I received a call about a consult for placement of a temporary dialysis catheter in the Medical Intensive Care Unit. When I arrived I quickly scanned the chart (coagulation profile, patient’s medical information etc.) and entered the room of the patient who needed the temporary dialysis catheter. Just before I entered the room, one of the resident physicians pulled me aside and said, “This guy weighs 500 pounds and let himself get to this point. On top of that, he smells. I just want to warn you to have your gas mask ready”. He laughed and I “thanked” him for the information and entered the room.
Lying in the bed was a 500+ pound gentleman who was restrained and mechanically ventilated. In one hand was an intravenous line which was leaking intravenous fluid. He had a very large abdominal pannus (apron of adipose tissue), multiple scars on both arms and both legs with both legs having open venous stasis ulcers that had become infected. I walked up to the bed and spoke to this patient to explain to him that his kidneys were failing and that he was going to need to have a dialysis catheter to help them along. He nodded to me but I wasn’t sure he could understand. I explained what I was going to do and that it might be uncomfortable but I would use as much local anesthetic as needed.
The nurse told me that the small intravenous line in his hand was not going to be adequate and that it was the only source of IV access that the patient had. It was tenuous at best. I asked if the patients family was present and the nurse said that they were in the waiting room. I told the nurse to gather the equipment for both a central venous line and a temporary hemodialysis catheter insertion while I went to speak with the patient’s family.
The patient’s wife was sitting in the waiting room with her daughter. She was tearful and spoke lovingly about her husband. She said that as he gained more and more weight, he became immobile. Finally, she said that nothing could get him out of his room and that she had difficulty getting him to comply with medications for diabetes and hypertension. She said that he would become angry and depressed when she attempted to help him with his personal hygiene or care of his venous stasis ulcers. I explained the need for the central venous line and the temporary hemodialysis catheter. I also explained the risks and benefits of the placement of these lines so that she could make an informed decision. She asked me to do what I could to help her husband get back to health.
After washing my hands and washing the areas of the patient where I intended to insert the catheters, I used a portable ultrasound machine to locate both the subclavian vein and the femoral vein. Both were fairly deep because of the large amount of subcutaneous fat that was present in this patient. I was able to mark off some landmarks and get to work. With the aid of a couple of nurses, I used adhesive tape to tape as much of the patient’s fat out of my way so that I could get to my intended target. After 30 minutes, I had inserted a central venous line into this patients left subclavian vein after taking about 20 minutes to carefully prepare the site. The more time I spent in prep, the easier it would be to get the line in under the best and most sterile conditions. I also had asked the nurse to give the patient a small amount of sedation so that the whole experience would be a little less alarming.
I then turned my attention to the femoral vein. Since temporary hemodialysis catheters were very large, I chose a long catheter and moved closer to the inguinal ligament as the vein would be larger there. As with the subclavian vein, I used a large amount of adhesive tape and three nurses to hold this gentleman’s large fat pannus out of the way. I inserted the line and had great blood flow and return. I also carefully secured the line with locking tape and sutures. I wanted to make sure that the patient would not be able to easily “pull” the line if he became disoriented and unrestrained. I also gave the local anesthetic plenty of time to take effect as most patients are pretty still if they are comfortable.
After a chest radiograph to confirm that my lines were in good position (with no pneumothorax), I phoned the nurses to let them know that the lines were safe to use. I also had “blocked” the hemodialysis catheter with an anticoagulant and thus I let the hemodialysis department know that this line was ready for use. I spoke with the patient’s family and let them know that the procedures, while taking a couple of hours, had gone well.
For the next three days, I went into the intensive care unit to check on the those lines and make sure that they were working fine. I spoke with the residents who kept congratulating me on “getting the lines in the whale” and laughing about this patient’s body habitus. On the third day, I didn’t see the joke and I didn’t see where calling this man a “hippo”, “whale”, or anything other than a sick patient was necessary. I asked them why they felt obligated to demean this gentleman that they didn’t really know (because he had been intubated) and they were charged with treating.
One of the residents said that he just doesn’t like “fat” people because they don’t take care of themselves and won’t follow his direction. He said that they could follow a good diet, exercise and not end up using up our precious health care resources for something that they “did to themselves”. Another resident said that he could “stand” the smell of the venous stasis ulcers and that he had to get out of the room as quickly as possible. While I appreciated their honesty, I couldn’t help wondering why they didn’t have a problem with treating an alcoholic or a drug addict who had become ill because of self-inflicted abuse of a substance. I had encountered some “skin popper” IV drug abusers who had multiple cutaneous abscesses that smelled far worse than a couple of venous stasis ulcers.
