August 29, 2015

loss of an titan

So often with titans in the medical field, there are egos bigger than buildings named after them. Not so with Dr Red Duke. The man was a legend, is a legend. One in a million. All those cliches, except in case they ar a absolutely true. He was larger than life and a model physician for everyone he touched. The patient ALWAYS came first and there was not even the slightest hint of pretentiousness.  He didn't care if it was a CEO, a president of the United States, a med student, or the cafeteria worker or the janitor. He treated everyone the same, and that was with dignity and respect.  He will be sorely missed. The story with videos at the link below are absolutely worth watching. And they are not embellishment. This cowboy, this giant among men was the real deal.

good, part II

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

     Implied is that I did good by correctly assessing the patient and ordering the best test to cut to the chase. But, good? I was off the next night so I did not have the opportunity to speak with patient. And the following shift I was off to take care off my own health problems by getting my bone marrow biopsy. Insert a two day training course on advanced life support for obstetrics and I've missed the patient for days now. I finally come back on only to find out the patient went downhill rapidly and ended up in the ICU.

     A sense of regret washes over me. I only performed HALF of my job. I was there to diagnose the ailment. But I was not there to console the patient. The rule of thumb is that is the job of the day team, not the night team. But not one of them knows pain like I do. And I hope they never do. But I still feel as if I let the patient down. So before it gets too late into the evening, I stroll into the ICU where it is no longer my domain. I stand and watch the patient breathing with a ventilator and say a silent prayer asking for a good death and peace for the patient and the family. The nurse looks at me a bit strangely and asks who I am. So I answer honestly. I admitted the patient and just wanted to do right by the patient by following up, no matter how too late it is.

So, did I do good? I honestly don't know. But I know how I will do it differently next time.

August 25, 2015

affordable care part II

     I lay face down as the tech prepped the area where they would be drilling a hole guided by a CT scanner into my bone to collect a bone marrow sample all in an effort to finally determine whether I have cancer or not.
     "Are you sure you don't want to be sedated?" the tech asks with a slight bit of concern. 
     "Trust me. Neither I nor you want me getting propofol or fentanyl. I'll start vomiting. And I'm talking projectile style. And y'all will have to clean up an awful mess. I'm fine with a small dose of dilaudid and versed."
     "You're the doctor."  Even as a patient, I'm addressed as doctor. I can't help it. It's not that I'm pretentious or want the prestige. It's just who I am. While waiting, a nurse began asking about diabetes drug options so I gave a list of options to bring up the next time they saw their doctor. The patient, sorry I was the patient and they the healthcare worker, walked away armed with far more information than they had before. And it just feels so natural to me. 
     The IV meds are pushed and the metal rod about the size of a good sized Phillips screwdriver is bored into my bone. The interventional radiologist scans me with the CT and then readjusts it. Repeat several times. And I'm not thinking about the physical pain. Acute pain I can handle just fine. It's the chronic one that wears me down. No, I'm wondering why did this take so long? Why did I wait with the potential diagnosis of cancer looming over me? In a word, Money. I had it scheduled before I was to start residency. After all, it was a lot easier to do then with respect to scheduling. But with my "affordable" care act insurance, this procedure was going to cost me $4,000. To quote the infamous Inigo Montoya from The Princess Bride to the government, "I do not think that word means what you think it means." So I had to wait until I started residency and got on a good insurance plan. So here I lay with a rod being shoved back and forth now able to get the necessary test run because I'm fortunate enough to be in the right labor pool. I am grateful for being able to finally get the test but I'm also not naive enough to think that our healthcare problem and it's looming insolvency is moving in the right direction. 

August 23, 2015

good part I

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     It took less than two weeks. I pull a stool up to the bedside in the ER to get the patient's story. I cinch the curtains shut to try to get as much privacy as possible but they remain impotent against the constant noise of controlled chaos that is a tertiary level ER. It becomes readily apparent after listening for five minutes that this story will not have a happy ending. I explain to the patient what general tests I am going to order, how the process of being admitted to the hospital works, and always end by telling the patient that I am here all night so if they need anything, just have the nurse give me a call. And I genuinely mean that last part. No matter how tired or what time of the night it is, I always answer the phone with a pleasant voice saying, "family medicine, this is Dr Isaac."
     I quickly enter in the admission orders along with a battery of tests to rule out some common things. But I know the most important one - a CT scan - and order it without hesitation. By this point, I have earned the trust of the third year resident so that he had deemed me competent enough to plan my own orders. He will review them to make sure I didn't forget anything but the point of being a doctor is learning to think on your own.
     A couple of hours later, I go home and hurry up and sleep. I only have a limited number of hours to eat and sleep before turning around and coming right back to the hospital. When I wake up, I check my phone for any texts or calls that I missed while sleeping. Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

August 17, 2015

the physical form

Working long and odd hours, I often get the gym to myself. I looked in the mirror and thought, though this physique is no Adonis, I wondered, does this body yet have cancer? I still do not know. Another consequence of working long and odd hours is that it's difficult to take care of yourself. I'd rather be asleep than waiting in a doctor's office. But the bone marrow biopsy is a day away and that shall reveal all.

August 15, 2015

Every morning I come home from work strung out on adrenaline and caffeine thinking to myself, it's astounding how much I can learn in just one night. And every evening I drag myself back to the hospital and a different patient comes along that makes me think to myself, I don't know jack shit.

August 7, 2015

vampire test

     I have been accused, justly I might add, of having a bit of an Eeyore personality.  My wife is my opposite and so at times will needle me initially to try to get me to smile, but failing that, then just to get any reaction out of me.  So it was the other day when I was stressed about not knowing whether I had cancer or not, my back pain was flaring up, and I had some work issues causing some stress.  So she poked, prodded and finally gave me a love bite, really more of a hickey than a bite, on my forearm which I admit did cause me to crack a smile at the absurdity of her action until I saw my forearm.  We both looked down.  On top of my skin resided a thin film of what medically would be called serosanginous fluid but in reality is blood with a bit of other fluid.
     Now, she didn't actually bite me.  She didn't bruise me.  But the capillaries in my skin are so congested with the excess red blood cells that they are easily ruptured.  Really easily, apparently.  I asked my wife if she tasted the salt of blood, to which she answered yes.  She then of course found it to be the funniest thing in the world at that moment that I'm oozing blood while I'm just thinking to myself, "This. Isn't. Normal."
     So the day before my next scheduled blood draw I'm curious what my red count is running so I just hand my forearm to my wife.  Yup, still elevated.  The results the next day confirm it.  Time to lower the dose of my medication again.

Disclaimer: The vampire test should only be performed under the supervision of a trained physician.