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. 

Facilitating a Correction

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

Working in a women's correctional facility over the past week has been a very insightful learning experience. In many ways, there are no differences between care on either side of the barbed wire. Patients present for treatment of hypertension, diabetes, GERD, thyroid dysfunction, asthma, irregular menses, UTIs, and general health maintenance. Labs can be ordered on-site, and a relatively large formulary is utilized. Patients attend all appointments and are 100% compliant with medications. As in an "outside" clinic, patients with surgical needs are referred to the hospital. If not for the homogenous uniforms and locking steel doors, one would never know the clinic was in a prison.

I was allowed to examine Monica, a very friendly middle-aged woman following up with several chronic illnesses. Aside from her shackles, she could have been any patient seen in outpatient clinic. As we lightly conversed about the weather and the prison food, I realized that I had been previously acquainted with Monica. Several years earlier, I met her under a front page headline of the daily paper, her smiling mugshot juxtaposed by the grisly details of a cold-blooded murder. Her arrest and subsequent trial had been sensationalized in the media, due to the sheer cruelty and brutality of the crime. Oh yes.  

That Monica.

During my first year of medical school, we completed an exercise to identify possible prejudices we may have toward different groups of patients. We discussed the reactions we may have to treating homeless patients, welfare recipients, drug and alcohol abusers, criminals, unmarried mothers, racial supremacists, undocumented immigrants, and other difficult social populations. Through that exercise, I learned that I was uncomfortable with murderers and sex offenders. It seemed rather contradictory to provide love and care for someone who deliberately preyed on vulnerable people, or who ended a life in a planned, methodical manner. Would treating these offenders facilitate them to commit more crimes? This dilemma was discussed, but not resolved. We were advised to be cognizant of our biases, and maintain professionalism. 

Personally, I believe the doctor-patient relationship to be the crux of primary healthcare. Forming a bond with a patient is the key to obtaining an exhaustive history, and unearthing previously overlooked details crucial to treatment. How could I connect with a person who committed such a heinous act?

How was I going to effectively serve this patient? Employment of a defense mechanism seemed most appropriate. While I listened to Monica's heart and lungs, I considered my options:

• Denial - believing I had the names confused, and Monica was not the killer I recalled
• Intellectualization - considering the pathophysiology of Monica's chronic diseases 
• Conversion - involuntary development of blindness in order to avoid completing the exam
• Reaction formation -becoming overly accommodating and friendly to compensate for my negative feelings
• Idealization - convincing myself of Monica's innocence
• Suppression - curbing my thoughts and focusing on completing the exam
• Rationalization - believing that Monica had a justifiable reason for her crime
• Humor - joking with the patient to circumvent the elephant in the room

While I contemplated this and moved to test Monica's reflexes, she intuitively asked me how I liked working in the prison. "Are you OK with treating all these crazy people in here? That's gotta be hard." Without hesitation, I replied. "It's not so bad. Really, patients need care no matter where they are — hospital, clinic, prison, nursing home, on the street. I love helping folks, and making life a little easier for them". Wow. Where did that answer come from? I have no doubt that divine intervention was in play. How humbled and blessed I felt to realize that the Most High had used Monica to teach me such an important lesson. Monica was no more or no less deserving than any other patient. My calling is to heal and serve, not to judge. As a physician, my role is to provided objective, empathetic care to help my patients live with good quality of life and optimal health. After accepting this call, my objections to treat patients are moot points. It only took a day in prison to facilitate this realization, and correct my attitudes. 

Thank you, Monica. 

The will of God will never take you, 

where the Spirit of God cannot work through you, 

where the wisdom of God cannot teach you, 

where the army of God cannot protect you, 

where the hands of God cannot mold you

~ Author Unknown

On the Edge

I was deeply affected by a blog I recently read, written by Dr. Elizabeth Breuer, for KevinMD (here), regarding a comment made to her by an attending on a stressful night. It must have been a difficult experience for her, struggling to effectively care for her patients, while the negative label adhered to her psyche like a name tag. It's very unfortunate that the attending didn't catch herself...had she forgotten what it was like to be a stressed yet diligent resident? What if Dr. Breuer didn't have a support system or a blog to provide an outlet?

Dr. Breuer's experience is not limited to night float obstetrics. How many times have you been affected by a fleeting, yet hurtful remark? The "sticks and stones" adage may be a nice sentiment, but is unrealistic. As social creatures, humans are affected by what is said to us. We thrive on feedback, and it penetrates into the soul. When that soul is tired, grieving, stressed, wounded, or weak, words may be the fatal bullet. 


You never know what may be going on in someone's life. The grocery store checker may have just lost her mother. The doctor may have a special needs child. The student may be the victim of domestic abuse. The police officer may have just received a cancer diagnosis. When people appear to be competent and put together, we may trust the facade, and lash out nonchalantly. We may scan briefly for signs of trouble, and proceed with snide comments.

The problem? People in crisis often conceal their pain. Tears have a stigma of weakness, a manipulation, a "secret weapon" to garner favors. To protect ourselves, we don suits of armor, put on our best poker faces, and hide the crumbling foundation within. We overcompensate with strength…and it works, until that one final push. 

It could be a flippant remark from a co-worker. It could be a "dressing down" by a superior. It could be an angry tirade from a parent. It may even be a less personal action- closing the elevator in someones face, cutting them off, stealing a cab, etc. Cyberbullying suicides rarely occur after 1 incident. It takes repeated harassment, with the constant suppression of emotion, to nudge a victim to consider escape, until that final step. Will your poorly chosen words push someone over the edge?

Please, be kind. You just never know.