Hard Times

I've never been a particularly emotional or "reactive" person. I think I get that from my mom. As an example (sorry, Mom) when I was a kid I'd get a lot of sore throats and Mom would tell me, "go gargle some warm salt water" or "drink some tea with honey" or "try to suck on a Sucret". Sometimes she'd just sort of look at me as if I'd told her something that happens every day like, "hey mom, I just took a dump" and she didn't know how to respond to such a declaration. Eventually, after about 5 episodes of strep throat, she figured out that when I told her I had a sore throat, it was the real thing and she would always take me into the doctor right away.

On top of my inherent nature to downplay things, I feel like medicine has calloused me even more. In my training, I've learned that doctors don't have the time to address every concern patients come in with. It isn't practical either. Patients have 15 minute "recheck" appointments where the doctor reviews vitals, labs, and checks in with the patient to see how they are dealing with their chronic disease such as diabetes, heart disease, and hypertension, or touch base on their recovery from a recent illness or hospitalization.

More often than not, patients come to these quick "recheck" appointments with a list of concerns ranging from (likely) insignificant from a physician's standpoint: "my shoulder really hurts, but I didn't do anything to it and it's been like that for years", "I stubbed my toe last week and my knee has been hurting ever since", "two weeks ago I felt dizzy for a split second" to very concerning (but the patients always downplay these ones): "I can't walk up my driveway without stopping to get air", "I've been having this chest pressure", "I am so tired that I sleep 20 hours a day". And then there's the reason for the scheduled appointment: "oh, and by the way, my sugars have been running 'a little high' (very vague...what is 'a little high' to a patient with uncontrolled diabetes, anyways?)", "my blood pressure 'is okay' (again, very nebulous)", or "well, I guess I'm still coughing and I have felt very tired and feverish since being discharged from the hospital."

In primary care, we also have to consider psychosocial issues. This is extremely important (but often overlooked due to time constraints) because it may be that a patient isn't able to take care of their medical concerns because they don't have the resources, support, understanding, knowledge, or psychological capacity. These are issues that if not address, will make it virtually impossible for patients to succeed in taking care of themselves.

As you might imagine, I have the task of learning to filter, prioritize, and categories the problems patients come in with:
1) what is most important to me?
2) what is most important to my patient?
3) what do we have time for?
I'm sure that my patients often feel like I did when I was a child and told my mom I had a sore throat, but she heard, "Mom, I just took a dump". I'm just sitting there, staring at them, processing the information I just heard and trying to decide what to keep and what to throw out. What they think is important and what I think is important don't always mesh and sometimes I'm wrong (yes, that's hard for me to say) and they are right; they may be telling me something that is very important, but I've just downplayed it, filtered it out, stopped listening, and moved on to what is on my agenda. Sometimes, I'm right on (like with Mr. CHF) and at other times I pick up on the subtle cues that they are throwing my way to let me know there is something more they want to discuss but are too afraid to come out and just say it.

In working with the doctors here, I've discovered that this is a continual learning process. No one is perfect, after all, we are all just human (even the one's with an 'MD' behind their names) and even veteran physicians struggle at times. We all make judgements based on knowledge and past experiences. Sometimes we get it right, other times we mess up, and then there are times when we do everything right, but the outcome is unexpected. Regardless, as cliche as it is and in the words of my good friend Jimmy Schatz, "we all learned a very valuable lesson" and take that with us for the next time.

____________________________________________________
Judgement Calls

Ms. Dyspnea (fancy doctor talk for 'short of breath') came to clinic Monday for a recheck from a hospitalization for pneumonia last week. Dr. Gunther was at a meeting, but I thought I'd get started on the visit, so I grabbed her chart and quickly reviewed her history. She has many medical problems that complicate her recovery including diabetes, heart failure, renal insufficiency, and COPD (not to mention she is 80 years old). She was discharged from the hospital with home oxygen, something she had not needed previously. I walked into the room to see Ms. D. and her daughter waiting in the exam room.

"Ms. D., how are things going for you?" I asked as I took a seat across from her. She looked tired, pale, and was a bit slumped over in her wheelchair.

"Not good. I am just SO tired. I can't breath. I can't even catch my breath if I have to get out of my wheelchair, and the swelling in my legs has never been this bad before."

