Top Ten #1: Reasons Your Patient is NOT in 10 out of 10 Pain

10. The patient is sitting in bed doing a crossword.
9. They are jabbering non-stop on the phone with the friend.
8. They ate their entire dinner and then asked for more.
7. They tell you that they're in 10 out of 10 pain in a totally dead-pan bored voice.
6. The patient gets up and walks around the hospital floor all the time.
5. Their blood pressure and heart rate are completely normal.
4. They are supremely worried about the channels they get on TV.
3. They will only take IV pain medications and will not try anything by mouth at all.
2. They are "allergic" to morphine.
1. They don't LOOK like they're in any kind of pain.

Is this cynical? Maybe.

John P. Pryor

We recently read some bad news about John Pryor, a trauma surgeon at the Hospital of the University of Pennsylvania, who died on Christmas day in Iraq.

I never met this guy, but I heard of him. Seems like he was an amazing guy.

Christmas at the Hospital

I think Christmas is probably my favorite holiday of the year. Despite having to spend it overnight at the hospital this year, for whatever reason, I was still in pretty good spirits. There was Christmas music playing on the radio, people are generally in pretty good moods (although there were definitely some sour faces at the hospital), and it's a relatively quiet night at the hospital - I think I got 6 hours of sleep on call, which is absolutely amazing! I played some poker with some other residents, we ordered some Chinese food (the only thing open on Christmas day), and just hung out.

However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.

Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.

Medical errors

They happen... just like they do in other parts of life. It's horrible and unfortunate, but it's a fact. They're also unavoidable. We can (and should) do everything we can to minimize them, but no matter what, they're going to happen occasionally, or hopefully, rarely.

I haven't had to deal with this issue until relatively recently, and I consider myself very very fortunate. It's going to be purposefully vague, but I'll tell a story now because I think it has some valuable lessons to be learned from it.

I was taking care of a patient who was admitted for lung problems, and we were giving her all the appropriate treatment and doing the right studies for her for the first few days. Then the 3rd or 4th day, a nurse went in and gave the patient the wrong medications. Someone from the family was with the patient 24 hours a day, and they didn't notice at first, but then the nurse went in and threw a medication away into the trash without saying why. The family thought this was odd (as would anybody) and they looked at it, and it happened to have a different patient's name on it. In this case, the different medications probably did not cause any harm to the patient, however, giving the wrong medication was definitely an error. It was horrible and should never have happened but I feel that what happened afterward was worse.

The family had to call in a different nurse passing by to see what happened, who then called me. When I talked to the patient's official nurse, the one who gave the wrong medications, she denied certain aspects of it and lied (whether knowingly or unknowingly) about certain things - I only found out the truth later. Moreover, she never explained what happened or what she did to the family or any other doctors, and she never apologized.

No matter what happens, no matter how serious, you ALWAYS NEED TO TELL THE TRUTH. Although I feel particularly strongly about it in this case, I feel that this should be something people adhere to in general when dealing with patients.

Secondly, I believe in apologies, which we did (on behalf of the nurse) profusely to the patient and her family. There's actually some debate about this, although perhaps less so now than several years ago. At one point, I believe lawyers may have actually advised medical staff against apologizing to patients, whether or not some sort of mistake was made. The thought was that if you apologized you would be admitting guilt, which then would make a court case much more difficult. I don't necessarily agree, but I could see a situation in which medical staff apologized for something that was not anybody's fault, and the patient took it the wrong way. However, now people are saying that apologizing, while that may seem like admitting guilt, often deters patients and their families from suing the hospital or the staff. Personally, I think if you or somebody that works for you did something wrong, and it was without a doubt an error, you should apologize. You are guilty in a way, and if apologizing is a way of admitting that, then so be it.

In this case, the family even said that had the nurse come in and explained what had happened and apologized, they would still have been upset, and rightly so, but they would not have been so angry as they were when we started talking to them. Unfortunately, at least at the beginning, the family was threatening to sue... however as time went on and everyone calmed down a bit, they didn't seem as litigation-minded. Actually, since no harm came to the patient from the error, they likely would not have won a court case anyways. Hopefully patients (and their families) realize that health care workers are, for the most part, all trying to do their best, and unfortunately, sometimes mistakes are made and all we can do is try to prevent them and correct them as best as possible.

