Hospice (or End of Life Care) I just came home from my "Hospice day." It is a required day for every student at my school during Family Medicine. Today, I went to one of the 2 larger hospice companies and went around town with a social worker and physician.

It was pretty cool. I enjoyed how upbeat the SW and physician were. It was somewhat depressing when we went into some of the houses, but overall it was a good experience.

For instance, the first stop we made was at a little lady's house just outside of town - about a 20 minute drive from the main office. She had been a home health patient for some time - she had a hospital bed and some other durable medical equipment (walkers, bath chairs, etc) in the house the company had already procured for her. However, her condition had deteriorated such that in the past week she became unable to rise from bed and go to the bathroom, feed herself, or go to her recliner.
She has worsening cardiac disease, and her exercise tolerance has gradually been worsening - now to the point to where she cannot even sit up without becoming short of breath and having to lay back down. She is completely bedridden.

The truly unfortunate thing (as if the above isn't enough) is, that in listening to her family, this woman basically raised her entire neighborhood. She was one who would help anyone that needed it - regardless of whether she had it to give. She lives in a little 2 bedroom house with her sister, her daughter, grand-daughter, and great-grand-daughter. 4 generations in one house. She is so frail - it really was a tragedy to see. And when she awoke, she was sweet as can be... It's just heartbreaking.

So, because of her worsening cardiac condition, she was qualified for hospice care.

If you don't know what Hospice means, let me briefly explain: There are (basically) two trains of thought when dealing with any illness - curative and palliative. They are not exclusive of each other - even when you go to your physician's office for a sore throat he tells you to use saltwater gargles along with the antibiotics he prescribes for you. Both palliative (comfort measures - the gargles) and curative (the antibiotics) together. However, when an illness or condition is terminal (cancer, end stage COPD, Liver disease, etcetera), while the initial stages of treatment may be curative AND palliative (i.e. the physician may try chemo/radiotherapy to cure the cancer or a liver transplant to cure your cirrhosis), if those treatments fail, then sooner or later palliative-only care will take over. This is Hospice.

It is something of a paradigm shift in the way the medical community has thought for many years. For the longest time, any death was deemed a failure. It was not always this way. Death is a part of life, as is birth. One is born, so one must die.. Ashes to ashes, dust to dust. You see the point. What hospice care does is make sure that a patient is comfortable when their time comes. They have hospice aides, nurses, chaplains/pastors/priests, social workers and physicians that work together to help the last days of a patient's life be as comfortable as possible.

How does one qualify for hospice? The general rule is a patient must be certified by two physicians to have less than 6 months to live. This is not a strict rule, but I've heard it said, "If it wouldn't SURPRISE you if this patient were dead in 6 months, you need a hospice referral." Maybe it is really 3 days, maybe it will be a year - but 6 months wouldn't surprise you.

The hospice program evaluates the patient, the patient (or surrogate) must fill out and sign a Do Not Resuscitate order, and the patient and family are educated on what hospice care is, not to call 911 for "emergencies," and how to deal with the upcoming changes. The hospice program sends an aide and a nurse daily, and a chaplain at least monthly. Social worker and physician visits are also at least monthly, or the physician may be reached by telephone for additional orders.

All-in-all, the patient is very well cared for. Hospice care can be done in the home (as is the case of the woman above) or in a nursing home. The only difference is who takes care of the patient when the aides, nurses, physicians, chaplains, and social workers are away.

I think it is a good system. I enjoyed my visit with the hospice program today. I learned a lot about the system and when to refer a patient to hospice. Hopefully my experience shared above can help you as well.  ¶ 11:26 AM 0 comments

  Foreknowledge This week has been really boring. One thing I did learn, though, is that I did really well on my Internal Medicine NBME Shelf exam. So now I've received emails from the Dean of Student Affairs and the Dean of the college congratulating me. Who would have thought - me, the person whom they gave an only lightly-veiled threat to dismiss, gets a letter of congratulations from all the big-wigs at my school.

I'm befuddled.

One of my fellow students at my Family medicine rotation keeps giving me the line, "It must be nice to know what you want to go into."

I think it is nice to have an idea at this stage in my "career." Of course, like I constantly tell people, I have a lot more background than most others. I've worked in the medical field for 5 years already - I have a lot more exposure to the different fields than someone who came directly from college (or even someone who had another non-health-related occupation). It isn't fair to compare my experiences or thoughts to someone with no frame of reference. There is plenty of time - the third year is for experimentation with many different fields to find one that fits your personality. The worst thing about it is we have very limited experiences compared to the multitude of specialties available. Going through 8 or 10 different basic fields does not adequately expose a student to the hundreds of fields open for specialization. In reality, all choices are made on faith when it comes to match day. You don't know if you'll like the place you match, if you'll really like the field you've chosen, or if you might want to change in a year or so.

