So Shall Ye Reap

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **

It is autumn in rural America. The green-hued sweet gums, oaks, and sycamore trees now boast their orange and yellow palates. The fields of corn which bore ears for the farmers markets and lifestock feed are actively plowed to the ground. Combines rest in the expanses after a hard day's work. Advertisements for fresh apples and pumpkins litter the roadway. It was harvest time. I drove to the hospital, surrounded by the changing fall landscape. Like the combine, I too was headed for a harvest.

To say that I met Kevin would be a misstatement. I became aquainted with Kevin in his ICU bed. He was a young white male, half a century younger than his hospital neigbors. He was intubated and unresponsive, with a central line sprouting from his neck, and an IV in his forearm. I examined him daily, noting his absent reflexes and fixed pupils. The ICU team evaluated him on daily rounds, noting any minute changes in his care. Kevin was not getting any better. He had multiple organ failure, and received multiple rounds of CPR over the past week. The treatment options for acute medicine had been exhausted. We placed a consult to the neurologist to test his brain function.

Kevin didn't blink when a cotton swab was placed on his eyes. He didn't turn when ice water was dropped into his ear. Hedidn't flinch when a reflex hammer was tapped on his tendons. Kevin was brain dead. His family was notified, and plans to withdraw care were determined. But there was a caveat; Kevin was an organ donor. His heart and kidneys had been damaged, but his eyes, liver, and lungs could be of use. We began giving IV fluids and monitoring his blood pressure more stringently, as to preserve the organs for donation. Surgical transplant teams were notified, and made plans to fly in for retrieval.

Since organ donation "harvests" take place at night, I was asked to attend. I had cared for Kevin for several days, and knew his histoy well.I arrived at Kevins hospital bed as the helicopter was landing 6 floors above. His family surrounded the bed. I noticed that he had been clean-shaven with the slight aroma of cologne on his bedsheets. He remained unresponsive as the family said their goodbyes, and whispered to him. The team slowly trailed into the room. Nurses, respiratory therapists, OR technicians, and myself were present as "farmhands", preparing and assisting in the process.I heard the screams and wails of his family behind us as we wheeled his bed towards the elevators.

The "harvest" went quickly. Teams from large institutions came in to retrieve the organs needed for their patients. Kevin remained sedated as the surgical specialists worked on various parts of his body, lowering his body temperature with ice to ensure that the organ was preserved for transport. They made the process as quick and as dignified as possible. The organs were packaged and placed in coolers, and rushed to the awaiting helicopter. I held his discordant, weak heart while his lungs were removed, and watched the contractions slow to a halt. Kevin's incisions were then sown together, and he was placed on a gurney.

Like Kevin, I too have elected to be an organ donor.This experience did not alter my decision-- I was comforted by the professionalism and dignity-preserving methods utilized by the transplant team.I was thankful for Kevin's decision to give life to strangers, to prolong the life of others, even in death.

At some point, I may find myself in an ICU hospital bed, awaiting "harvest".

As ye reap, so shall ye sow.

Spiked

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  
  
Today was opening day of the 2013 NFL season. Thousands of NFL players and NFL fans geared up to watch the Dallas Cowboys play the NY Giants. Today, I sent a Redskins fan into the game of his life. 

I met John in the emergency department. He was a healthy looking middle-aged man, dressed in a Redskins jacket and blue jeans. His chief complaint seemed rather benign. He experienced rectal bleeding for about a week, which he attributed to hemorrhoids. After further questioning, he did recall having some nagging abdominal pain, but stated it was probably gas or constipation. Come to think of it, he had been having some trouble defecating, but that could be related to hemorrhoids too, right? I continued the physical exam, only finding exactly what he told me -- blood in his rectum.

Per protocol, I started the regular workup for a gastrointestinal bleed. I ordered a CT scan to rule out possible perforations. The ER physician pulled me aside. Her eyes were suspicious. "I have a bad feeling about this one", she whispered. 

I read the CT report. His stomach, liver, spleen, kidneys, even his pancreas were unremarkable. The colon, however, was not. I sensed the dread in the radiologist's voice as he dictated the remainder of the report. "Suspicious mass, possible adenocarcinoma. Recommend further testing."

John didn't have cancer. He was a healthy man. He ran 5 miles each morning through the Virginia hills. He ate a "balanced" diet, except for a few Sunday beers and pepperoni rolls while watching the football games. There had to be another explanation. Had he been constipated? Perhaps he had an obstructed bowel. Or maybe he had appendicitis. Or an inflamed bowel. Did he drink from any country streams? His symptoms may be caused by a bacterial infection. Could he have had intercourse with men? Perhaps he inserted a foreign instrument into his rectum? I was desperate. The answers to all of these questions were negative. 

We scheduled John to undergo a colonoscopy to biopsy this "suspicious mass". I talked with him briefly before the procedure. We joked about the cleaning out process involving a bottomless container of GoLytely liquid. He was prepared, but visibly worried. We sedated him, and completed the colonoscopy, snagging a suspicious piece of tissue along the way. A preliminary examination of the biopsy was significant for adenocarcinoma.

The Society for Translational Oncology recommended the SPIKES method for delivering bad news, especially that of malignancy.

• Set up the environment. Ensure privacy, involve family members. Limit interruptions, and connect with the patient. Ask "are you comfortable?", "are there any other family members or friends you would like to be here?"
• Perception. Find out what the patient's understanding is of the medical condition, testing, and possible diagnosis.
• Invitation to choose the method of disclosure. "How would you like me to give the information about your test results?"
• Knowledge. Give a shot in the dark first, such as "Unfortunately, I have bad news to tell you...", then pause. Avoid being extremely blunt, especially when the prognosis is poor.
• Empathy to emotions. Observe the patient for signs of shock or sadness. Identify the emotion, and the reason for it.
• Strategy and summary. Ask if the patient and family are ready to discuss a treatment plan. Then, summarize the information given.

