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.

Autopilot

After a night of turbulent air travel home from the American Academy of Family Physicians Conference this weekend, I relaxed by watching a NOVA documentary on— what else —air travel. This particular program investigated Air France flight 447, a flight from Brazil to Paris which crashed into the Atlantic Ocean on June 1, 2009, killing 218.

A team of independent investigators compiled evidence from the plane wreckage, weather conditions, transcripts from radio communication, and reports from past malfunctions of similar aircraft. It was determined that the plane had encountered a severe thunderstorm, which coated exterior speed sensors with ice. This caused the automatic flight systems to shut off, leading rapid deceleration and an eventual stall of the plane. A flight simulator was set up with similar conditions to that faced by the pilots of Flight 447. During the simulation, experienced training pilots relied on their manual skills to fly the plane, and immediately took control to right the plane. It was postulated that the pilots of Flight 447 may not have had the training to manually maneuver a plane out of complex situations, due to the over-reliance on automated technology. Once the automatic system failed, they may have hesitated to take manual control, advancing into an irreversibly, and ultimately fatal situation.

How does this apply to medicine? In this day and age, the growth of technology has been exponential in the healthcare setting. Digital imaging, electronic medical records, nuclear scans, Doppler ultrasounds, tablets and laptop computers have all become commonplace in America's hospitals and clinics over the past decade. Vital information regarding patient treatment and history is stored digitally. Simultaneously, blogs and editorials have been published describing the "death" of the physical exam, criticizing the ineptitude of recent medical graduates performing basic exams and missing obvious signs. 

Like the crew members of Air France Flight 447,  we are highly trained professionals, tested and trained for the worst-case scenarios. We are very comfortable with technology, and do our jobs using electronic tools as aids. This is sufficient greater than 90% of the time, but what happens when we encounter situations which void our tools? Can we effectively rely on "manual" medicine (inspection, auscultation, palpation, percussion) to diagnose and treat? Can we function without "autopilot" applications and calculators? Are we less adequate physicians because of our reliance on technology? And, in the worst case scenario, will our inadequacy cost lives?

Pained

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

Last night was my first night on call. Halfway through the night, we got a call from the ED to admit Tom, a 25 year old man complaining of chest pain. As I made my way to his room, I was already envisioning his presentation and thinking of labs to order and supportive measures to keep him comfortable. What I found in the room was not a cardiac case. 

Tom was diaphoretic, hypercapnic, and writhing in pain. He attempted to sputter out a history, but kept pleading for a Percocet. He didn't complain of any chest pain; in fact, his pain couldn't be localized to any specific location. His skeletal body was folded into a fetal position. Tears were in his eyes as he begged me to do something for his pain. He vomited on the floor at my feet. I have never witnessed such anguish.

I reported the findings to my resident. She requested a stat drug screen, which was positive for opiates. He reported daily consumption of a smorgasbord of prescription narcotics. We started him on anti-nausea medication and tried to extract details about where he got the pain medicine from. He promptly had a grand mal seizure. 

After he recovered, we questioned his plans upon discharge. Was he interested in rehab? Was he going to wean himself off opioid pain medications? He again emphasized his need for Percocet due to a degenerative joint disease. The suggestions of physical therapy, NSAID therapy, and alternative treatments were all rebuffed. Tom was indignant that he needed these pain medications to ever feel better. No other solution was feasible in his eyes. 

I have never witnessed a severe drug withdrawal of this nature. Tom was in unrelenting pain. As we filled out order forms and wrote progress notes, I wondered how many Toms are created every day. Some may be created out of malpractice and negligence by overzealous practitioners. Others may have good intentions, but may inadvertently create opiate addictions in patients who could have been managed in other ways.

Pain management has always been a "hot topic" in medicine, due to the variable response to treatments, risk of addiction, and of publicized celebrity prescription abuse. Recent emphasis has been placed on the treatment of chronic pain, to reduce associated physical and mental comorbidities. In 2006, the American Board of Medical Specialties added palliative care to their list, perhaps signifying the need to further investigate and improve the treatment of chronic pain without creating dependency.

So, what will happen to Tom? He is ensnared in a vicious cycle of addiction and withdrawal. He needs pain medication to avoid withdrawal, but the medication heightens his tolerance. When he runs out of pain medication, he will delve into withdrawal, requiring higher and higher doses to prevent seizures and excruciating pain. During rounds, as we left Tom in his room knees-to-chest, wailing in pain for his Percocets, our attending commented, "The doctors who prescribed his medications need to visit their creation."

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.

Memoratus in Aeternum

Mid-October has been a special time for me, since 2002. I am currently on the verge of sitting for my first "Step" in licensure, and felt it prudent to reflect upon how I arrived at a career in medicine. 