The truly unfortunate thing is once you've started a training program it's very difficult to change without having to start over. I've heard of physicians that finished residency and worked for a year or two before they learned they couldn't stand it and then started over with residency. That is one advantage to nursing, NPs, and PAs. There is no specialization - you can move to another field if you hate what you are doing without any hassle.

I'm done blathering for now... I'll post some more later. Besides, I have to write a synopsis of an Ethics Committee meeting I attended.  ¶ 9:31 AM 0 comments

  Some Thoughts Just a couple of things I've been pondering:

Why are there no prostate cancer prevention walks and/or foundations? Mars candy corporation has recently decided to make pink and white M&Ms to benefit the Susan G. Komen Breast Cancer prevention foundation. I want to know why they don't make prostate shaped M&Ms and money go to research and prevention. Even better, why not have a testicular cancer prevention corporation. Mars can make penis and scrotum shaped M&Ms to celebrate the event.

I love weekends off. Family has the BEST schedule! 8-5, 5 days a week.. And as a student - no pager or calls at night. Life is good.

Of course, I have to lead a discussion on the latest and greatest in hypertension diagnosis and treatment. So I've been pouring over JNC 7 recommendations and emedicine to "refresh" myself on this all to large a subject. Not that I'm complaining - I love learning. Hell, that's a very large part of why I came back to school - I missed it. I really think I am one of those people that could go to school forever. Professional student... If I kept half-time, I'd never have to pay back the loans. An idea is born...

not really.

I've been listening to Opie and Anthony alot lately. They are a couple of shock-jocks that were kicked off the air by the FCC after they were caught promoting a sex event in NYC. They've been off the air for 2 years now, but they are back and will be on XM radio starting the beginning of October. Now I have to get XM so I can listen to them. Or maybe the group of fans that have been digitizing all the old files will continue and I can get them offline. I'm freaking thrilled. I love OnA. Check them out at OpieandAnthony.com You can listen to some bits on OpieAnthony.net - check out the MP3 player on the left hand column.

They freaking rock!! Be warned that they are not NEARLY as PC as myself.

You were warned.

I'll write more later. I'm getting dinner ready.  ¶ 9:59 PM 0 comments

  Spousal Abuse? Man Tries to Sue Wife for 5-Day Sex Denial

Fri Sep 17,11:11 AM ET

MADRID (Reuters) - A Spanish man tried to have his wife charged with domestic abuse because she refused to have sex with him on five consecutive days, Spanish newspaper El Sur reported on Friday.

The middle-aged man from Seville -- the city of Don Juan and Carmen -- said her refusals amounted to "degrading treatment" and domestic abuse, a term used more often to describe wife-battering.

The judge shelved the case, Andalusia-based El Sur reported.

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I found this entry on Yahoo! News today... I thought to myself, "This must be a sign of the times."

Of course, this would be a pretty nice precedent for all us guys should she be found guilty...

"I have a headache..."
"But honey, it's been four nights. You wouldn't want to reach the 5 night limit, WOULD YOU???"

HAHAHahahahahHAHAHhahahahHAHAHAHhahahahHAHAHAHAHhhahahaha!!

just kidding.  ¶ 7:05 AM 0 comments

  3 Years Past Ok, so this entry is actually a couple of days late.

And there are many people who will think I am a complete and total @ss.

But I don't care...

September 11th has now become the newest (unofficial) commercialized holiday.

Only slightly behind Christmas in popularity, 911 has now been commercialized by the United States to mean, not the emergency response system it was meant to signify, but a day - 3 years ago - that we still mourn over like it was our own baby.

Wake up, people.

Yes, it really sucked. Believe me, I know - I was about an hour away from NYC when it happened. I got called in on my day off to work a 12 hour shift because the hospital had gone on disaster alert. I had no freaking clue what had happened when they called me and told me I needed to come into work. I remember the sinking feeling. But we need to move on.

Yes, I realize some 3000 people died. People die every day. We still need to move on. Tragic or no, untimely or not. We've killed over 1/3 that since in our little "war on terrorism." And that's just counting our troops. Nevermind the Iraqi people we've slaughtered.

Yes, I realize this was an open act of hostility against our country by a group of psychotic religious fanatics. We still need to move on or we run the risk of turning into THEM. Oh, wait - too late. We just don't do it in the name of religion. We do it in the name of W.

Yes, I realize we went to war shortly after this occured. I've said my piece about this. It was a mistake then, it is still a mistake now. We need to withdraw from Iraq post-haste, pour the money we are wasting over there into development of alternative fuel sources and rid ourselves of our dependence on the middle east altogether. If it weren't for oil, would we have ever been interested in that area? No. Why would we need to - they don't make anything but camelshit lotion and, oh yeah, OIL. Remember what I said last paragraph? W. Move on.

