Posts Tagged ‘ultrasound’

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.

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Slowing down: fifty-four, not seventy-two

April 26, 2011

Here’s a fact that I’ve found

This one I’m sure will astound

     It’s just fifty-four

     Hours, no more

But really, I am slowing down

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  On assignment on the North Island of New Zealand, I’m living in an apartment attached to a clinic in Matakana, north of Auckland.

ANZAC day commemorates the Australia-New Zealand Army Corps losses, first in WWI and then in later wars. It’s not my holiday because I’m not a Kiwi, and I volunteered to work the clinic today. This year the coincidence with the Easter weekend gave the country a four consecutive days off.  I tacked my fourteen hours today onto the fourteen I did on Good Friday and the twenty-four I worked the day after.  I worked at a reasonable pace, and got at least one break a day; today I took a morning and afternoon tea break and went out for both lunch and supper.

Yesterday evening I stopped being able to stay awake at 8:00 PM and went to bed; I slept soundly till 4:30.  Breakfast followed shower.  Without the anticipated traffic I arrived twenty-five minutes early.

Holiday business continued; as of 6:00PM I’ve seen twenty patients and done (or not done) phone prescriptions for 4 more.

‘Two patients have studies pending which I hope prove me wrong.

I looked at one patient whose dermatologic problem has failed to clear for nine years, and instantly disagreed with the previous diagnosis, in part because of inadequate response to medication.  I prescribed a skin creme, handed over my card, and requested a post or email if a cure resulted.

I treated six patients non-pharmacologically. 

I lost track of the number I told to quit smoking and drinking.

I made four patients better before they left; I cured one.

I did no defensive medicine.

When I went out to eat I walked down Wellsford’s main street in the rain, glad of my duck-hunting jacket and my cap.  I heard a couple speaking Spanish outside a cafe; I threw six words into their conversation and made them smile.  I wanted to stop and chat, to find out where they were from, and the forces that had acted on them to be here in this place at this time, but I walked on so I wouldn’t breathe their cigarette smoke.

They had left  by the time I returned; the nurse departed at eight and I spent the next two hours on-line researching my next placement.  When I turned out the lights and set the alarm at ten, I had worked fifty-two hours, twenty less than I usually work on Easter weekend. 

Pouring rain lengthened the drive home by twenty percent.  With light traffic, I fought the urge to break the speed limit along the straightaways.  I arrived in Matakana, the town was dark and quiet, and, like me, tired from the long weekend.

Thirty-eight CT scans later, life’s lessons from a musician and a teacher

January 6, 2011

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog. 

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant. 

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her. 

“Well,” I said, “Just lay back on the exam table while I check your tummy.” 

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart. 

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.   

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

Title 47, a pulsatile mass in the abdomen, a conversation in Spanish, and a lecture on snowy owls

July 14, 2010

 

Consider that whitest of fowl

Whose scream sure isn’t a growl

     Avoiding conjecture

     I went to a lecture

About the North Slope’s famed snowy owl

All patient information in this post was included with the permission of the patient.

Because schizophrenia exists worldwide, all cultures have a mechanism to deal with people who act irrationally.  No two states have the same laws;  the phrase “danger to him/herself or others” recurs frequently. 

Alaska’s physical realities do not permit such leniency; those whose thought processes are clearly out of control warrant safe placement because of carnivores and a hostile climate.

Our morning conference featured a long discussion of Title 47, the state law that deals with involuntary commitment.

Later in the day a person came in with pain in the top middle part of the abdomen, just below the ribs, where I could feel an apparently enlarged aorta.

An aneurysm happens when an artery becomes more like a water balloon than a garden hose; the larger the aneurysm the greater the chance of rupture.  If the aorta, the largest blood vessel in the chest and abdomen, develops an aneurysm and the aneurysm ruptures, the patient usually dies. 

Ultrasound makes the diagnosis, surgery cures the problem. 

With one ultrasound machine and tech for an area the size of Minnesota, I had to scurry to bump another patient off the ultrasound schedule.

The Medevac planes are still out of commission.

I attended a Mexican patient whose last name was not at all Hispanic.  I showed off my Spanish and put the patient at ease.  I hadn’t realized how much I missed speaking Spanish.

A  lot of people from tropical countries moved from the Caribbean or the South Pacific or Florida right to the most Arctic place in the country.  They never complain about the cold.

The ultrasound was OK, I was able to reassure the patient with the tummy ache and diagnose a much more prosaic problem.

At seven in the evening I went to the Heritage center, next to the library.  I walked past the Arctic Ocean crashing onto the ice on the shore, the wind at my back, to a lecture about snowy owls.  Most of the people in the audience were young non-Inuit.  The lecturer has been coming from Montana to Barrow to research owls for nineteen years, and spoke with a Boston accent.

They are very large birds.  They kill snow geese and Arctic foxes on a routine basis; aggressively protective males attack human researchers approaching the nest.  Their favorite prey is the lemming.  Once the females have eggs, they scream loudly to the male for food, all summer.  A physically aggressive male and a loudly screaming female have the best chance of successfully rearing young.  The females are bigger than the males.  Males are pure white, females have bars and spots and look like dirty, melting snow.  Owls banded near Barrow travel from eastern Canada to Siberia. The Russians trap them for their eyeballs, which are marketed as an aphrodisiac.  

Walking back, the fifteen mile per hour wind was in my face, and I still need the long johns.  Last summer was much warmer here.