Dylan's triathlon with Team in Training, the Leukemia and Lymphoma Society

My good friend Dylan Rivas started a blog about his training for the Lavaman triathlon with Team in Training, which is part of the Leukemia and Lymphoma Society.

A few friends have done this (I don't think I ever could) and I think it's a great idea - the triathlon is in Hawaii, which I'm sure is absolutely amazing for the participants. They raise a large sum of money, and 25% or less of what they raise goes towards the participant's flight, coaching, overhead, etc. The Leukemia and Lymphoma Society gets the remainder, which is a substantial amount. Moreover, it supports an active lifestyle, which not many fundraisers do!

Here's a haiku in his honor:

Go Dylan Rivas!
Many miles to bike, swim, run
Good luck and have fun

Respecting patient's wishes

I haven’t been in this business very long, but I have already seen many cases in which a patient’s wishes were not respected. What I write next may be surprising – it’s never the doctors or nurses or medical staff. It’s the family. This especially happens with very old or demented patients, or very young patients. The patient often wants one thing and the family, or at least their closest relative or spokesperson, wants something else.

One case I remember particularly well. This was an 80-something year old gentleman who had lung cancer, diagnosed perhaps a year ago. He had it surgically removed (which is not a small surgery by any means) and was doing relatively well for the better part of a year. However, more recently, he started changing. Whereas he used to be able to walk well, talk normally and knew where he was at all times, he occasionally became unsteady and unable to walk, he started slurring his words, and sometimes became confused about where he was, what day it was, or who he was with. After admitting him to the hospital, we found out he had lung cancer that had spread to his brain. At this point, there were three options for him: do nothing, give him radiation, or operate on him. Doing nothing would obviously lead to death the fastest way possible. Giving radiation is usually not curative, but can buy patients time at the expense of different possible side effects of brain irradiation. Surgery was the only option that really provides any hope of a cure, although the chances are incredibly slim, and for someone who is that old and sick already, there’s also a high risk of never recovering from the surgery.

We (the doctors) talked to the patient and his family extensively. It seemed the patient was learning towards doing nothing, or at the most, going through radiation. However, after many days, the patient’s family was able to convince him to go through surgery. Now, I’m not saying this was a bad choice – I have not yet had to be in this situation, and I’m sure it can be incredibly difficult. It sounded like this patient had been an incredible father, brother, uncle, etc and his family all wanted him to live many more years and have a wonderful life. His daughter, who was the main spokesperson, was a nurse and was a major player in convincing her father to have the surgery. I can’t say I would not do the same, although I hope not.

The patient had the brain surgery, with plans for eventual chemo or radiation after recovering, and slowly, over the next 4 weeks, deteriorated more and more. Before going through surgery, the patient had told the doctors (and I thought the family as well) that in no way did he ever want a feeding tube, or if his heart should stop beating or his lungs stop breathing, did he want CPR with shocks, chest compressions, or a tube shoved down his throat to help him breathe. However, it seems that once he became unable to make his own decisions after the surgery, his family decided that they wanted everything possible done for him.

The patient became unable to swallow on his own without choking and eventually, a feeding tube had to be put down his throat so that he could be fed. Even then, he started regurgitating food from his stomach into his lungs and developed a lung infection. His body became weaker and weaker and he could no longer go through physical therapy. His mind also deteriorated as became less able to talk or recognize his family members. I realize that this is a very difficult process, but the family members, including his nurse daughter, seemed unable to process the fact that he was going downhill and it seemed very unlikely that he was going to recover from this. They asked for the feeding tube to be put in (a risk in itself), which after it was inserted, could not be used much anyways because of his risk of lung infection. They wanted everything (CPR, intubation, chest compressions, shocks) to be done for their father, although in his debilitated state it was unlikely to succeed, and they wanted him to go through physical therapy whether or not he was in any condition to go through it.