We need to silently withdraw from the world. No more troops, no more money. Just close our borders and say, "Sorry f*(kers.. you're gonna have to fend for yourselves for a few decades." Let all the starving Sally Struthers children starve (rather than live in the half-crap-ass existence your 17 cents a month can give them) and all the crazy nut-jobs kill each other. We'll be in self-preservation mode. And if anyone attacks us, we strike back swiftly - with nuclear weapons - and wipe whomever it was off the face of the earth. We're serious when we say LEAVE US THE F*CK ALONE!! No more of this surgical strike bullshit - just take the whole area we think they MIGHT be hiding in and make some glass...

Of course, I might be just a bit extreme.

I'm just tired of W using what is arguably the worst day in our country's history as a selling point for his re-election campaign and Kerry using it as his.

I'm tired of these crying families on the news bawling their eyes out - see a freaking grief counsellor and take Effexor (haha! That drug rep dinner really came in good for something, didn't it?) or something.

I'm tired of continuous news coverage of everything bad that ever happens. Hell, we have continuous news coverage of hurricane IVAN, and it hasn't even reached the US yet. There is a point when we need to turn off the news and look at something real. The news isn't real - it is some producers slanted view of the world.

We need to start reading again. Burn the cable companies to the ground and hand every man, woman and child in the country a freaking book. Tell them to read it (if they even know how to read - nearly 1/4 of high school graduates can't) and prepare a 2 page book report due the next week. If they can't read, shoot them - they've wasted 12 years of the country's resources. That's enough, no more, the store is closed.

And quit buying into all the hype about 911 - 3 years is enough time to grieve. These families have been through enough. Do we really need to drag them through it again every year? Have some compassion, people. Let them heal, let them move on. No more "well, it's been 3 years since we all watched your husband/father/brother/son jump off the 72nd floor to his certain death in order to escape the flames that were engulfing the building. How are you dealing with it? How do YOU remember that day?" How do you think they would be dealing with it when you just recreated the whole thing for them (all the while playing the film on national television)?

I hate newscasters.

I hate politicians.

I hate lawyers.

But I love America. I just wish she'd pick herself up by the boot straps and get back on track. She could be a great nation again if only she'd take care of herself and solve her own problems instead of trying to solve everyone else's for them. All the other countries in the world are big boys and girls - they can play alone for awhile.

What do you think about that?

-- Proud fighter for the highest common denominator!  ¶ 9:27 PM 0 comments

  Letter Writing Campaign??? WTF??!?!?!!? I've recently been trying to keep more abreast of the news, especially when it has to do with medicine. I think it is important to know what is going on in the world around you - it hasn't hurt that I currently am co-students at my family practice clinic with 2 of (probably) the most political and outspoken people in our class - so I get to overhear a lot of their conversations/debates and occasionally pitch in my 2 cents.

I was surfing the American Osteopathic Association website today (for fun, or something) and came across this. Now, I realize that there is a need to educate people about the Osteopathic philosophy, but is petitioning television shows the best way to do it? I can see it now:

Dear ER executive director,
Did you know that in all your shows' 11 seasons there has never been a DO as a cast member? How can that be, when there are obviously two perfectly legitimate schools of medical training in the US - allopathy and osteopathy? I would highly recommend that next season there be a new crop of students and one of them be a DO student. When discussing a patient with back pain, the student can pipe up and talk about Osteopathic Manipulative Treatment, a hands-on manual therapy founded in the late 1800s by Dr. Andrew Taylor Still.
I feel this would be a great way to get the word out about Osteopathic Medicine and would give your television program a wonderful means by which to educate the general public...

Blah, blah, blah... Does anyone else not see this as a bad idea? I can see it now - that same scenario comes up, and the student is granted the opportunity to use OMT on this back pain patient (which I am sure will need an open thoracotomy any minute for sudden cardiac arrest). Instead of utilizing OMT correctly, the student (who is a bit naive) performs HVLA on the patient which causes paralysis of both legs because (had the student checked more closely) the patient had nerve impingement signs and never should have had HVLA performed - MAYBE soft tissue, muscle energy, or indirect techniques.

What the people who are proponents of this sort of "free advertisement" don't understand (apparently), is that OMT is very rarely indicated in the ED, nor does an EP have the time to perform it.

I realize the idea is a great one - get the name of osteopathy in front of an audience of 40 million all at once. But I don't think it would turn out like they want it to. At the most, they will be able to spend 5-10 seconds on it, then they would be off cracking someone else's chest because they are in asystole (and everyone with asystole warrants a thoracotomy with direct cardiac massage, don't you know). People would be left with a lot of questions - and they would probably look online for more information and be misled or misunderstand what they read. It has too great a possibility to take a negative turn.

