Posts Tagged ‘cancer’

Syphilis and gold: finding what you look for

April 2, 2014

Across the car park I strolled
In the rain and the wind and the cold
The thing I did find
Brought hope to my mind
And turned out to be real gold.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.

On my first Monday back from Alaska I went into the office to catch up on the miscellany that accumulated in my absence. I found 320 clinical items on my electronic desktop along with 78 administrative emails. In the quiet of the early morning, when my body clock should have screamed for sleep, I dug in and started plowing through the items one by one.

About half had to do with bad things that had happened to my patients, requiring hospitalization, while I vacationed. Every admission generated an ER note, a history and physical, progress notes, lab and x-ray reports, and a discharge summary. I could not determine the importance of each item without reading it.

I ran into some surprises.

Three patients received malignant diagnoses, and I judged each cancer gratuitous. None of them did anything to deserve their tumor.

One person’s syphilis tests came up positive. I followed the communications; saw that my partners had done the right thing through the health department notification, the lumbar puncture, and the penicillin injections. I look forward to seeing if the patient’s symptoms improve.

When my father attended medical school, his professors would lecture, “Know syphilis and know medicine,” but since then the frequency diminished to the point where we rarely think about it, and sometime we forget to look for it. Lyme disease brought a resurgence in testing because searching for one justifies testing for the other.

I left the clinic at 1230 to go home for lunch, and as I got into the car, I saw a faint gleam of yellow on the pavement. Smaller than a dime, when I picked it up I saw it had suffered from passing car tires grinding it into the gravel. But it had a milled edge, which marked it as a coin.
At age 9 I found a dollar bill in the street in front of our house, a powerful experience at the time, and even more so because of the large purchasing power it represented in 1959. I started looking for more. One finds things that one looks for.

During med school, the Michigan State school paper published a piece by a student who also found money and who kept track of it; he commented that as inflation eroded the value of money he found more and more. Perhaps because of its lower worth, and perhaps because I keep getting better at spotting it, I find a lot more money than I used to.

When I came back to the office, I stopped in at the pawn shop across the street, and asked my friends there to check the tiny item for gold content, which came, to the surprise of all, as 22 karat; I accepted the spot gold price and walked out a happier man.

I worked through till 530, when I cleared out the last of my electronic communications, thinking about how one find things that one looks for.

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Scenes from a weekend on call

September 29, 2013

The weekend covers days three

And guess who’s on call?  It is me!

With period and comma

I document drama

You wouldn’t believe the stuff that I see.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

Scenes from a weekend on call

Saturday Morning

I sit in a hospital room with a new admit and I take a history.  Sunlight streams through the window, the first day of fall gleams outside with perfect temperature.  When I get to my 84-question Review of Systems, where I ask about every conceivable symptom, violence from the next room shatters the mood.  A domestic disturbance has broken out in the adjacent room and spilled into the hallway along with items of furniture and things that can be thrown.  A mother hurries away with an 8-year-old in tow.  I read the child’s face and the look of wonder and awe, and I see he has been handed a script loaded with dysfunction.  Overcoming what he accepts as normal will take intelligence, persistence, insight, determination, optimism, and, probably, help.

Saturday Morning

I sit beside the patient’s bed.  “What do you think the CT showed?” I ask.

“I don’t know.”

“Do you want to guess?”

“I don’t know.”

The patient knows, and I know it.  I make small talk and then start the trip around the track again.  “What do you think the CT showed?”

After four laps I get the patient to say “cancer.”

Saturday Afternoon

“Yeah, I know I got cirrhosis and I know I should quit drinking but hey, you know, I was about oh I don’t know probably about 3 or 4 weeks and I hadn’t had a drink then, oh I  don’t know, I got pretty hammered.  But I didn’t do it that much and I only did it a couple of times.  And sometimes, geez since July I blow up and then I’ll pee off like about 25 pounds and it comes and goes and now my belly hurts up here on the right.”

 

Saturday Afternoon

“I think she has decided to die.”  The patient’s children look at each other and their faces carry nuance beyond description.