It was not until 3-4 weeks of counseling the family almost every day or every other day that they finally realized that he may not recover and decided that they didn’t necessarily want him to go through CPR should his heart or lungs fail, although they were still pushing the feeding tube and physical therapy. Purely coincidentally, the patient died several days later. However, if we hadn't gone through those weeks of counseling and reasoning with the family, that patient's heart would have stopped, and we would have gone through 45 minutes of trying to bring that patient back to life, breaking ribs during CPR, trying to ram a throat down his throat, sticking every possible vein and artery with different needles to try and get IV's in or blood drawn, etc etc. All against the patient's wishes.

I tell this story for several reasons. For one, it highlights how someone’s illness is often a whole family’s problem, not just a single patient’s. You often have to not only treat the patient, but their entire family, and that can involve a lot of talking, explaining, and counseling, no matter how much many doctor’s may detest it or try to avoid it. It’s what you would want if your father were the one that were ill. Secondly, it demonstrates how important it is for someone to have that conversation with their family or to have a living will. If you don’t want CPR, or a feeding tube or anything like that, it’s important to explain it to your sons, daughters, other close relatives ahead of time so that they understand, because to be honest, if you tell the doctor, who then try to tell the family, they may not believe the doctor or understand. If you can get this in writing in a living will, it’s even better – then the family has proof of your wishes, and also less power (I believe) in changing how you want to die. I think this is especially important if you’re elderly or sick, but realistically, I think everyone should at the very least, talk about it with those close to them. It can certainly save a lot of heartache and problems later on.

The holidays

It turns out I will be working in the hospital over Christmas. The hospital can't stop over the holidays and not only will I be there, but many other doctors, nurses, staff, and of course, the patients. I have it better than most though - by pure luck, I managed to get off both Thanksgiving and New Year's. No doubt about it though, it definitely sucks to be in the hospital, whether as staff or as a patient, when you know your family and friends are out there having a good time. To be honest, I think it's worse for the patients - not only are they sick, but they're pretty much stuck at the hospital the entire time. For staff, even if they work a 36 hour shift or spend the entire actual holiday working, they eventually get to go home, perhaps see some friends or family if they're not too tired.

In general, I think most people are pretty good at making the most of it and that's probably the best anyone can do. The staff often have small holiday parties in the hospital, which they can attend in between duties with patients. The cafeteria and food services tries to make a nice meal for Thanksgiving or Christmas dinner and sometimes there are holiday activities for the patients, if they can attend or participate. Hopefully, families come to visit their loved ones in the hospital over the holidays, bringing a piece of home with them.

The sad cases are when you realize that a patient doesn't have any family to visit them, or even think about them. It happens quite often in the hospital, especially with the elderly. I haven't seen it myself (yet) but I've heard some families don't want to deal with an elderly relative, sometimes over the holidays, and they just drop them off at the emergency room with a real or fabricated problem, and they get admitted to the hospital for several days so the family doesn't have to deal with them. Sometimes the family doesn't have time, or the desire to visit the relative, even over the holidays. I had a patient once who lived with his daughter. The family was very nice, but the daughter was taking care of 3 of her own children, not to mention a few other younger siblings, and didn't have time to visit her father every day. The son would often come, but he was pretty much useless in terms of helping coordinating care for his father. Unfortunately, the father didn't know his own home phone number, or a way to contact his daughter, so even though we discharged him from the hospital, it was 3 days before we could get word to the daughter to pick him up! Incredible.

And finally, the saddest cases are when you realize a patient doesn't have any family at all. They may have a friend as an emergency contact, or worse, they have no emergency contact at all. Last month I had an elderly female patient who was very very sick - the only family she had at all was a sister who lived 2 hours away and was sick herself and couldn't make it to the hospital to visit, much less help with her care. We could speak to her over the phone, and let her know updates about her sister, but that's about it. Not surprisingly, the patient was pretty depressed and often didn't want to take care of herself or agree to different studies or take necessary medications. It's horrible - what can you really do in these cases?

It just makes me feel even more fortunate, especially during the holidays, that I have a very loving husband and extended family, who will support me no matter what happens.