I had an elderly gentleman roll in to clinic today at the VA. We have been following a pretty large non-healing surgical wound due to advanced peripheral vascular disease to the left leg for the last month. Last week it looked manky with exposed bone at the tip of his second toe, but there was some improvement in the wound over last week so the podiatrist I was working with that day sent him back to the nursing home with instructions to the nurses re: bandage changes and a course of Cipro.
In clinic today that toe looked awful and smelled mighty interesting to boot. Worse, the patient was now A&Ox 1 with a temp of 102F. ER admit, right? Below the knee amputation to the offending leg and hope there's enough circulation that high up to allow the wound to heal this time? The family responded that they didn't want him admitted. They didn't want any surgeries. That we should send him back to the nursing home.
My first thought was that the family didn't really understand what was happening, that they were going to kill their grandfather through ignorance. After a long phone conversation however it sounded as though they wanted him to be admitted too. Their grandfather and they had had multiple conversations about future hospitalizations, future surgeries, and live extending procedures and it had been his wish not to undergo any further amputations. (Like I said, bad PVD and it showed.) We finally sent him back to the nursing home. I with a sinking feeling in my heart.
So I think I'm most astonished with the fact that I was standing next to a patient today who made a rational, thoughtful decision about how he wanted to end his life; a patient who has the beginnings of a septicemia and will now die soon.
I was surprised at how outraged I had felt that the family didn't request heroic life saving measures for their loved one. And yet I KNOW that even if successful it would be the beginnings of the end for this particular patient. I KNOW that the most money spent by Medicare is done in the last weeks of a patients life. Spent wisely? Spent with the patients' quality of life in mind? Or is it spent preserving a life because we don't know how to do anything else?
I'm glad that the patient had discussed his wishes for end of life care. It definitely felt creepy sending him home, but hopefully that's what the patient wanted instead of being left in the forceps of modern medicine.
Noah
Thursday, September 20, 2007
Wednesday, September 19, 2007
Sunday, September 16, 2007
Hey gang!
I've been up at the Coalville clinic with Wain (yes, that's how he spells it) Allen. I really like him. First- he's a total smart ass, so we get along there. Second- he wears cowboy boots and jeans to work, so I wear mine now too. And third- he knows and loves Caddyshack as much as I do.
We've been doing hospice care in Heber on Monday mornings, and Thursdays are spent in Kamas. We even do house calls. There's a decent amount of mullets and handlebar mustaches in the area, which is nice. Wain is also the bishop, and he entered veggies in the fair. Gotta love small towns.
So I'm in clinic the other day, and my patient is a sweet old gentleman (I'm talking like 90+ old) in with abdominal pain, so I had him lying down and, being the good student, I wanted stethoscope on skin. So I was pulling up his t-shirt, and pulling up his t-shirt.. finally I get to something that looks like cotton paneling when I realise I've just given this poor old one piece garment wearing feller the power frog-eye wedgie of his lifetime. Of course he's not saying anything- still just smiling up at me. Then he says "Miss, you're not Mormon, are ya?" I turned beet red and apologized, but didn't have the courage to un-do my damage so I left the room so he could re-adjust. I think he just thought it was funny, and maybe even a little exciting. Anyways, I blame Darin for not covering that in cultural competency (or did he? Guess I wouldn't know).
Looking forward to seeing your mugs in a few weeks. Cheers- G
I've been up at the Coalville clinic with Wain (yes, that's how he spells it) Allen. I really like him. First- he's a total smart ass, so we get along there. Second- he wears cowboy boots and jeans to work, so I wear mine now too. And third- he knows and loves Caddyshack as much as I do.
We've been doing hospice care in Heber on Monday mornings, and Thursdays are spent in Kamas. We even do house calls. There's a decent amount of mullets and handlebar mustaches in the area, which is nice. Wain is also the bishop, and he entered veggies in the fair. Gotta love small towns.
So I'm in clinic the other day, and my patient is a sweet old gentleman (I'm talking like 90+ old) in with abdominal pain, so I had him lying down and, being the good student, I wanted stethoscope on skin. So I was pulling up his t-shirt, and pulling up his t-shirt.. finally I get to something that looks like cotton paneling when I realise I've just given this poor old one piece garment wearing feller the power frog-eye wedgie of his lifetime. Of course he's not saying anything- still just smiling up at me. Then he says "Miss, you're not Mormon, are ya?" I turned beet red and apologized, but didn't have the courage to un-do my damage so I left the room so he could re-adjust. I think he just thought it was funny, and maybe even a little exciting. Anyways, I blame Darin for not covering that in cultural competency (or did he? Guess I wouldn't know).
