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Medicine’s Alternative Universe

luckyby S. Goldberg, Med’Toons, Medmaster

An alternative universe is an unseen dimension. When we round and enter the patient’s room, we don’t experience this hidden dimension, just our own world with its medical technicalities.

The hidden dimension is the hospital experience from the patient’s point of view. The patient is not necessarily thinking what the therapist is thinking. I entered this dimension recently after undergoing coronary artery bypass graft (CABG) surgery.  Here are my impressions of the physician’s dimension as opposed to the patient’s dimension during evaluation and treatment:

On being wheeled in a bed to angiography and by-pass surgery that night:
PHYSICIAN: Wheel the patient to the procedure room, adequately sedated.
PATIENT: Nervous; too late to change my mind. As one patient put it “Imagine someone sawing your chest in two and pulling you asunder and then doing some crazy shit to your heart?”  Lying in bed, I don’t have to do any of the wheeling. I’m a VIP from Hell.

Immediately post operation:
PHYSICIAN: Family visitations OK in ICU.
PATIENT: Family scared looking at me recovering from anesthesia. They heard a lot of moaning (which I don’t remember) and thought I might die. I can’t engage in meaningful conversation with them. I don’t look so great the rest of the hospitalization either.

PHYSICIAN: After admission to ICU; remove endotracheal tube (I don’t remember that); monitor vital signs; chest tube should be draining; Foley catheter in place; measure urine volume; IV drip with correct medication flowing at an optimal rate; nasal cannula in place with adequate flow; arterial line from angiography remains in place in groin in case arterial access is needed.
PATIENT: Groggy; pain on respiration largely from chest tubes; have to stay still and supine so as not to disrupt arterial line in right groin. Uncomfortable. I’m used to turning from side to side when I sleep. Can’t do that now.

During 6 days of hospitalization:
PHYSICIAN: Throughout each night, draw blood tests; check oxygen saturation; give medication; check BP, pulse and ECG.
PATIENT: At 3AM every night? Can’t sleep well as is, especially with the background noise and light; try sleep mask and ear plugs; can’t find good sleeping position; have to frequently call nurse to adjust body position; after a few days, need to sleep in chair part of night. So many pills; should I take them all at once or one at a time? Better take one at a time so I don’t choke. What if I arrest? Would they give me chest compressions with this fresh chest wound? Bed pan no fun. You never hear about bed pans in movie plots.

PHYSICIAN: Respiratory therapy – instruct patient how to use volumetric spirometer; administer respiratory inhalant in the middle of the night.
PATIENT: The respiratory therapist is encouraging, but I’m not going to break any Olympic records for volume of inspiration with this spirometer.  Inspiration with the device difficult due to coughing.

PHYSICIAN: Have patient sit in chair, not in bed all the time.
PATIENT: Need warm blankets, since I’m cold. The staff is busy. Not me. Nothing of interest on TV. I specialize in staring into blank space. Can’t work; depressed. Life is accelerating downhill. What about my family? My work? I don’t want to be a burden.

PHYSICIAN: Ambulate patient after 1 day.
PATIENT: Legs feel heavy; hard to stand or walk; in danger of fainting; need assistance in walking short distances, with shuffling. Need a walker; who, me? I’m a patient now!  I think the only difference between being sick and dying is that you don’t get better with dying. I’m walking a little better each day.

PHYSICIAN: Give patient colchicine to reduce cardiac inflammation.
PATIENT: Colchicine causing diarrhea. Hard enough getting out of bed with assistance to go to toilet, and, with all these IVs, need my butt wiped by the nurse.

PHYSICIAN: Time to remove 2 of the 3 chest tubes on day 2; leave one of them in, maybe until tomorrow, since there still appears to be significant fluid in the lungs.
PATIENT: Please take out that last tube tomorrow so that I can breath better with less pain.

PHYSICIAN: Surgery group says chest incision looks good.
PATIENT: It may look good, but it feels more like in the Alien movie before the alien burst from the chest. I guess it’s “better to look good than to feel good.” But I’m glad I’m still above ground. I’m growing a beard; look scruffy and old.

PHYSICIAN: Apply automatic inflatable cuffs pumping continually on calves to help prevent clotting.
PATIENT: Helpful, but another restriction to moving.

