but whatever is hurting in their elbow is what is weighing most heavily on their mind.  Hypertension, high cholesterol, or diabetes for the most part, are mostly symptom free.  So why worry about something that you can't feel?  So you make a deal, albeit not explicit, with the patient.  You will address their concern but in return, they agree to actually take their lisinopril, or increase their dose of insulin.  It requires some bargaining, some threatening of tough love, and sometimes pleading.  It's the art of medicine.

joy

     What's that thing on my face?  It's a strange feeling.  Using muscles that I'm not used to using.  It's a bit awkward but spontaneous.  Oh, yeah, it's a smile!  Maybe it's that I'm no longer buried in endless texts, or that my dad is doing well, or that I'm out in the "real world" again, or that my grief has matured into a healed scar.  And I know that this feeling will probably go away when I get my STEP I score, or when I have to take the board exam for family medicine, or perhaps when I hate my next rotation.  But for right now, at this moment, I am enjoying myself and that is enough.

roots of pain

     I don't even remember why she came in.  Most likely something to do with pain or arthritis.  But given my prior life experiences, I know that physical pain and emotional pain are inextricably tied together.  So I underhandedly steered the interview towards how she was doing emotionally.  There is no specific strategy that works for all, or even most patients.  It's an ebb and flow that one just gets a feel for by trial and error.  In other words, a relationship.  The patient begins to open up and turns to me and says, "I don't know why I'm even telling you this.  I ain't ever told anybody this."  She pauses a minute, wags her finger at me in a revelatory manner, "You're going to be a good doctor.  Uh-huh.  You're easy to talk to.  A good doctor."

drug seeker

I take the extra two minutes to log onto a computer to quickly check the patient's chart.  I refuse to be that doc who walks in clueless.  It reads on the reason for visit as follows:

1. Diabetes
2. Medication refill

     Sweet.  This should be straightforward.  My lunch break started 15 minutes ago and I'd like to be able to eat.  Within 60 seconds of walking into the room, I kiss any hope goodbye of a lunch that doesn't involve inhaling the food in 4 minutes.  Clearly what was communicated to the nurse making the appointment was in stark contrast to reality as the patient clearly didn't realize that to be diagnosed with diabetes, one must actually be diabetic. 
     Crazy idea, I know.  High blood sugars?  Diabetic.  Normal blood sugars?  Not diabetic.  We are taught real cutting edge stuff like that.  Want to hear something even more wild?  We don't give insulin to people who have completely normal blood sugars.  It could kill them.  Wild, right?  This seemed to fall on deaf ears.  While the patient is talking, all that is running through my head is, "please stop inventing symptoms and conditions so I can have ten minutes to eat."  I go to present my "findings" to my attending doc and as I soon as I open my mouth to try to give the history, I start laughing inside because I can either get angry or I laugh it off.  A psyche referral isn't even on the table as the patient was no danger to anyone and got angry at even the insinuation that some mental health might be a good idea.  Besides, they weren't really psychotic (I've seen that, too, and I had nothing but empathy for the patient but that's another story).  They just thought they knew more than the doctors.  My hunch is they want to feel important by having a doctor pay attention to them.  My attending shakes his head as if to say, "crap, there goes my lunch, too."

I will once again rely on the genius of The Simpsons.  THIS was my patient, only a younger and non senile version of Grampa Simpson.  I should've had fun and used the approach of Dr. Nick.

truth

"A rabbi would never exaggerate. A rabbi composes. He creates thoughts. He tells stories that may never have happened. But he does not exaggerate." - The Simpsons Book learning as the exclusive form of learning is done. In its place is experiential learning via clinical rotations.  The next two years are filled with them.  First is family medicine.  In 4 short weeks, I get a whirlwind tour of what family medicine is like in a county clinic run by academics.  It's only been 4 days and in addition to the staples of family practice - hypertension and diabetes - already I've seen bipolar, heart failure, liver failure, and osteoarthritis to name a few.  I've even seen completely fabricated diseases.  Interesting does not begin to describe them and they are wonderful tales to be told.  But in order to respect the patient's privacy, I will do as the rabbi above does.  I will compose.  I will create thoughts.  I will tell stories that are not quite historically accurate.  But they are all 100% true.