I find it difficult to blame the patient for their disease. In my mind, just as a diabetic can’t make insulin, a morbid obese patient has a metabolic problem that is not under their control. By the time a patient winds up weighing 500 pounds, all personal control is lost. If you couple the massive weight with psychiatric disorders such as depression, one finds a very difficult and challenging patient with multiple problems that need to be addressed. I can’t just afford to “like” or “dislike” any of my patients because they need my help and not my judgment.
Two weeks later, I received a call from the hemodialysis unit secretary. The nephrologist wanted me to stop by the unit so that I could “speak” to this patient. He was off the ventilator and was not going to need hemodialysis as his renal function had greatly improved. When I saw him, he said that he remembered my speaking to him in the ICU. I was amazed that he would remember me with his condition but he remembered how I explained everything that I was going to do for him and how I spoke to him with respect.
I later heard from his attending physician that he entered a rehab center and was on his way to losing 100 pounds. His hypertension was greatly improved and his diabetes was managed by diet. Though he had a long way to go, he was moving along on his journey. Hearing this made me remember why I went into medicine in the first place. It is simply to help people regain their health.
I can’t make judgments on my patients because “there but for the grace of God, go I”. I have been given the privilege and opportunity to touch the lives of thousands of people. I have also been given the trust of those thousands to also have only the best of intentions when I treat them. This is what makes medicine like no other career on earth.
Showing posts with label Medical practice. Show all posts
Showing posts with label Medical practice. Show all posts
03 February 2008
What do you want from a career in medicine?
I am often asked why I decided to pursue a career in medicine; starting at a later age and with many demands both mentally and physically. Quite simply, I knew that I would enjoy those mental and physical demands because I love working with my patients to identify and help solve their health problems. When a patient walks into your clinic, office or you encounter them in the hospital, the most amazing relationship develops that you will ever experience. A person walks into your life and puts their health and trust into your hands. This trust means that you give your best knowledge in terms of figuring out their needs and meeting them.
Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.
In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically.
Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.
The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses. I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open. I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?
The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school prepares you for residency and residency prepares you for practice.
Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.
This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon. Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.
Too many people will confuse what they see on the telly (House, Dr. Kildare, Gray’s Anatomy,Ben Casey, Scrubs, ER) with what is the actual reality of being a physician. There is little “glamor” in this job but there is loads of personal satisfaction in winning those hundreds of little “victories” that you will win over the course of a day. There is also the knowledge that if the health care system continues along the road that it has taken, you are going to make less money for every day that you work in the practice of medicine. The question that you need to ask is “am I willing to work this hard for this career?” If you can answer this in the affirmative no matter what the future holds, then likely you will have a satisfying career in medicine.
In no other career are you asked to be out of the work force for essentially 8 years just to be able to enter a job where you will be making less than minimum wage with an average educational debt of more than $150K. In no other career is your income totally dependent on the policies and regulations of private industry, government regulatory agencies, Congress and state governments. You have no control over what reimbursement will be for your services (those reimbursements have been cut every year in the name of holding down costs) while your costs of maintaining your practice have continued to increase dramatically.
Primary care (Internal Medicine, Family Medicine, Pediatrics and OB-GYN) have seen their ranks shrink in popularity among graduates of American medical schools for a number of reasons not the least of which is the extremely high costs of medical education, rising interest rates on loans and decreased pay. Those people who are yet to enter medical school and those who are yet to graduate face even more challenges in terms of just being able to make a living (purchase a house, pay off educational loans, open a practice). If you are not yet in medicine/medical school, you are likely (unless you enter the armed forces) not going to be able to afford to enter primary care because of past educational expenses. Along with that, add the fact that if you are not a very strong performer in medical school, you won’t be eligible for residency in one of the “money” specialties and thus, you will be scrambling to make a living even if you are able to get into medical school.
The American Medical Association has been extremely slow to organize and speak for the needs of the young physician. Most of the people (and I am thankful for their efforts) that are able to lobby, have been established physicians in specialties such as opthalmology who can afford to take a day away from practice because their loans are paid off and their homes are purchased and their children have their college education paid for. They have little in common with the newly minted physician who has a young family, a 10-year-old car from residency and a $2,000 a month loan payment in addition to rent (mortgage if they are lucky)and office overhead expenses. I remember my cousin, who is a neurosurgeon state back in the early 1990s that she had to make a minimum of $10,000 per week in order to keep her office door open. I am sure that number has increased (increased malpractice costs and office costs) while her payments have been decreasing. In the face of this, why would anyone want to enter this career? How would anyone afford to enter this career?