PHYSICIAN: Take frequent BP readings, with cuff remaining in place.
PATIENT: Cuff causes an irritating blister under my left arm and has to be moved to the right.

PHYSICIAN: Keep IV going.
PATIENT: IV is infiltrating, blowing up around the needle. Will the nurse come? I’m running out of veins. Was that the last vein available? What will they do if I run out of veins!?

PHYSICIAN: Keep controller near patient to control TV, adjust bed, and enable patient to call nurse.
PATIENT: Help, I can’t find the controller. I’m doomed, unless I yell for assistance. Would they come?

PHYSICIAN: Keep track of urine volume.
PATIENT: I find the male bed urinal difficult to use. Which way? Up or down? I wet the gown and bed; hard to pee when supine; need to stand up.

PHYSICIAN: Administer prescribed diet.
PATIENT: Not hungry; ate little.

PHYSICIAN: Do direct stick for arterial blood gases.
PATIENT: More like several painful sticks; apparently harder to get arterial blood than venous blood; also I’m collecting an assortment of ugly purple patches from blood leaking under my skin. I’m looking more like a patient.

PHYSICIAN: Incisions in right leg to get vein for grafting is healing well.
PATIENT: I forgot that I have more incisions.

PHYSICIAN: Take patient down for x-ray.
PATIENT: I’m down in Radiology, but no one is coming. How long will I wait?

PHYSICIAN: Once outside ICU, arrange consultation for the Surgical team, Pulmonary, Internal Medicine, Cardiology, Physical Therapy, Social Services.
PATIENT: I’m losing track of all the consults. Nursing care very good, but more attentive in ICU where there is higher nurse-to-patient ratio. Medical consult passes through quickly. Does he really care, or has the bedside just become routine and impersonal? Does he know anything about me other than the lab values?

PHYSICIAN: Pain Medication PRN.
PATIENT: I don’t want to take any more meds than necessary. Pain improved on removing chest tubes, but have pain in back, shoulders, and neck, maybe from awkward sleeping position or the surgery itself. Maybe just Tylenol.

PHYSICIAN: Discharge patient, 6 days post-op.
PATIENT: On 11 different medications!!?? Discharge group conference discussed diet, activity, nursing and physical and occupational therapy visitations for 2 weeks, followed by cardiac rehab in 1 month post-discharge. Regarding depression, the group answered any questions and pointed out that I would feel better in time. They did a good job.

Start cardiac rehab 1 month post-op. Exercising more in Rehab; feeling better than I have in a long time 2 months post-op. I am grateful for a new heart. Another benefit: weight loss.

I wrote this blog entry to remind the student and physician that there is another dimension to making rounds, that of the patient’s feelings and point of view. Regretfully, empathy with the patient often diminishes in the latter years of medical school, probably due to lack of time and the mass of technical information that has to be absorbed, in addition to the stress of being personally involved with patient and family. Rather than quickly passing by the bedside on rounds, sit down for a minute with the patient to empathize at the patient’s level. That is also therapy. Do you know who your patient is? Is he/she just “the CABG in room 612?” The patient “won’t care how much you know until they know how much you care.”

Steven Goldberg – In Memorium

Last week Steven Goldberg (no relation), a former student of mine at the University of Miami School of Medicine, passed away of lymphoma at the age of 42.  After 25 years of my teaching at the U of M, his name stands out in my mind, not because of similarity of name, but because of his brilliance and character.  He was a true mensch.

Steve was born with transposition of the arteries, which required surgical correction.  When he advanced in medicine, his goal was to become a pediatric cardiac surgeon and offer to other children what had been provided to him.  He did just that, training at the same institution that had operated upon him as a child.  He specialized in difficult cardiac procedures in children, including the kind of congenital defect that he had, as well as cardiac transplantation.

You can gain a better glimpse of his character through the YouTube video he prepared for LeBonheur Children’s Hospital last year. Within only a few days of his passing, there were hundreds of facebook postings by people whose lives he had touched.