She was clearly getting short of breath just talking to me. "Why don't you have your oxygen with you Ms. D.?"

"Oh, it's not the portable kind, so I couldn't bring it."

"I'm going to step out and get a pulse ox, Ms. D. I'd like to see how your oxygen saturation is doing."

As I left the room, I ran into Debbi, the nurse. "She looks bad doesn't she?" Debbi asked.

When I returned to the room, I slipped the pulse ox on Ms. D.'s finger and continued with my questioning: how's your breathing? are you having a cough? any fever or chills? what medicines are you still on? The pulse ox started beeping rapidly after a few seconds. I looked at the number: 68%! (As a reference, you and I have an oxygen saturation close to 100%. Below 90% is bad. 68% is approaching incompatible with life). I stopped my questioning, grabbed Debbi to get some oxygen, and called Dr. Gunther out of her meeting. Dr. Gunther said she'd be right over.

I started the oxygen at 4 liters/minute with a response up into the 80%'s, so I dialed it up to 6 liter/minute when her sats reached 91%. Ms. D. said she felt better. When Dr. Gunther arrived, we discussed what the plan was for Ms. D. During her hospitalization, her kidneys started failing, but her heart failure was under control, so her diuretics that treat the heart failure were stopped. Managing a patient with heart failure and renal insufficiency is like walking a tightrope: the medicines that treat the heart failure work by taking fluid out of the body through the kidneys and increasing urinary output (diuresis). As you might imagine, this works the kidneys pretty hard and can send a person with healthy kidneys into renal failure. If you cut back on the diuretics, the heart failure gets worse.

Now that Ms. D. had been off her diuretics for a few days while we were giving her kidneys a break, her heart failure had gotten much worse. We decided to send Ms. D. home with instructions to double up on her diuretics for the next three days and we'd see her back at the end of the week. Because she did not have portable oxygen, we wanted to know if she lived close to the clinic and would be able to make it home without oxygen. Ms. D.'s daughter told us it was just one mile and we didn't feel like she would have a problem being off oxygen for just a few minutes.

Ten minutes later, Dr. Gunther got a call from the ER. Ms. D. was in cardio-respiratory arrest and they were in the process of resuscitating her. Her daughter had made it half way home when she noticed Ms. D. slumped over in the back seat of the car; she pulled a U-ee and drove to the ER ambulance bay.

When Dr. Gunther and I arrived at the hospital, Ms. D. was intubated, but only slightly sedated. Her blood pressure was being kept above 90/50 with pressors as she was not able to maintain adequate pressure on her own. Her blood gases showed acidemia, elevated carbon dioxide, and very low oxygen. Together, Dr. Gunther and I discussed a plan. We wrote orders and talked about the things we would need to be thinking about while we managed her in the ICU: cardiovascular and respiratory status, kidney function, and diabetes. Dr. Gunther was kicking herself, "I shouldn't have sent her home. I should have just admitted her to the hospital from the office. I don't know if she'll come out of this; I'm not sure she'll even make it through the night." It looked grim for Ms. D.

The next morning when I arrived to the hospital, I was surprised when I got report from the ICU nurse: Ms. D. was no longer requiring pressors, she was keeping her blood pressure around 120/90 on her own since 11pm; she was only requiring 0.5 units of insulin/hour; her urinary output had picked up to around 50cc/hour (which is great, we like to see greater than 30cc/hr) and her creatinine was stable; she was comfortable, alert, and refusing pain medications or sedatives.

When I went to examine Ms. D., I placed my hand into hers, "Ms. D.? It's Emily." She gave my hand a squeeze. "Are you in pain?" She shook her head, 'no'. "Are you comfortable?" She shook her head 'yes'. I told her what we were trying to do for her and tried to explain things. She seemed to understand.

The main goal now was to try and wean her off the ventilator. This is not as easy as it sounds. She already has compromised lung function from her COPD and recent pneumonia and to take a hit like she had done the day before when she arrested, was pretty devastating. Through the day, the respiratory therapists worked to wean her by decreasing the respiratory rate. This gives a patient time to initiate a breath on their own and start using their muscles to bring air in. Ms. D. did not do well with this: she would take occasional breaths on her own, but not frequent enough and she began requiring increased FIO2 (the percent oxygen provided by the ventilator; i.e., air is 21% O2 and we had the ventilator set at 50% O2) to keep her sats above 90%. We decided to give her a rest and try it again today.