Looking forward to seeing your mugs in a few weeks. Cheers- G
Saturday, September 8, 2007
Labor: There ain't nothin' natural about that
So I delivered my first baby yesterday. I have to say, so far (one week) I have really liked Ob/Gyn. Didn't think I would be that interested, but I am. After originally thinking I wanted to do FP or IM after graduating, and then going through my last month of inpatient IM, I am now thinking that there is just WAY too much info to know in general practice. Maybe a specialty is a better idea...
Anyway, back to the baby story. My doc had been out of town the previous week, so he didn't have time to "beat the bushes" as he puts it (maybe a poor choice of words in this context) to get inductions set up. Dr. Hoegh likes inductions. A lot. He sees no reason for a woman to go past 39 weeks if she doesn't want to. His day for L&D are Fridays (there are seven docs in the practice, they each take a day doing L&D for anyone that goes into labor and anything scheduled, and the rest of the days they see patients in the office). Alas, he had been out of town, so he couldn't convice all of his 39 weekers to come in and get induced this Friday, so we only had two inductions (reportedly 10 is more his style). They both went pretty quick and I stood by and observed on the first one. The next one was thirty minutes later. Dr. Hoegh got the head out and then stood up from the stool, turned to me, and said "take a seat." (I'm thinking of the poor woman in labor at this point. If I were her I would be thinking 'What the f&@*! Why is he letting a student deliver my kid?? But I guess maybe she had other things on her mind, like a baby half sticking out of her vagina.) So I sit down, suction the kids nose and mouth, put my hands around it's neck like Dr. Hoegh instructs, and start (gently) wrenching the thing up and down to get the shoulders out, and out that little sucker flies.
Now, I admit is was a cool experience and I look forward to doing it again. However, anyone who says childbirth is the most natural and beautiful thing that exists is a damn liar. There is nothing natural about something that size squeezing its way through the vaginal canal, or the bones of it's skull folding over each other, or a head sticking out of someone's legs with the body still inside. There is nothing pretty about 2nd degree lacerations or gushes of amniotic fluid and blood. Nothing. It's weird, it's freaky and it's hard to believe anyone can survive such a thing - baby or mother. Dr. Hoegh says that I am going to want kids by the time I finish my rotations with him. After yesterday, all I have to say is, there ain't no effing way that is going to happen.
Anyway, back to the baby story. My doc had been out of town the previous week, so he didn't have time to "beat the bushes" as he puts it (maybe a poor choice of words in this context) to get inductions set up. Dr. Hoegh likes inductions. A lot. He sees no reason for a woman to go past 39 weeks if she doesn't want to. His day for L&D are Fridays (there are seven docs in the practice, they each take a day doing L&D for anyone that goes into labor and anything scheduled, and the rest of the days they see patients in the office). Alas, he had been out of town, so he couldn't convice all of his 39 weekers to come in and get induced this Friday, so we only had two inductions (reportedly 10 is more his style). They both went pretty quick and I stood by and observed on the first one. The next one was thirty minutes later. Dr. Hoegh got the head out and then stood up from the stool, turned to me, and said "take a seat." (I'm thinking of the poor woman in labor at this point. If I were her I would be thinking 'What the f&@*! Why is he letting a student deliver my kid?? But I guess maybe she had other things on her mind, like a baby half sticking out of her vagina.) So I sit down, suction the kids nose and mouth, put my hands around it's neck like Dr. Hoegh instructs, and start (gently) wrenching the thing up and down to get the shoulders out, and out that little sucker flies.
Now, I admit is was a cool experience and I look forward to doing it again. However, anyone who says childbirth is the most natural and beautiful thing that exists is a damn liar. There is nothing natural about something that size squeezing its way through the vaginal canal, or the bones of it's skull folding over each other, or a head sticking out of someone's legs with the body still inside. There is nothing pretty about 2nd degree lacerations or gushes of amniotic fluid and blood. Nothing. It's weird, it's freaky and it's hard to believe anyone can survive such a thing - baby or mother. Dr. Hoegh says that I am going to want kids by the time I finish my rotations with him. After yesterday, all I have to say is, there ain't no effing way that is going to happen.