Steve was also a skilled artist who illustrated significant parts of my books on Clinical Physiology Made Ridiculously Simple and Med’Toons. Here are three of my favorite cartoons that he drew:

Emphysema in wolves

From Med’Toons, by Stephen Goldberg, Medmaster

Immune-picture

T-helper cell function in the immune system.
From Clinical Physiology Made Ridiculously Simple, by Stephen Goldberg, Medmaster

Steve will be greatly missed.  He was the personification of the ideal physician.

Drawing The Patient Into the Decision-Making Process

From Med'Toons, by S. Goldberg, MedMaster

From Med’Toons, by S. Goldberg, MedMaster

Should the patient and family participate in the decision-making process as to whether or not to pursue an aggressive course of therapy?

Of course, there are those patients who say “Whatever you think would be best doc.”  And there are others who are so mentally incapacitated as to not be able to render an intelligent decision.

But what if a patient wants to help decide on the course of therapy? There are two points of view.  There are physicians who feel that patients and family should not participate in decision-making in aggressive treatments, such as surgery, radiation, and chemotherapy, as they are too emotionally involved and may not think rationally.  I feel otherwise.  Apart from the patient having the right to agree or not agree to a particular treatment, there are situations in which the patient may be in a better position than the physician to decide.  For instance, say a patient has a tumor of the arm and the statistics indicate that there is a 90% chance of survival if the entire limb is removed, but only a 70% chance of survival if the tumor is removed locally, but leaving the function of the arm intact if successful.  What should one do?  Leave the decision up to the physician, or seek the patient’s opinion?  The physician may opt to remove the arm to improve the chances of survival but the patient may want to take the gamble, in order to keep a functioning limb. The patient’s choice may well be the better one; it suits the patient’s individual needs.  The patient and family may be willing to gamble, while the physician may not.

If the patient and family are well-informed of the facts, the therapist should encourage their participating in the decision-making. The patient and family not only have the right to do so, but their input may be helpful, even invaluable, in making the right decision.

The Importance Of Patient Followup

The spontaneous cure has kept many a healer in practice.

In the busy pace of medical practice, whether in-hospital or outpatient, it is common to lose track of what happens to the patient after discharge.  There are two good reasons to try to follow up, when possible, on how the patient fared after leaving the hospital or outpatient office:

1. Calling a patient is important psychologically to the patient.  Your call lets the patient know that you care by taking the time to follow up.

2.  It is important to your own education.  Once the patient leaves the hospital or office, if you don’t hear back is it because the patient improved and doesn’t feel the need to return? Or perhaps the patient’s condition has not improved and the patient may have sought care elsewhere or otherwise feels hesitant to return.  This is an important source of learning that can help you in treating future patients.  You wouldn’t want to continue a treatment that doesn’t work, but you would want to emphasize one that does.

*****

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The Healing Power Of Just Sitting Down

We enter medical school full of humanitarian goals. Somehow, though, something seems to happen all too frequently in the clinical 3rd and 4th years and beyond.  There is less focus on the patient as an individual and more emphasis on lab tests and presenting on rounds.

Perhaps it is the busy schedule, where so much time has to be spent with performing, ordering and reviewing lab tests, making rounds, writing notes, and preparing for presentation to interns, residents and attendings.  Perhaps it would be too draining to become emotionally involved with the patient’s illness, as would be the case for a family member.  But the opposite extreme, of overlooking the patient’s emotions, is not good either;  there needs to be a happy medium.

When I was a student, I noticed that the internal medicine interns and residents who were considered the best knew their medicine and were up on their lab tests.  But there was little evidence that they really knew who their patients were as people.  The chief resident, who had the most status, had even gotten an article published in the prestigious New England Journal of Medicine.  He was very much involved in the lab tests, but I doubt if he knew anything about who his patients were as individuals.

With such a busy schedule, there is a simple change on rounds that can make a difference.  That is sitting down with the patient, rather than standing and quickly passing through.

Sitting down briefly doesn’t take much time.  But it gives the patient the feeling that s/he is not just a statistic, and the physician truly cares; it relieves some of the patient’s mental stress, which is part of any illness.  It also gives the physician a little insight into the patient as an individual.  We call this bedside manner.  It is practiced much better by certain practitioners of questionable areas of “alternative” medicine.  There is no reason why it can not be done in all areas of medicine.