Saturday, November 26, 2011
A Bad Situation
Just a quick post about a bad situation. A 16 year old male came into our ED the other night with an osteosarcoma of his femer head. An osteosarcoma is a bone cancer that you don't want to mess around with. Complicating this is that he is an illegal from Mexico. He was diagnosed and treated there, when medical complications arose the mother lost faith in her country's doctors and crossed the border to the US, where a certain hospital took her son in. The hospital offered to pay for his medical treatment for free. As treatment progressed it became understood that the only way to save this young man was to do a hip disarticulation, basically cut out all of the tumor and amputate the leg. Since a large portion of the hip would have to be removed, getting even a fake leg would likely be impossible, this boy decided he would rather die. After lengthy discussions with the boy and mother, they left the hospital on pain medication, before leaving they were warned that they would not get the same generous offer upon returning and were unlikely to find it elsewhere. I meet him two months later when his pain medication is no longer controlling his pain. They are now requesting that we move ahead with the surgery that the other hospital purposed. I call the higher ups to request admission...admission denied. Per congressional law I'm alotted the power to stabilize any acutely life threatening problems and discharge the patient after that is done. We run basic labs and find no such immediately "life threatening" problems. I sit with the mother and tell her as she's crying that we can't help her son. I offer what little I can, a script for improved pain management and advice to return to Mexico as soon as she possibly can (which she has the power to - I asked - but which she is extremely resistive). I sat there in silence for a long time...what could I have done differently? I don't know. I've thought about this alot and I can come up with two arguments one very logical, cold, and practical and the other much more humanistic, either way I can't really wrap my head around it yet...the factors that led to that situation are just so complex, so horribly muddled, that I can't even process it. Any takers? Did I do the wrong thing? Part of me says I did, despite having done it "by the book", part of me says I didn't. That mother thinks we did. Do you?
Wednesday, November 9, 2011
My Belly Hurts
So the night after writing "moon walking" a friend of mine who is now one of the head residents, a "chief", calls me wanting to know specifics on a kid I treated as an intern, she is giving a lecture for morning report (doctor's lectures to other docs). As she is retelling what she knows of this patient, a little cute girl, Emily, comes into my mind, she's sitting in bed with pink jammies telling me, "My belly hurts". She's one of those kids that you hope that you would have someday, cute and sharp as a button tack, she loved to play soccer, she was 4 or 5 at the time. She came in with abdominal pain and occasional headaches, we did a quick workup culminating in a endoscopy and colonoscopy by the gastroenterologist which showed an odd finding, as they scoped her the very mild stress of the procedure on the colon was causing bruises and hematomas (collections of blood). We didn't have a clue what was going on. Then, my golden weekend came and I left for home to ponder what was wrong with her wondering what they would have found when I returned but, when I did come back the attendings had discharged her to continue the work up for her problem in outpatient, as she was medically stable and not in danger.
As time went on, I'm ashamed to say she left my mind, this girl in pain that we couldn't help. Now a year later, my good friend, tells me that what had caused all this was hypertension (high blood pressure). I looked at and wrote down her blood pressures every damn day! The high blood pressure was causing the headaches and the bleeding and the stomach pains....and later as she went on over a YEAR undiagnosed and untreated it started to affect her vision...it started to affect how she thought...she eventually was so debilitated she no longer could play soccer. When she told me what had caused the pain, I cursed. When I asked how she was doing, my friend tried to soften the blow, but I looked up her records...and I know that if I'd just been better I could have caught it, such an easy catch...and yet it went undiagnosed for over a year, with high blood pressures documented at every visit, sick and well, just one doctor recognizing a single number was high could have changed her life. The problem lies in that childrens blood pressures are much lower than adults. An adult BP (blood pressure) is typically normal at 120/80...she had the misfortune of having a blood pressure too close to the adult normal, and as such she was overlooked until her BP got higher than the adult norm.
As I thought of that little girl sitting at home sick for a year, sitting out of games, and crying in pain, it really started to wear on me...her sight almost lost...I found myself crying on the way to work, this was only supposed to be a job!!! What kind of job hurts people when you screw up?!?! If I didn't realize the gravity of my job before, I do now, I don't even know if you should call it a job, it's something else entirely to me now. For every "moon walking" story, how many of these stories are slipping passed me quietly? Whenever I think of that girl, I feel a great regret and a mistake that I can't fix no matter how I try. I went to the computer people where I work and got the computer to recognize age and height specific blood pressures, it should be working within the month, within a month this kind of error won't be possible again...it doesn't seem enough. I don't care if I save hundreds kids from her fate with that fix...I didn't save her. I'm already thinking up more schemes to improve the system, but when I get down to it, I don't think I'm ever going to get rid of her skipping around in the back of my mind, weeks later it still stings when I think of her...when I think of my son, should he endure a similar fate. I've thought about calling the mother and apologizing but I shy away from it the second after...I come up with excuses (bla bla legal bull crap bla bla your not the only one to blame bla bla is the apology for you or her? bla bla bla)...I don't know if my cowardice will allow me...maybe in time, after I feel that I've in some way made up for it (if that ever happens)...I don't know...Whatever happens in the end my mind will work her memmory over till her rough stone in my stream of consciousness becomes smooth as a river rock but, regardless how I wear down the sharp edges, she's a part of me now and likely forever. Like I said, occasionally I find my feet on the moon but it doesn't take long till I find them slapped down to earth again, reciting my mantra, trying to clear the pain of my mistakes from my head, "I'll do better next time...I'll do better next time...I'll do better next time...God, Emily, I'm so sorry."