Sunday, September 2, 2007
A Fond Experience
Let me set the stage: Labor Day weekend in the middle of southern Utah’s natural playground. That means everyone and their brother must ride around the sand dunes on dirt bikes and ATVs. Alcohol is a requirement and helmets are for the weak. The alignment of the planets at this time also gives everyone the notion that they are as talented as Evil Knievel. A 24 hour on-call ER shift was going to be lots of fun!
A young woman showed up around 10 pm to have a baby. This was after a full day of caring for the following: “I was trying to run alongside my bike as I did that jump and…”, “this bee sting is just getting huge and I only took one Benadryl 16 hours ago…”, “I couldn’t take her temperature, but she felt warm and she had a runny nose…”, and “I just didn’t feel right this morning…”.
Her family had been passing through three days ago when their truck broke down. She and her significant other (another big no-no down here is having 3 children with a man that you do not call husband) decided Kanab was a wonderful place to settle down and canceled the rest of their trip. They were currently staying at a local motel.
Quick facts about Kanab: 1) there are no taxis or public transportation; 2) you can walk to the motel in about 10 minutes; 5 minutes at a nice jog.
Dad paced around the ER and got angry at our kind secretary because he didn’t believe she was really trying to get him a ride back to their motel paradise where his other two children were being watched by a man they had recently met. He had just found out that the babysitter was a registered sex offender. As a concerned parent, he waited 45 minutes for us to arrange a ride for him to save his children. Please refer to # 2 of the last paragraph.
Back to the delivery room. After two pushes a slimy, blue, hairy thing popped out from another slimy, pink, hairy thing. All seemed well until we realized the cord was wrapped around the baby’s head twice. No panic. The doc cut the cord, suctioned like the dickens, and gave the silent, slimy object to the nurse.
As the poor nurse was trying to get a response from the infant the incompetent PA student was asked to get a heart rate. Heart sounds were ok, but there was still no breathing or crying. The doctor came over and after what seemed like forever we got a slight gurgle and cough. Finally, he gave a good cry, turned pink, and we stopped bagging.
Unaware of the babysitter issue at this time, I asked where dad was. Mom said she called the Motel of Impeccable Customer Service and asked the owner to tell her “husband” she had the baby. Being the kind, compassionate, and completely sick of the damn ER person I was at the time, I said, “If he doesn’t come in 20 minutes, let me know and I can go down and tell him. He can bring your boys up and I’ll watch them so you and your husband can have some time together.”
“You would do that for me?” the sweet, angelic mom said weakly. Man, I am so nice!
More facts: Kanab is a safe town. One month ago, they had their first-ever mugging reported. Turns out the victim had just fallen down in his drunken stupor. All of a sudden, I was at risk of a gunshot wound or other terrible demise as I informed the staff of my plan to see dad. They agreed to let me go if I went with the secretary. By agreed, I mean I just left.
Two minutes later, we were in front of room 16. I knocked on the door and shirtless Larry appeared. I told him he had a new son and mom wanted him to visit. He said the boys were sound asleep and he didn’t want to wake them. No shit. I told him if he changed his mind, I would be at the hospital and could watch them.
I told mom that Larry wasn’t coming and then fixed her a chicken sandwich. I was hoping she would get tired and want us to take the baby to the nursery so I could have some baby time. I could be patient. Besides, I had a full day of Typhon to do.
At 3:30 am mom requested my presence. When she saw me, she smiled and asked, “Could you do me a huge favor? Will you go down to Larry’s and get a cigarette for me?” Was she f-ing nuts? Did she really think I would drive back down there at this hour for a cigarette!
My response, “You’re in the hospital and just had a baby.”
“I know, but I really need one,” she whined.
I stood my ground. “I can’t allow you to smoke right now. You just had a baby and we’re monitoring your blood pressure. You’ll have to wait until later to smoke.” Now I just wanted to take the baby and run!
She let out a big sigh and said, “It’ll be morning soon and Larry’ll be here.”
