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Demystifying Medicine One Month at a Time

Category: medical education (page 1 of 14)

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Triage

The following is a guest post from Dr. Sarah Fraser:

During my surgery rotation as a third year medical student, my resident sends me to the Emergency Department to assess a new consult. She tells me to “make it quick” and I hustle down to meet my patient.

Mr. Jones is a 64-year-old male who rarely goes to the doctor. He has been vomiting for two days and has a fever. His heart rate is up and his blood pressure is low; his belly is swollen up like a beach ball. When I examine his abdomen, he winces in pain with even the lightest touch. The x-ray shows a bowel obstruction and free air in the belly, a sign of intestinal perforation. I know he needs surgery.

Stat.

I text my resident who tells me I have five minutes to get the paperwork in order before transporting him to the operating room. As I am about to start writing my note, a frail, elderly woman emerges from a different room with a troubled expression on her face.

“I need help. My husband’s IV is beeping and we need to shut it off.” There is fear in her voice.

I quickly decide that her problem is not an urgent one. The IV is probably beeping because the fluid is done dripping in, or maybe the line is kinked. But the man with the busted bowels–that is urgent. I need to devote every ounce of my attention toward finishing my note and getting that man into surgery.

“I’m dealing with an emergency right now, but your nurse should be back shortly.”

“We need to stop the beeping!” She is on the verge of tears.

“It’s probably nothing serious. I’m really sorry but I can’t help you right now.” I put my head down and continue writing.

“The help here is awful,” she says, returning to her room with her sick husband and his beepy IV.

A knot forms in my stomach as I continue with my note.

Was there time to have helped her? Maybe, but I had a short deadline and was feeling the pressure. Relieving the concerns of this elderly lady would have taken away from the care I was providing for a the very sick Mr. Jones. So I prioritized, and in doing so, I failed to address her request, leaving her disappointed and probably scared.

Though I didn’t realize it at the time, when I ignored one person and prioritized a sicker patient, I was doing something called triaging. Every day in the Emergency Department, doctors and nurses are forced to choose who needs help and attention more critically.

Before entering the field of medicine, I remember sitting in the Emergency Department as a patient with a fever and chills, watching others who came in hours later being treated before me. Nobody likes to feel ignored. What the general public does not always realize is that there is a triaging system, where patients are given a score from one to five based on how sick they are. It is a system that helps us deal with the sickest first, though it can lead to long wait times for those with less serious issues.

Though I postponed dealing with the concern of the elderly woman that day, I also learned an important lesson. In medicine, you need to assess and assign degrees of urgency, and in doing so, you can’t please everyone all the time. And you have to be okay with that. What matters most is that you prioritize to the best of your ability, and do your part to keep everybody healthy, and most importantly, alive.

Dr. Sarah Fraser is an author, family physician and human rights activist in Nova Scotia, Canada. She is author of Humanity Emergency, a poetry collection about the need for more compassion in the field of medicine. Her work appears in the Canadian Family Physician, Ars Medica and the Journal of Academic Psychiatry, The Coast, Capital Xtra and on kevinmd.com

Match Day 2017

Click on the link below to see an essay from NPR on learning from and working with foreign medical graduates.

All in honor of St. Patrick’s Day, which this year is also Match Day — when medical students learn where they will match for residency — the next chapter in their training.

Medical Revolution(s)?

9780465050642This week an essay in the New England Journal of Medicine asks if our collective learning to handle uncertainty should be ‘the next medical revolution.’ It caught my eye because many of the medical educators I follow on social networks were abuzz about it.

Coincidentally, I’m reading a fuller-length exploration of medical uncertainty, a book called “Snowball in a Blizzard,” by Steven Hatch, an infectious diseases doc at UMass.

Both the essay and the book remind us to have humility: though medical technology and scientific knowledge have leapt ahead and continue to hurtle forward, our profession’s abilities to diagnose, treat, or predict future health outcomes with precision remain stubbornly elusive.

The metaphor of the ‘snowball in a blizzard’ comes from the world of radiology–in particular mammograms. That’s what radiologists who read mammograms are looking for on the images they see. It’s challenging and inexact work. Often they miss tumors that are cancerous; to correct for this, it’s natural that radiologists need to be extra cautious and have women with anything even remotely suspicious follow up for more images and possibly biopsies. [With negative biopsies, such mammograms become known as ‘false positives.’]

I agree with the thesis that we should all become more comfortable with uncertainty. But it will be challenging.

As patients, we want our doctors and scientists to be able to give us predictions that are accurate.

  • Is this the right diagnosis?
  • Will this treatment work?
  • How long have I got?

As doctors, we wish we had greater ability to answer these questions.

As ‘consumers,’ we are fed an unending stream of media that tell us what we ‘should’ do, what we ‘need’ to be healthy, and what will make us live longer. Much of it never offers the necessary caveats about the inexactness of the science. This will be an uphill battle.

I was pleased to see a chapter in Hatch’s book devoted to health media, featuring Gary Schwitzer and his website HealthNewsReview.org. Gary has devoted his latter career to debunking medical hype. His site is well worth perusing.

The Evolution of Hospitals

I-love-Lucy-assembly-line-300x223Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really — if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get one ‘bundled’ payment for the whole hospitalization based on the patient’s diagnosis. Average length of stay for hospitalized patients went from thirty days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay — depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

‘Throughput’ became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than four days. (Of course, for mothers with normal births, this is even less — about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now — can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there’s a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

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