I stood in John's hospital room. His eyes diverted from the football game, and placed on me. His wife placed her novel on the bedside table. Should I be the one to break the news? John had only met me a day ago. And I was only the family doctor, the middleman. I was neither the radiologist who spotted this lesion, nor the surgeon who actually visualized it, nor the oncologist who would treat him. I couldn't answer his questions regarding treatment options. 

I recalled my grandfather's anxiety while waiting for his own diagnosis. I recalled my own angst about his care and the way his physicians broke the news and prognosis to him.

So, like a losing quarterback with time running out, I spiked.

Pained: Folie a Deux

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  

Marla was in pain. 

Pain is subjective. Heart rate and blood pressure tend to elevate with pain, but this is not definite. We attempt to quantify pain by using a scale of 1 to 10, with a "10" equivalent to childbirth or the passage of kidney stones. Again, this is subjective. It can be a challenge to evaluate and manage pain, especially with the growing issue of narcotic abuse.

Marla rated her pain as "100 out of 10", and writhed in pain as I obtained her medical history. Her pain was generalized -- she couldn't verbalize a specific part or region that aggravated her. Her husband held her hand, and interjected responses designed to guide my decision making. She needed pain medication, he said. Surely I understood. Marla looked at her husband before answering my questions.

I observed their interaction as I listened to her tachycardic heartbeat. Her husband was agitated, and rambled about getting rich from filing million-dollar lawsuits against the hospital. They had visited numerous emergency departments in the area, and one one understood their predicament. She was hesitant. Was she afraid of him?

Gut feelings are hardly admissible as objective medical findings or evidence in a courtroom, but I was suspicious of Marla's husband. I examined her carefully, searching not only for the source of her pain, but for signs of domestic violence. Her abdomen could be concealing a pregnancy or inflamed appendix, but could also hold welts. Her eyes may have the recession of dehydration or the pallor of anemia, but may also reveal the jaundice of healing bruises. Her bare arms were tattooed, but may have also been burned by cigarettes. I found nothing. 

Marla's husband grew impatient. He yelled in my face, demanding a prescription for Dilaudid to relieve his wife's pain. She flinched as he raised his voice. Was he using her to obtain narcotics? Did he force her to come to the ED?


I escorted her to the restroom with a specimen cup. Before she shut the door, I whispered the SAFE screen. Did she feel Safe in her relationship? Had her husband ever threatened or Abused her? Would her Friends or Family know if she were hurt by him? Did she have an Emergency plan? Her responses centered around the supportive nature of her relationship. She told me she would have never survived without his support. Her eyes were dull, but she begged me to believe her witness.

Still, I wasn't convinced. Were my suspicions valid? Perhaps my reaction was transference from my prior violent relationship, and I identified with Marla. Perhaps I was searching for the real reason for her vague symptoms and intense pain. Should I refer her to the police? A social worker? What would I say to them? I had no evidence to support my suspicions. I also had no evidence to support a prescription for narcotics.

I watched as they left the hospital, arm in arm, commiserating about the unfeeling doc who wouldn't give her Dilaudid. 

TIH: Tant (Tent)

This was it. We had eagerly awaited the day when we would enter the "DPs" (displaced person camps) that had been shown behind news anchors reporting on the slow recovery following the earthquake that shook Haiti on January 12, 2010. We had heard of the conditions -- the sweltering tents, the shortage of clean water, the lack of toilets, the abundance of crime secondary to resource shortages. From my vantage point, I believe the team wanted to be part of the earthquake relief efforts. We wanted to feel that we had impacted those most destitute among the residents of Haiti. 

To accommodate the needs of those we were visiting, our team was split in 2. The first group set up clinic in a trio of abandoned, gutted buses left baking under the Caribbean sun. David, our security director and guide, pointed out a few positive signs -- heavy tents were slowly being replaced by 10' x 15' plywood box houses. These were not spacious, not cool, but at least the wood houses provided shelter from the wind and rain. 

The second group traveled a few blocks down to another camp, where we established a camp in a community building. The building's hot tin roof was unkind to those inside, but we made due. We hastily set up in order to begin seeing patients. 

Right away, the difference was noticeable. The people who visited our clinics were weaker, more somnolent, in greater need of care. Security guards were employed to identify patients in need of immediate care, and were triaged to the front of the line. Many needed assistance walking, as they were too woozy or weak to maintain balance. The lack of hydration, underneath the baking sun, inside a heavy canvas tent was a perfect formula for heatstroke. We supplied patients with cups of clean water, but they needed more aggressive methods. In the US, patients with suspected heatstroke may be provided with ice packs, fans, cotton gowns, or even cooling baths. But, this was Haiti. Our suffering patients needed hydration, so we set up a makeshift ward, using wooden pallets as beds and hanging IV saline bags from nails in the wall. 

The patients rested while their family members or friends wiped their brows. One after another, weak patients stumbled towards our makeshift hospital room. Would we have enough IV fluids for all of them? How many needed care in a true hospital? 

The heat was taking a toll on me as well. I began feeling queasy and light-headed. Our team leader Amy voraciously protected us from becoming patients ourselves by insisting upon breaks, water intake, and lunch. My body appreciated the cool water, but after eating, emesis et al were certain. (David teasingly nicknamed my symptoms "Papadoc's revenge"). I asked for the toilet. In the DP camp, the toilet stalls were locked by key, to avoid vandalism, and to ensure that they were clean for the American medical mission team. While gripping my stomach, I retrieved the key. I unlocked the stall door, and walked in. 

TIH

[to be continued...]