Newbie Doc
As time went on, I'm ashamed to say she left my mind, this girl in pain that we couldn't help. Now a year later, my good friend, tells me that what had caused all this was hypertension (high blood pressure). I looked at and wrote down her blood pressures every damn day! The high blood pressure was causing the headaches and the bleeding and the stomach pains....and later as she went on over a YEAR undiagnosed and untreated it started to affect her vision...it started to affect how she thought...she eventually was so debilitated she no longer could play soccer. When she told me what had caused the pain, I cursed. When I asked how she was doing, my friend tried to soften the blow, but I looked up her records...and I know that if I'd just been better I could have caught it, such an easy catch...and yet it went undiagnosed for over a year, with high blood pressures documented at every visit, sick and well, just one doctor recognizing a single number was high could have changed her life. The problem lies in that childrens blood pressures are much lower than adults. An adult BP (blood pressure) is typically normal at 120/80...she had the misfortune of having a blood pressure too close to the adult normal, and as such she was overlooked until her BP got higher than the adult norm.
As I thought of that little girl sitting at home sick for a year, sitting out of games, and crying in pain, it really started to wear on me...her sight almost lost...I found myself crying on the way to work, this was only supposed to be a job!!! What kind of job hurts people when you screw up?!?! If I didn't realize the gravity of my job before, I do now, I don't even know if you should call it a job, it's something else entirely to me now. For every "moon walking" story, how many of these stories are slipping passed me quietly? Whenever I think of that girl, I feel a great regret and a mistake that I can't fix no matter how I try. I went to the computer people where I work and got the computer to recognize age and height specific blood pressures, it should be working within the month, within a month this kind of error won't be possible again...it doesn't seem enough. I don't care if I save hundreds kids from her fate with that fix...I didn't save her. I'm already thinking up more schemes to improve the system, but when I get down to it, I don't think I'm ever going to get rid of her skipping around in the back of my mind, weeks later it still stings when I think of her...when I think of my son, should he endure a similar fate. I've thought about calling the mother and apologizing but I shy away from it the second after...I come up with excuses (bla bla legal bull crap bla bla your not the only one to blame bla bla is the apology for you or her? bla bla bla)...I don't know if my cowardice will allow me...maybe in time, after I feel that I've in some way made up for it (if that ever happens)...I don't know...Whatever happens in the end my mind will work her memmory over till her rough stone in my stream of consciousness becomes smooth as a river rock but, regardless how I wear down the sharp edges, she's a part of me now and likely forever. Like I said, occasionally I find my feet on the moon but it doesn't take long till I find them slapped down to earth again, reciting my mantra, trying to clear the pain of my mistakes from my head, "I'll do better next time...I'll do better next time...I'll do better next time...God, Emily, I'm so sorry."
Newbie Doc
Thursday, November 3, 2011
Moon Walking
I remember writing about how medicine and becomeing a doctor is discouraging. It's like your goal is journeying to the moon and you are so far away and every day is only a single step, it seems unobtainable. My thoughts concerning that goal over a year of being a "doctor" hasn't changed...you still take it a step at a time, each achievement you pat yourself on the back for and each failure you close your eyes and recite your mantra, "I'll do better next time". You keep telling yourself that every failure and every success just moves you one step closure to that goal that is so far away.
For the past 3 years I've been practicing my eye exam. To me it's a very hard thing to do, use that opthalmoscope. I've been using it almost daily for the past 3 years and I've finally gotten to a place where I can routinly see the vessels in the back of the eye. Some patients I still have a problem with and can't for some reason. Many of my collegues when I question about it say they don't even try...I myself have wondered why I keep it up. Well several months ago now I got a 14 year old male in the hospital with a horrible headache, he'd been into several emergency departments and urgent cares, all of which had treated him as a migraine and sent him home. I met him early in the morning, he had continued 10 out of 10 pain despite adequate pain management (which honestly is pretty typical of most teen migraines), however some things struck me different about this patient. His mom was histerical and insisting something was wrong with her son. Most mothers of teen migraines have seen it before and in the back of their mind, either know that the child is just having a migraine or in the case of most female teenage migraines know that the child is faking it (evidenced by the 17 year old female text messaging her boyfriend with a smile on her face saying that her headache is a 10 out of 10 pain level). What added to that was this was a stable family, I notice most males with migraines either have a strong family history or an unstable family/social environment. On top of that, he was complaining of symptoms that were very un-migraine, he said that his hands were balling up involuntarily.