Good ole Larry. I replied, “When he gets here you can have all the cigarettes you want against medical advice.” I marched back down the hall feeling bewildered. I told the story to a wise nurse who stated, “What is appreciated today is expected tomorrow”.
How true. I learned my lesson. Never be nice to patients. Treat them all like crap because it’s always the ones you bend over backwards for that will sue your @$$ off in the end anyway.
A young woman showed up around 10 pm to have a baby. This was after a full day of caring for the following: “I was trying to run alongside my bike as I did that jump and…”, “this bee sting is just getting huge and I only took one Benadryl 16 hours ago…”, “I couldn’t take her temperature, but she felt warm and she had a runny nose…”, and “I just didn’t feel right this morning…”.
Her family had been passing through three days ago when their truck broke down. She and her significant other (another big no-no down here is having 3 children with a man that you do not call husband) decided Kanab was a wonderful place to settle down and canceled the rest of their trip. They were currently staying at a local motel.
Quick facts about Kanab: 1) there are no taxis or public transportation; 2) you can walk to the motel in about 10 minutes; 5 minutes at a nice jog.
Dad paced around the ER and got angry at our kind secretary because he didn’t believe she was really trying to get him a ride back to their motel paradise where his other two children were being watched by a man they had recently met. He had just found out that the babysitter was a registered sex offender. As a concerned parent, he waited 45 minutes for us to arrange a ride for him to save his children. Please refer to # 2 of the last paragraph.
Back to the delivery room. After two pushes a slimy, blue, hairy thing popped out from another slimy, pink, hairy thing. All seemed well until we realized the cord was wrapped around the baby’s head twice. No panic. The doc cut the cord, suctioned like the dickens, and gave the silent, slimy object to the nurse.
As the poor nurse was trying to get a response from the infant the incompetent PA student was asked to get a heart rate. Heart sounds were ok, but there was still no breathing or crying. The doctor came over and after what seemed like forever we got a slight gurgle and cough. Finally, he gave a good cry, turned pink, and we stopped bagging.
Unaware of the babysitter issue at this time, I asked where dad was. Mom said she called the Motel of Impeccable Customer Service and asked the owner to tell her “husband” she had the baby. Being the kind, compassionate, and completely sick of the damn ER person I was at the time, I said, “If he doesn’t come in 20 minutes, let me know and I can go down and tell him. He can bring your boys up and I’ll watch them so you and your husband can have some time together.”
“You would do that for me?” the sweet, angelic mom said weakly. Man, I am so nice!
More facts: Kanab is a safe town. One month ago, they had their first-ever mugging reported. Turns out the victim had just fallen down in his drunken stupor. All of a sudden, I was at risk of a gunshot wound or other terrible demise as I informed the staff of my plan to see dad. They agreed to let me go if I went with the secretary. By agreed, I mean I just left.
Two minutes later, we were in front of room 16. I knocked on the door and shirtless Larry appeared. I told him he had a new son and mom wanted him to visit. He said the boys were sound asleep and he didn’t want to wake them. No shit. I told him if he changed his mind, I would be at the hospital and could watch them.
I told mom that Larry wasn’t coming and then fixed her a chicken sandwich. I was hoping she would get tired and want us to take the baby to the nursery so I could have some baby time. I could be patient. Besides, I had a full day of Typhon to do.
At 3:30 am mom requested my presence. When she saw me, she smiled and asked, “Could you do me a huge favor? Will you go down to Larry’s and get a cigarette for me?” Was she f-ing nuts? Did she really think I would drive back down there at this hour for a cigarette!
My response, “You’re in the hospital and just had a baby.”
“I know, but I really need one,” she whined.
I stood my ground. “I can’t allow you to smoke right now. You just had a baby and we’re monitoring your blood pressure. You’ll have to wait until later to smoke.” Now I just wanted to take the baby and run!
She let out a big sigh and said, “It’ll be morning soon and Larry’ll be here.”
Good ole Larry. I replied, “When he gets here you can have all the cigarettes you want against medical advice.” I marched back down the hall feeling bewildered. I told the story to a wise nurse who stated, “What is appreciated today is expected tomorrow”.
How true. I learned my lesson. Never be nice to patients. Treat them all like crap because it’s always the ones you bend over backwards for that will sue your @$$ off in the end anyway.
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