Again, I think the idea is good, but the practicality of it isn't. Instead of pouring all this time and effort into trying to get Osteopathy mentioned on some television soap operas, the AOA should spend a little time actually advocating for the physicians it represents, stop opening new schools to further dilute the applicant pool and try something else to educate the public about Osteopathy. Of course, this begs the question: if most patients don't know what degree their physician holds, why do we even care? Why do we have this burning NEED to educate the public and get Osteopathy in the public eye if it doesn't really matter - we are equal in every way to allopaths (some would argue better), we have every right to practice in any specialty, etc. Why do we need to pick little stupid battles like this? Why don't we work on getting equal practice rights in every country in the world rather than argue where we're already equal. What if I (hypothetically) want to move to France and practice after my training is over? Ooops, I can't - DOs don't have full practice rights there..  ¶ 3:20 PM 0 comments

  In Focus I don't know if anyone else keeps up with medical news regularly (other than what they show on the nightly news), but I am a fan of medscape dot com. I have been a member for roughly 7 years and have long used the resources available there. In particular, however, I am a fan of a certain EM resident that writes articles for the site. The reasons should be pretty obvious why I'm such a fan.

He is a great writer, and always seems to find subjects that are very touching for me. For example, his latest article is about how often the medical system fails those people that just "fall through the cracks," so to speak. It also speaks to how the medical administration is frequently responsible for the rift between physicians and their patients, and how, in EM, it is difficult to help mend that rift.

Physician-patient relationship. That is a term often thrown about lightly in school, but never really defined (so to speak). The easy definition would be superficial and would be the fulfilling of the patient's needs on a particular visit. This is often the sense of the term used in the ED (being an urgent care setting).

However, in the more encompassing definition (i.e. the one I am learning about now on my Family Medicine rotation), it means much, much more. It is knowing not only the patient, but the patient's parents and children - and sometimes their grandchildren. It is calling them by their first name when you first see them, not checking their last name as you walk in the room so you'll remember. It is being involved in their lives - seeing them in church, in the mall, at the grocery store - and always portraying the role of the physician-teacher - for that is what we all should strive to be.

This month has opened a whole new dimension of the physician-patient relationship for me. Being an integral part of patients lives and actually making a difference to them.. now I can see why Matt M so much desires to enter this field. It is actually much more appealing than I ever dreamed.

I'll be sure to keep you updated with more as the 2 months go on. For now, let me end with a story to emphasize my point:

A 41 y.o. WF came into the office last week for a medication refill appointment. How boring, you might say, right? Med refills? Come on!?! But every visit is a chance for patient education and to see how everything is going. Knowing this patient has a history of HTN, smoking, Hep C induced liver failure and bullous pemphigoid from reviewing her history, I armed myself to go talk with her.

The first thing that I noticed when I entered the room was the pervasive smell of cigarette smoke. My eyes started watering as I entered the room, it was so strong. But I persevered, introduced myself and clarified that she was, in fact, here only for medication refills. I talked with her for a while about how she had been: what has her BP been like, has she had any outbreaks of her pemphigoid, etc. I broached the subject of smoking with her briefly - she said she had considered quitting, but didn't think she could do it unless her husband also agreed. So I spoke with both of them briefly about smoking cessation and encouraged them to quit. I then proceeded to a brief physical exam. What I found would change the course of the visit.

On every patient I see, I always do a cardiovascular, pulmonary, abdominal and brief extremity exam - no matter the reason for the visit. Just seems prudent to me. As I was performing the pulmonary exam, I noted pretty widespread expiratory prolongation - an early physical finding in COPD. I asked the patient exactly how long she had been smoking and how much: about 40 pack-years is what it came out to be. I also asked her whether she frequently became short of breath or wheezy - she said "yes, how did you know?" So I discussed the physical findings I discovered on her exam. As I explained what I found and what the possible implications were, a look of fear and understanding came over her. She said "my father and brother died with emphysema from smoking.." and became very quiet. I explained that these are early findings and if she quits smoking now, the damage will stop - but cannot be reversed. She turned to her husband and said "I need to stop now."

Just that small physical finding - something one might miss if they weren't paying attention - may make such a huge difference in the patient's life (if she, in fact, chooses to stop smoking). As she left with her prescriptions, I felt a small amount of joy - thinking that I may have actually helped someone that day.

The smallest things can sometimes make the largest amount of difference: a 5 minute physical exam may change the course of a woman's life.

Maybe.  ¶ 3:15 PM 0 comments