“We kinda thought that since we read that book.”  They refer to Love, Medicine, and Miracles.

 

Sunday Morning

“I gotta be outta here tomorrow for a court appearance.”

I nod.  I have a patient with a heart attack waiting for me in the ER across town and I need to move.  “So how are things going for you?”

“MM?”

“You know, life in general.”

“Real good.”

“Do you really believe that?  When you just told me you girlfriend left with your kid and you have a court appearance?”

“Yeah.  (pause) Well, no.  No.  I got a country and western song in my head.  It’s my life.”

Sunday Evening

It’s past midnight and I’m talking to a judge by phone.  I explain that the patient’s brain function, loosely connected by an accident of genetics, has not improved with a major electrolyte imbalance occasioned by and coincident with severe hypothyroidism and failure to take meds as prescribed by a psychiatrist and endocrinologist.  After non-stop clinical work starting 19 hours previous I can remember the patient’s name and age but not birthdate.  I can, however, relate details about the request for hospitalization, docility in the ER and a quiet hour on the medical floor followed by increasingly loud, bizarre, and violent behavior over the subsequent 2 hours (which responded temporarily to 1 mg of Haldol, but which will necessitate a 48 hour court hold).  The call takes twenty minutes and ends at 1:30.  Vigilance robs my sleep for the next 3 1/2 hours and then I get up, shower, eat, and start rounds again.

Short call on Labor Day weekend

September 3, 2012

Labor day spent making rounds.

You wouldn’t believe the diagnoses I found!

It wasn’t quite call,

I avoided a brawl,

And sent four to their homes out-of-bounds.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week

Our hospital service has grown to the point where two docs get assigned every weekend, one each for a long call and a short call.  I drew the short call this holiday weekend, not the same as the short straw.   I requested, and received, assignment to my preferred hospital, where I’ve done morning rounds now for four days. 

My natural tendencies wake me early, but today I ate a leisurely breakfast before Bethany dropped me in the deserted doctor’s parking lot.  I printed my patient list in the doctor’s lounge at 6:58 AM and took the elevator to the 5th floor. 

I returned to the doctor’s lounge, emotionally tired, at 11:30.  I had rounded on 13 patients, each one a unique human being whose illness brings drama and irony to their lives and the lives of the people around them.  Each has a marvelous story, rich with details, triumphs and tragedies enough for a series of novels.

While I can’t discuss patients in particular, I can talk about the patient population in aggregate.

Four patients carry the diagnosis of schizophrenia.  Eight qualify as hard-core alcoholics requiring treatment for alcohol withdrawal.  Bipolar disorder (previously called manic-depression)afflicts three.

Eleven of the thirteen didn’t quit smoking soon enough, such that they required treatment for nicotine addiction or emphysema or both. 

More than one has chronic kidney failure necessitating dialysis. 

Others had cancer, HIV, depression, gallbladder disease, broken bones, dementia, urinary infections, lupus, and coronary artery disease.

The nurses on the psych floor warned me about a violent patient after a near confrontation.

I didn’t even bother to count the number of patients with the garden variety problems of diabetes, high blood pressure, and high cholesterol.

I had to deal with two patients with adverse drug reactions, their hospitalizations complicated by the very medications their doctors ordered.

I discharged four patients and dictated their discharge summaries while leaning my back against the wall; I wrote prescriptions for three of them.

One of those represents a triumph of medical care; we cured the problem and sent the patient home in less than 72 hours.  Such satisfaction comes rarely and I relish it when it does.

The doctors’ lounge stood deserted at noon on Labor Day, and I power napped ten minutes before the next task, reviewing transcriptions.  I had 37 in my queue.  After that I dictated six discharge summaries.

I left the hospital at 12:40PM, the rest of a fine summer day right in front of me, and headed home for lunch.

Rounds from Dawn to the Newborn Nursery.

July 26, 2012

 

Sunrise in the ICU

I started the day making rounds

Checking the lungs and heart sounds 

 

It started with dawn,

Where has the day gone?

