Posts Tagged ‘A different side of medicine’

ZWEI ALLEIN (TWO ALONE)

May 14, 2015

The man was adamant.  “My wife will not have chemotherapy.  We survived the concentration camps, and we will both go together.”  His wife had cancer metastatic to the brain, and other than radiation, there wasn’t anything else we were going to be able to do except control brain swelling.  I had the sense the man was challenging me, but I wasn’t about to fight them, not a pair of concentration camp survivors fighting their own losing battle.

A few weeks later, I read in the newspaper that there had been a murder-suicide in an elderly couple.  The name was familiar, and I knew exactly what had happened.

I watch German videos online every day.  I no longer spend 3-4 hours daily learning vocabulary, memorizing lists, or studying grammar.  I did that for a few years, but I moved on to other interests, as I knew I would.  I like exploring the world; there is so much to see and do, and I find the time short.

Today, I listened to a video where the ending was not perfect, unfinished.  It was real. It was powerful. The plot was simple enough.  A woman, Henriette, and her sister were walking in a park, when suddenly a robber jumped out, stole the sister’s purse and shot Henriette in the abdomen.  The sister was unhurt and got help, but Henriette died in the hospital during surgery.  There had been 4 murders in the park in the past several months, so this appeared to be another.

Benedikt, her husband, was a bus driver.  The next day, he went to work, confused, and drove the bus past people waiting, through a red light, and was pulled over by the police.  When they learned his wife had died the day before, they told him they would take him home.  Benedikt suddenly left the bus and took a cab, not home, but by places where he had spent time with his wife.  For the next several days, he acted like a grieving man. Flashbacks were shown, one finally showing the Henrietta with him, months earlier, suddenly collapsing from abdominal pain.

It dawned on me that perhaps this shooting was intentional.  Indeed, it soon became obvious.  The woman had visited a gynecologist and had a malignancy, likely ovarian cancer, although it was not stated.  She and Benedikt had discussed her disease, decided against further treatment.  The police in the meantime, had discovered the perpetrator, but the latter stoutly denied anything to do with this murder, even as he laughingly admitted to the others.

At the end, it was obvious that Benedikt had shot his wife, with her prior consent.  His sister-in-law finally discerned the truth and watched helplessly at the end, as Benedikt held a gun to his chin.  He suddenly fired the gun at the sky, at God, he said, and the movie ended. There was no “closure,” a term that needs to be used less, since many seem to believe that candlelight vigils and other memorials will help speed closure.  They don’t.  Closure takes time, and Americans, for whom time is precious, want to speed up something that has its own schedule.

In Oregon and four other states, Benedikt’s wife and the woman with metastatic cancer could use Death with Dignity.  Both women were had a life expectancy fewer than 6 months, mentally competent, and would have qualified for a prescription, if two physicians, one of whom could be the individual’s personal one, agreed that she were terminal. Two requests have to be made 15 days apart.  This is not a “I want it tomorrow” issue.   The prescription is then taken to a specific pharmacy, filled by a specific pharmacist, because some pharmacists refuse to fill it.  Then, at a time of the patient’s choosing, the patient takes the pills, becomes unconscious and die.  No gun, no jail for the spouse.  It is terribly sad, but the individual is in control of the dying process, which was going to occur soon regardless.

Do we think that people don’t know they are dying?  Do we have to let the soon-to-come death come on its terms, rather than on a patient’s terms?  Oh yes, there is palliative care, and while it is good, if I have pancreatic cancer or a glioblastoma I don’t want death on death’s terms.  I don’t want to lose half my weight, become jaundiced, lie in a bed for weeks, slowly dying, even with pain control, seizure control, and being kept clean, all a very tall order, because not all palliative medicine is the same.  There won’t be a sudden miracle, and anybody who practices medicine as I have is far more an expert than those who live in a dream world of fluff and unicorns, where there are happy endings.  No, I wouldn’t want to die.  But I would not take my life, the disease would.  If it is a matter of one day vs. a few weeks, why should I not have control?  Isn’t that a civil right of mine?  What is more private to an individual, more of a right, than their right to exist?