The year 2002 started off normally for my family, a close-knit group of 4-mother, child, and grandparents. Of these, my grandfather seemed the healthiest, save for a few bouts of gout every year. He led a healthy lifestyle, getting frequent exercise with his shepherd/husky mix, chopping trees, shoveling snow and visiting neighbors. He would fatigue quickly, so made a habit of taking daily naps. In late January, my astute mother noticed his ankles were edematous, and made an appointment with his PCP. The PCP prescribed diuretics and advised to follow up.  Shortly thereafter, my grandfather mentioned a nagging pain in his left side. My mother asked for a CBC, which was never completed. My grandfather was tested for heart failure, diabetes mellitus, and various other common ailments. Trips were made back and forth from the doctor; finally a CBC/peripheral blood smear was done, and a diagnosis was made- Chronic Myelomonocytic Leukemia; an extremely rare leukemia with no cure, and no detectability until the "crisis" stage, though commonly associated with chronic gout and splenomegaly.

My grandfather was referred to an oncologist, and began getting blood transfusions. He was put on a few blood-boosting medications and full-time oxygen. He tried to lead life as normal, continuing to cut branches and untangling the dog from the snarls of the oxygen tubing. When he felt well enough, he attended my dance performances, and we even went to see Mel Gibson's "Signs", although he was embarrassed to tote the heavy oxygen canister though the theater. I accompanied him to his blood transfusions, taking careful mental notes of the nurses too busy with birthday celebrations to notice that his oxygen canister was empty and rattling, or too engrossed in watching "The Price is Right" to remove his automatic blood pressure cuff after discontinuing his IV. I watched my strong, 6'3", 230lb grandfather slowly waste away, while trying to maintain normalcy in our lives.

The entire family worked hard to help him heal. In an effort to limit his fluid retention, we cooked low-sodium, low-fat foods, which were labeled and charted to ensure he was getting enough nutrition without harm. My mother purchased a CraftMatic bed for him, so he would be more comfortable and wouldn't use his precious energy trying to sit up in bed. He listened to self-hypnosis tapes and meditated daily, to focus his energy on healing and controlling proliferation. His oncologist seemed to be uncomfortable discussing his prognosis, and advised against splenectomy, due to my grandfather's insurance and age.

By the end of September, and with little encouragement from the oncologist, he decided that treatment was futile. "Save the blood for someone else," he said. "Someone who really needs it".  The oncologist offered to refer for splenectomy, but he was weary and resigned by this point. We discontinued the sodium and fat controlled foods, and made his favorites- lobster tail, hot dogs, shrimp. He passed away in his CraftMatic bed on Oct 17, 2002, missing his birthday by 6 days.

Every patient knows a story like this, either experienced personally or heard from others. Every doctor knows a hundred of these stories, shared in medical journals or by colleagues. Did a medical error occur? Patients and families may emphatically agree; Physicians may not feel the same. My point in writing is not to place blame, gripe about the state of healthcare, or lament that not enough was done to save my grandfather.  Perhaps the disease was caused by years of exposure to benzene from working in a pharmacy laboratory. Perhaps the cause was due to inhaled cigarette toxins, and he hadn't quit in time to prevent damage. Perhaps there is no attributable cause. Whatever the case may be, I believe that a plan is set out by the Most High, and for whatever reason, I needed to experience this loss, this suffering, in order to become a more observant, empathetic physician. I am so grateful for the time I spent with my grandfather, especially while he was most vulnerable. I am grateful for the lessons I learned through this process. When I approach the computer on Wednesday, I am confident that the spirit of my beloved grandfather will be with me. 

I love you and miss you, GVS. 

Take Your Time, Do It Right...

After watching the final moments of the Chilean mine rescue last night, I was impressed by the amount of patience exhibited by all involved with the ordeal. It took 69 long days to evaluate the situation, assess the most dire needs, and formulate a plan to keep the victims alive until the point of rescue. Once commenced, the rescue would have to be done slowly and safely, despite the anticipation of the crowds and media. What would have happened if the mine was exploded in a brazen effort to dig up the miners? Most certainly, the miners would have been buried forever. What would have happened if the rescue tube was yanked up expeditiously? The cable would snap, and the tube would plummet almost a half-mile back into the depths of the earth. Though not the quickest, last night's rescue will be remembered as the safest and most miraculous in history. 

What about patient rescues? Should all patient encounters be performed as quickly as an ER trauma or  life-flighted victim in shock?  As medical students, we are trained to perform physical exams in 15 minutes or less, pressured to elicit a detailed history in rapid-fire. A novice desperately auscultating for an ejection click or a bruit is unlikely to find it in the 3 minutes set aside for cardiac examination out of those 15. Patients are conveyor-belted through vital signs, insurance forms, physical exams, and deposited outside with a prescription in hand. Is this medicine? Or is it crowd control? 

I fear for the future of healthcare. I believe that Obama's healthcare changes will put more emphasis on efficiency rather than quality care. The shortage of healthcare professionals will be pressured to see more patients with less resources available, possibly missing crucial signs and symptoms. Can we still save lives with so little time to work? I can hardly imagine Hippocrates keeping an eye on a sundial as he examined a patient, or Osler advising his rounding medical students to speed up the patient's history because there were simply too many patients to visit. Physicians need time to process the data received, to think through the pathophysiology of the disease presentation. Occam's razor may apply in the majority of cases, but lives may be cost adhering strictly to it, and discounting other possibilities because the history is too long-winded, or because the diagnostic tests are too expensive. The speeding healthcare train must be slowed before it runs out of track. There should be no consequence for taking time to perform one's job properly.