Beauty is where beauty is found.

 

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I started so early that when I saw my first hospital patient, a perfect sunrise broke as I entered the room on the top floor of the hospital.  The water content of the atmosphere blocks the view of the sun most days till the red disc has ascended well above the horizon, but with the hot dry weather we’ve had, there was the sun, just peeking up.  And the ICU offered a spectacular view of the city in the morning.

The patient couldn’t speak and could barely respond.  Even if the patient can’t talk, I speak to him or her, tell them who I am, the date, where they are and why they’re there, and I try to give a few headlines from the news.  In this case I called attention to the phenomenal sunrise, but the patient didn’t look. 

From the ICU on 6th floor I went to see a new admission on 5 Medical, and discharged a patient who had recovered enough to go home.  Striding down the corridor to the opposite end of the hospital I came to 5 Behavior Health, the psychiatric service.  I did medical consultations on two patients admitted during the previous 24 hours.

The psychiatric portion of the service consists mostly of people who didn’t ask for their problem but got it anyway.  A surprising number of schizophrenics also qualify as bipolar.  More than 90% smoke, and a lot of them come down with type I diabetes as their pancreas withers away.  They lose years of life.  A majority of schizophrenics also have drug and alcohol problems, and they can’t learn from their mistakes.

Our society has failed our schizophrenics.  At one time institutionalized, they were turned onto the streets when the institutions closed, and went right into the criminal justice system.  The ones who stay out of incarceration use a lot of health care.

Fourth floor holds the oncology (cancer) and surgery nursing units on the south.  Contrast being the essence of meaning, I talked to those who know they have no cure and to those with a reasonable expectation of cure.

The pediatrics wing sits on the north end of the fourth floor, and I had no patients there.  Fewer and fewer children need admission to the hospital as the years wear on.  Vaccinations have prevented most measles, mumps, chickenpox, polio, rotavirus, pneumococcal, and meningococcal disease.  We see a tenth of the croup that we used to.

On the third floor orthopedics unit I did two consultations for people after total joint replacement, and on the second floor I took care of two newborns.

Death, the ultimate drama and the ultimate irony, came to three of my patients during the day.  One in middle age died surrounded by grieving family.  One went unexpectedly and alone.  A third died so old and full of years that few remained to note the death, though many, on reading the obituary, will sigh and reflect on how the passing impoverished the world. 

 

 

Life, death, Facebook, drama, and irony

July 12, 2012

Time becomes wisdoms fount,

We’re given an unknown amount

But for family and friend,

When we’re close to the end,

We try to make each minute count.

 

I won’t say when and where these events happened.

On a Monday I attended a hospital patient with a very bad malignancy.  A gratuitous cancer with a notoriously bad reputation had flung metastases to the bone, liver, lung, and brain.  Yet doctor after doctor hadn’t penetrated a wall of denial.  My job description has never included taking away a patient’s hope.  After my usual questions, exam and update, I sat and listened and didn’t contradict.

In the subsequent week, a drama played out over Facebook.  A young couple (not my patients) had found out at the 18 week ultrasound their baby had a problem incompatible with life and decided to carry to term.  The child survived a few hours.  (Not the first time nor only time such irony has appeared on Facebook, I hope that such regrettable circumstances bring learning and insight to the readers.)

The next time I talked with my hospital patient, acceptance had swallowed denial, and Hospice arrangements occupied most of the visit.

At visit’s end, the patient revealed the importance to her of a close family relationship to two teenaged grandchildren.  They had not yet received news of the poor prognosis, and the patient didn’t know whether to tell them or not.

I related the story of the people on Facebook.

In the final analysis, I said, none of us know how much time we have with our loved ones.  Though we tend to squander precious hours, when we know the time has a definite limit, we make the minutes a priority.  If those who cherish you know that the end is approaching inexorably, they will prioritize spending time with you, and they’ll treasure the moments.  Thus they need to know.

And without telling the patient, I remembered the last three days I spent with my mother after she had decided to die.