The answer to these questions are not easy but they are expensive both in time and energy. The truth of the matter is that you had better know as much about the day-to-day practice of medicine before you enter your pre-med curriculum because by the time you have finished your first two years of medical school, you have racked up too much debt to be able to do anything else. Little is taught about practice management/investment/finance either in medical school or residency. Medical school prepares you for residency and residency prepares you for practice.
Some people want residency programs to include more about practice management, marketing and finance but along came the 80-hour work week restrictions and thus, most residency programs are still scrambling to make sure that they can include all of the experiences that residents need to learn just to practice let alone add to what they need. The business of medicine is very complicated and growing more complicated daily with policy changes at both the federal and state level. It takes many hours to keep up and keep yourself informed.
This gets back to what do you want from a career in medicine? Financial/job security isn’t out there anymore. Definitely respect and admiration are not out there anymore. Hard work, long hours of study and personal and financial sacrifice are definitely out there and ahead. i caution anyone to look long and hard at this career because it’s not easy and there is no relief on the horizon. Be very, very sure that you have a realistic idea of what day-to-day life is like for physicians who are coming out today and not what you see on the telly. None of those shows are remotely close.
14 December 2007
A Memorable Patient
I have been thinking about some of my more memorable patients these days. I especially remember one of my younger surgical patients from when I was a junior resident. I was on the Colo-Rectal surgical service, which was one of the more interesting rotations that you can have a resident. Colo-rectal surgeons handle just that, diseases of the colon and rectum that have to be treated surgically. One of the nice things about the service is that the colo-rectal attendings were among the most personable and knowledgeable of my junior years. They loved to teach and they loved to have us involved in their cases at every step.
One day, a gentleman presented to clinic for the final scheduling of his upcoming surgery. He was a young man (less than age 40) with a very low rectal tumor that we knew was cancerous. His presentation had been rectal bleeding and when his primary care physician found the tumor (it was palpable on digital rectal exam), he immediately referred the gentleman to our clinic for workup and surgery. At this point, the workup was complete: CT Scan, blood work and chest film. We reviewed everything and the patient was scheduled for AM admission, given pre-op orders and sent home to report back to the hospital two days later.
Two days later, we greeted the patient and his wonderful wife in the holding area. They had followed the prep instructions to the letter and he was cleared by anesthesia for the case that we would be doing. We had planned an abdominoperineal resection which involves wide excision of the rectum to include the lateral attachments and pelvic attachements and the creation of a colostomy. In the performance of this procedure, abdomen is opened and examined to see the extent of spread of the disease if any. Since we had a CT Scan that was two weeks old, that showed no evidence of spread of disease to other organs, we were confident that we would be able to remove the tumor, fashion a colostomy and get this patient on to recovery.
To have a colostomy at such a young age is life changing but to die of rectal cancer would be a tragedy and thus the patient was eager to get the surgery over with and get on with chemo and his recovery. He had been very eager to learn about colostomy care and life with this procedure. We open the abdomen and to our shock, the cancer had spread to his liver. As I moved my hand over the liver, the extent of the numerous tumors was quite evident. We all scanned the CT to see if we had missed something but we had not and neither had radiology. The tumor did not show on the CT Scan.
At this point, I helped my chief resident close the abdomen while our attending went to deliver the devastating news to this patient's wife. The cancer was unresectable and the patient had little chance of living more than a few months with the extensive liver involvement. The next day, we ordered another CT Scan and sure enough, there were multiple tumors throughout the liver in addition to the tumor in the rectum which really hadn't changed much in size.
The next two days, I rounded on this patient and wrote notes. I made sure that his pain was under control and I met many of his relatives who were just wonderful and very grateful for everything that we had done for the patient. I felt horrible because we all wanted to do more but there wasn't anything more that could be done from a surgical standpoint. On post op day 3, the patient was ready for discharge from the hospital. He was scheduled to see a wonderful oncologist and the possibility of enrollment in an experimental protocol was there but still, it was difficult to see this situation.
A week later, the patient came back to clinic for removal of his surgical clips. His incision was well healed and he joked about the small shave prep that had been performed. His lovely wife said that every day she had with her husband was a gift because he had been badly injured in an accident three years earlier and given little chance of survival but he did. She said that she was so happy to take him home and that he was a well-loved man.
