Thursday, February 12, 2015

It works for a while then stops....

I always wondered why patients say "the prozac worked for a while then psychiatrist had to switch me to another".   "The GI specialist started me on Prevacid but my gerd flared up again and he tried nexium".   "The pain doctor put me on a a vicodin and I was pain free for a while but now I'm on oxycontin (oral morphine)".   The blood pressure pill was helping but for some reason he had to give me a stronger one after a few years".   In the short visits spent with patients in the immediate care setting, I would see this over and over; along with a typical 30-40year old with a list of 3 meds. 40-50year old with 4 meds/2 vitamins, and a 50-60year old with 5meds/3 supplements.  Oh....I make it a hobby to ask about weekly activity and relaxation practice-same answer: no time for "exercise" and "I'm not stressed out".  I don't usually have the time to go through quid pro quo about nutrition knowledge but my hot button there is to look at weight/BMI and that's the answer to eating style.

Returning to primary care office work (seeing patients routinely and getting follow up vs the take care clinic band aid work) I can see a repetitive occurrence of people leading unhealthy lives; coming in for short fix prescriptions; coming back with temporary but unsustained response; going onto multiple rx management, eventually being sent to the specialist care for BIG medicines or surgery.   On the flip side- around every 20th patient is taking my advise for beginning a relaxation practice, switching to some form of nutrition practice, starting a supplement and fixing sleep.  I had a lady with severe symptoms of hypothyroid/fibromyalgia/sleep disturbance see me last month very frustrated with previous docs....made a few recommendations like the aforementioned and 1 month later she is a different person.  (that is one of the fastest turn arounds yet!)  My pessimistic self says maybe it is all placebo and just the fact that I told her she will get better orchestrated the flip of her switch.   My optimistic and evidence based self said she is getting better because she removed herself from poor nutrition practice, supplemented for deficiency, started breath work and templated a healthy schedule of sleep and exercise.   Bottom line is -doesn't matter how it happened, I just have to help guide change and keep the ball rolling.

I feel that in most cases, the reason pills give a temporary response is because no one changed the unhealthy thinking/eating/activity of the person taking the pill.  New drug will give a nudge to the system.  Forcing the brain to simulate happiness: the gut to stop secreting acid: the body to ignore inflammatory signals from twisted body parts....but if no change is made to the "body part" then this magnificent machine called the human body will find another way to send signals saying SOMETHING IS NOT RIGHT!!!.  At least until a different medicine is used to suppress the annoying alarm.  Better than spraying foam on the kitchen fire is turning off the gas main.

A patient yesterday said she was worried before she came in that I was a Family Medicine doctor and not Internal Medicine trained.   She went on to say"....but I can tell you are different and that makes me feel hope".   I believe telling people their "blood tests say the medicine is working,  see you in a few months" is reassuring.  I feel guiding people to develop sustainable changes in areas they didn't recognize needed change -is empowering.  Pulitzer prize winner Dr Siddhartha Mukherjee said "Physician honesty need not equate with hopelessness".  He was referring to life ending disease.  As a primary care doctor I deal with life altering disease but the same fundamentals are in play - don't just surrender to the disease and wait -empower people to live life with hope.

Sunday, February 8, 2015

Push back check out time please

The other day in the office, one of my favorite 80+ yr oldie's came in to see me.   She was quick witted as usual but after checking out, she started "checking out".  First she started slowing down her snail pace to almost a stand still.  Then she remained silent while standing (this is one of those souls who makes play by play commentating like she is talking to a radio audience...."it's cold", "it's so white out", "that will take forever"......)  Then as I sat her down the well known slump of death started.  It's when a human that was previously made of flesh and bone suddenly is a 110 lb bag of melting ice.  You would be surprise at how difficult it is to carry someone when there is no life, turgor, or blood flowing through the body.  I'm pretty fit but as I picked her up like a sleeping child, she started sagging like gravity was pulling body parts between my arms.  Got her up on an exam table and had her in semi flat (in the field if someone passes out I place them in trendelenburg with head down and feet up to pour life restoring blood into the brain but with her age, I wasn't sure if she was having a stroke out so I rigged this first aid position).  Blood pressure was really low and she was unresponsive so I asked relatives if she was DNR-they said yes and after some debate, we decided to postpone calling 911.  As I mentioned hospital and IV ...she suddenly started speaking with a muttering in a barely audible voice.  I went closer and she said "I don't like the hospital".   Huumm.......I decided to get her grand daughter on the phone and asked the kid to say hello.  Guess what, grandma started talking louder....albeit her blood pressure wasn't reflecting any level of what I would consider normal for a human, in fact it was still dropping.  I was very uncomfortable with keeping her in the office; because the experience I have working in ER's the resources available to  orchestrate resuscitation in second and begin a diagnostic work up makes it temping to use the God Complex to say I can fix this.   But Dad popped into my head (-being guided by my favorite mentor).  He told me...wait.  So I continued to observe, provide comfort and just reassure the patient I was there for her.   I felt like I was back in med school where I was the "human cardiac monitor" and had to repeat vital signs every 10 minutes and assess color, turgor, heart sounds, neck veins, level of consciousness to determine what the cardiac output was; preload, after load, cerebral perfusion, peripheral perfusion - all the basics of human physiology which will give just as much information as a $10,000.00  monitoring system in the ICU (yes, this is why a 10 minute trip to the ER for a fever and Tylenol will cost you and your insurance a thousand bucks).

Bag-o-Jello suddenly started to take human form again, voice strengthened, color returned, blood pressure was normal.. then she said she wanted soup (probably the brain triggering the need for fluid volume and salt?!)  I asked her how she felt and she said I'm OK, can I go now?  What the #@$@, such a resilient generation this lady was born into.  I told her she had to take it easy because she just went through a life threatening experience.  She just said "I'm hungry" as if nothing just transpired over the last 60 minutes that in my mind was like an eternity.  She got back up, finished checking out at the front desk, proceeded to the parking lot and left with her care giver.  I heard her say in a loud voice...."it's so cold!!".  They went on to eat Sinigang and Lechon at a Filipino restaurant (2 pork heavy traditional meals!).

The hour  of "back country" monitoring this tough but delicate lady was more than a a review of basic physiology and wilderness medicine.  More importantly it showed me that sometimes there is more to lifesaving than just running protocols and algorithms....the human soul ultimately decides when it's time to check out.  Learning to listening to it is good for the patient and the healer.