When you suspect brain pathology (a mass or increased pressure) there are only a couple of things you can do. You can do a neuro exam, look at the backs of the eyes, and take picture of the brain with an MRI or CT. By far the quickest check is to look in the back of the eyes with the opthalmoscope, but I'm convinced not many doctors (even the experienced ones) can do this...(I've seen most just defer it and do one of the other tests or order an optho consult). But, I've been diligently practicing, so I dim the lights, focus the scope, and tell him to pick a point in the room and focus on it. I pull the scope up so we are centimeters from each other. My light coarses through his pupils and I see the back of his eye clear as day. I focus a bit more until the vessels are crisp in my vision and then I follow them to the source, the enterence of the vessels into the eye...I'm shocked...I see a glimpse of white...it's ussually red/pink/orange. I peer closer, he must feel like I'm going to jump inside his skull. There surounding the enterence of the eyes is a white puffy donut...papilledema, wow, after years of practicing it's finally paid off! In a second for free, I've identified the cause of this kids headache. He has increased pressure on his brain that is pushing on the backs of his eyes. I've done what a CT and MRI couldn't, I send him for an STAT opthomology consult to confirm my findings (Come on I'm practiced but I'm not at all confident)...they confirm my findings and he's sent for a lumbar puncture which removes the excess brain fluid, his headache is cured. Although time has passed from that moment, days have turned to weeks, and weeks to months, and during that time I've found myself still on that long journey still millions of miles away from my goal, in that one moment I was standing on the moon.
Newbie Doc
For the past 3 years I've been practicing my eye exam. To me it's a very hard thing to do, use that opthalmoscope. I've been using it almost daily for the past 3 years and I've finally gotten to a place where I can routinly see the vessels in the back of the eye. Some patients I still have a problem with and can't for some reason. Many of my collegues when I question about it say they don't even try...I myself have wondered why I keep it up. Well several months ago now I got a 14 year old male in the hospital with a horrible headache, he'd been into several emergency departments and urgent cares, all of which had treated him as a migraine and sent him home. I met him early in the morning, he had continued 10 out of 10 pain despite adequate pain management (which honestly is pretty typical of most teen migraines), however some things struck me different about this patient. His mom was histerical and insisting something was wrong with her son. Most mothers of teen migraines have seen it before and in the back of their mind, either know that the child is just having a migraine or in the case of most female teenage migraines know that the child is faking it (evidenced by the 17 year old female text messaging her boyfriend with a smile on her face saying that her headache is a 10 out of 10 pain level). What added to that was this was a stable family, I notice most males with migraines either have a strong family history or an unstable family/social environment. On top of that, he was complaining of symptoms that were very un-migraine, he said that his hands were balling up involuntarily.
When you suspect brain pathology (a mass or increased pressure) there are only a couple of things you can do. You can do a neuro exam, look at the backs of the eyes, and take picture of the brain with an MRI or CT. By far the quickest check is to look in the back of the eyes with the opthalmoscope, but I'm convinced not many doctors (even the experienced ones) can do this...(I've seen most just defer it and do one of the other tests or order an optho consult). But, I've been diligently practicing, so I dim the lights, focus the scope, and tell him to pick a point in the room and focus on it. I pull the scope up so we are centimeters from each other. My light coarses through his pupils and I see the back of his eye clear as day. I focus a bit more until the vessels are crisp in my vision and then I follow them to the source, the enterence of the vessels into the eye...I'm shocked...I see a glimpse of white...it's ussually red/pink/orange. I peer closer, he must feel like I'm going to jump inside his skull. There surounding the enterence of the eyes is a white puffy donut...papilledema, wow, after years of practicing it's finally paid off! In a second for free, I've identified the cause of this kids headache. He has increased pressure on his brain that is pushing on the backs of his eyes. I've done what a CT and MRI couldn't, I send him for an STAT opthomology consult to confirm my findings (Come on I'm practiced but I'm not at all confident)...they confirm my findings and he's sent for a lumbar puncture which removes the excess brain fluid, his headache is cured. Although time has passed from that moment, days have turned to weeks, and weeks to months, and during that time I've found myself still on that long journey still millions of miles away from my goal, in that one moment I was standing on the moon.
Newbie Doc
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