When I left the hospital this morning, we were just starting our second attempt at weaning her. I've been thinking about her a lot and it's not an easy thing. There are so many questions which don't have clear cut answers like: will she ever be able to come off the ventilator and breath on her own? if so, how long will it take? how long do we do this? what will her quality of life be? is this what she wants? Because she is cognitively intact, I feel like this makes all those questions that much more difficult to answer; it's not like she is in a vegetative state--she's comfortable and without pain, fully alert! The last question (which I don't even like to write because I don't want to sound heartless or insensitive) is one of futility: is it worth it? Is it worth the resources, the money, the time, the effort? Is it right? Americans spend insane amounts of money on health care, particularly in the last few days of life. No other country in the world does that. Whatever happened to a peaceful death at home for an 80-year-old woman who has lived a full life? Just because we have the technology and capabilities to keep people alive, does that mean we should?

____________________________________________________
Enough is Enough, I suppose

I was standing at the nurses station yesterday afternoon working on some discharge paperwork for one of my patients and Terri, the charge nurse, asked me if I had heard an update on Mr. COPD. She knew I'd taken care of him the last two hospitalizations. I hadn't heard anything, but I was half expecting him to be in the hospital by now and have gotten in the habit of checking for his name on the board every morning.

"No, I haven't. Is he coming back in today for more respiratory problems?"

"No, he shot himself in the head. He's not having anymore problems with his breathing."

My heart skipped a beat and Dr. Gunther's reaction was exactly what I felt my body trying to do: she gasped, jumped back, covered her mouth with her hand, and moaned, "Oh, no!"

I've also been thinking a lot about Mr. C. today. I've come to the conclusion that he's been trying to kill himself for a long time now. I think that his recent hospitalizations were brought on because he overdose on his morphine. I believe now that these were intentional overdoses even though he denied it when we asked. I think that he was sad, sick, and lonely. His quality of life was poor at best: he had chronic pain, couldn't walk, couldn't breath, and had no joy, no one to share things with, no one to love him. He was getting tired and giving up; I saw that during his last hospitalization when he would ask what would happen if he took his BiPAP off and how long it would take. Perhaps I didn't see the seriousness of his questioning or maybe I just tried to deny it.

When I think about his situation, I feel so incredibly sorry for him. It makes me wish I could have done something more and then I wonder if I could have done something more. Should I have pushed him more to talk about his suicidal feelings? But would that have made a difference?

I may be speaking on emotions right now and just reacting to Mr. C.'s death and this may sound morbid, but everyone says they don't get suicide. I can see their point when someone has a family, kids, a job, etc. But honestly, I do get it for some situations. I get why Mr. C would take his life: his life was shitty--he was sick, in pain, no family, no friends, no love...so what's the point of going on? I can totally see why he did it. I'm not saying it's right or that I could ever do it, but i can see why he did it. If I were standing in his shoes, I might have had similar feelings of having nothing to live for and just wanting to be free from the pain.

Thinking about lives like Mr. C.'s reminds how lucky and blessed I am to have my health, good relationships with family and friends, love, joy, and a sense of purpose in my life. I am so fortunate and it's easy to take this for granted.

____________________________________________________

This has been a bit of a rough winter for the doctors and patients here in Libby. We've seen many elderly people die from pneumonia and surgical complications, a stillbirth, deaths from motor vehicle accidents, depressed and suicidal teenagers, and had to deal with the politics of what to do with a psychiatrically impaired physician. I suppose that even through the struggle in the end there is a reward when patients see me in town and tell me, "I had the best physical of my life last week when I saw you in the office, you will make a great doctor" or when Ms. D.'s daughter tells Dr. Gunther, "the care you have provided over the years for my mom has been outstanding; I know that without you, she might not be here today". Knowing that we helped a few and made a difference in their lives makes it worth while. I have said it before, but I am in awe of this journey I'm embarking on; it is such a privilege to learn through experiences and patients, good or bad.