I heard that this patient died peacefully at home six months after the surgery. His wife sent us an obit notice and wanted us to see that she had directed all donations go to the American Cancer Society. She thanked us again for the great care and the time that she had with her husband. Those words stung then and they still sting as I think of that lovely family from time to time.
It is always patients like this patient that remind me to give my best always. We don't know if we will be the last physician or the physician that will make an impact on our patients. This patient gave me so much by just putting his trust in our team. I see him often when I have to deliver bad news to a family or to a patient and I hope that he is at peace. His wife said that his death was peaceful and that his 10-year-old child was with him as was his mother and father. I can only hope that all of my patients can leave behind their disease in peace when the time comes. I am certain that the oncologist made sure that he was pain free as much as possible.
It's this time of year when I think of some of my more memorable patients. The ones who show me how to live by being a great example with their lives. I am a very fortunate physician.
One day, a gentleman presented to clinic for the final scheduling of his upcoming surgery. He was a young man (less than age 40) with a very low rectal tumor that we knew was cancerous. His presentation had been rectal bleeding and when his primary care physician found the tumor (it was palpable on digital rectal exam), he immediately referred the gentleman to our clinic for workup and surgery. At this point, the workup was complete: CT Scan, blood work and chest film. We reviewed everything and the patient was scheduled for AM admission, given pre-op orders and sent home to report back to the hospital two days later.
Two days later, we greeted the patient and his wonderful wife in the holding area. They had followed the prep instructions to the letter and he was cleared by anesthesia for the case that we would be doing. We had planned an abdominoperineal resection which involves wide excision of the rectum to include the lateral attachments and pelvic attachements and the creation of a colostomy. In the performance of this procedure, abdomen is opened and examined to see the extent of spread of the disease if any. Since we had a CT Scan that was two weeks old, that showed no evidence of spread of disease to other organs, we were confident that we would be able to remove the tumor, fashion a colostomy and get this patient on to recovery.
To have a colostomy at such a young age is life changing but to die of rectal cancer would be a tragedy and thus the patient was eager to get the surgery over with and get on with chemo and his recovery. He had been very eager to learn about colostomy care and life with this procedure. We open the abdomen and to our shock, the cancer had spread to his liver. As I moved my hand over the liver, the extent of the numerous tumors was quite evident. We all scanned the CT to see if we had missed something but we had not and neither had radiology. The tumor did not show on the CT Scan.
At this point, I helped my chief resident close the abdomen while our attending went to deliver the devastating news to this patient's wife. The cancer was unresectable and the patient had little chance of living more than a few months with the extensive liver involvement. The next day, we ordered another CT Scan and sure enough, there were multiple tumors throughout the liver in addition to the tumor in the rectum which really hadn't changed much in size.
The next two days, I rounded on this patient and wrote notes. I made sure that his pain was under control and I met many of his relatives who were just wonderful and very grateful for everything that we had done for the patient. I felt horrible because we all wanted to do more but there wasn't anything more that could be done from a surgical standpoint. On post op day 3, the patient was ready for discharge from the hospital. He was scheduled to see a wonderful oncologist and the possibility of enrollment in an experimental protocol was there but still, it was difficult to see this situation.
A week later, the patient came back to clinic for removal of his surgical clips. His incision was well healed and he joked about the small shave prep that had been performed. His lovely wife said that every day she had with her husband was a gift because he had been badly injured in an accident three years earlier and given little chance of survival but he did. She said that she was so happy to take him home and that he was a well-loved man.
I heard that this patient died peacefully at home six months after the surgery. His wife sent us an obit notice and wanted us to see that she had directed all donations go to the American Cancer Society. She thanked us again for the great care and the time that she had with her husband. Those words stung then and they still sting as I think of that lovely family from time to time.
It is always patients like this patient that remind me to give my best always. We don't know if we will be the last physician or the physician that will make an impact on our patients. This patient gave me so much by just putting his trust in our team. I see him often when I have to deliver bad news to a family or to a patient and I hope that he is at peace. His wife said that his death was peaceful and that his 10-year-old child was with him as was his mother and father. I can only hope that all of my patients can leave behind their disease in peace when the time comes. I am certain that the oncologist made sure that he was pain free as much as possible.
It's this time of year when I think of some of my more memorable patients. The ones who show me how to live by being a great example with their lives. I am a very fortunate physician.
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