Oh, I know the arguments.  Hospice can do this, except there are hospices that don’t do it, and I don’t want to end up in one of them.  One charged Barbara Mancini for murder when she handed her father morphine that he asked her for.  It wasn’t even clear he wanted to end his life then.  He wanted it for pain and was taken to the hospital against his wishes and given naloxone to reverse the morphine.  He died a few days later, the way he did not want to.  About $100,000 later, jail time, and national press, Ms. Mancini was acquitted, with a 42- page scathing report written by the court against the prosecutor, who may now be in Congress.

I am not on a pedestal shouting this to the world.  Or maybe I am.  In any case, the slippery slope that the Catholic Church and others predicted would happen in Oregon didn’t.  The thousands of people predicted to die every year hasn’t reached one thousand yet, and the law has been on the books for 17 years.  A third of the people who get the drug never use it.

I say all this as a former neurologist who spent 17 years practicing in a Catholic hospital, where I had no trouble pulling tubes and stopping feeding of those on whom I diagnosed irreversible brain injury and the family told me “he never wanted to be like this.” I wasn’t playing God.  The Church and I had no disagreement about discontinuing futile treatment.  Many of my colleagues disagreed with me, and I wasn’t popular, although a dozen referred their families or themselves to me, even if they didn’t refer me patients.  The ICU nurses, who frequently dealt with death, respected me.  That respect mattered.

The probability we will live to 90 in great health and suddenly die is highly unlikely.   I’ve seen and dealt with the reality.  We need to remain compassionate, accessible to families, and allow in all 50 states this final civil right.  It isn’t suicide, and it isn’t forced.  It’s humane, sacred, and its time has come.

DEATH AND LIFE

April 24, 2015

A few nights ago, or in the morning, whatever one calls 2 a.m., a young man and woman, both in their 20s, died when their car struck a tree, right down the road from where we live, where the speed limit is 40, and the road curves, but easily taken at 40.  Today, there is a memorial on the sidewalk, tree, and a few people are present.  The news reported, “speed has not been ruled out as a factor.”

Like so many accidents, the final results of the investigation are either never published or are so hidden in the newspaper that one often never learns the cause.  When I walked back home from a hands on children’s museum last Sunday, after showing sunspots to kids and adults, I was in sight of the tree that would be struck. The two victims were then alive and vibrant, full of life, full of promise, four decades of life ahead before they reached my age.  Now they are corpses, a dreadful word, but the truth.

For the truth is dreadful.  They are dead.

Not only are they dead, there is a high likelihood they didn’t have to die.  Driving the speed limit in a modern car, wearing seat belts and with air bags, one is likely to leave the road only by being distracted or intoxicated, both of which may well have been factors.  The kinetic energy at 40 mph is 45% that at 60 mph, for kinetic energy of a moving object increases with the square of the velocity, and the extra 55% may be enough to convert an accident with injuries into one with fatalities. Being belted in and having airbags doesn’t prevent death from a crash, but it greatly decreases the probability.

Too many don’t understand this concept.  To them, one counterexample invalidates a whole theory.  “She did everything right and died from xxx, so it didn’t matter.”  That might have been said about the woman, 60, who died from ovarian cancer, or a 52 year-old colleague who died from an astrocytoma, a colleague’s wife who died at 49 from a ruptured aneurysm, or the obituary today of a 35 year-old, killed by a drunk driver.  “Everything right” that we know of often doesn’t work.  Sometimes, it is as simple and as awful as being in the wrong place at the wrong time, like being a 9 year-old girl at a Tucson Safeway on 8 January 2011.

Other times, it is just bad luck.  I never knew Mark Edelson, photo editor of the Palm Beach Times, named Newspaper Picture Editor of the Year nine times.  He recently died of lymphoma, only 64.  Reading that, I realized how lucky I am, how little I have to complain about, and how much more I must do with my life.

Doing everything right can greatly decrease death from lung, skin, cervical, colon, breast, hematopoietic, and other cancers, allowing people with these and other conditions to live far longer than they used to.  Acute lymphoblastic leukemia was a death sentence 40 years ago;  it is curable in 85% today.

Last week’s Stammtisch, a gathering of German speakers (or wannabes like me) was the only group in the pizza parlor.  For once, it was quiet, so I could understand people, which with my hearing is difficult enough in English, let alone in German.  I listened to a young man in his twenties, from the Portland area, living here, speaking German fluently.  He had studied it three years in high school, more it in college, and spent a year in country.  That’s how to learn a language.  Start young, study hard, and live in country for a year.

Peter, several years my senior, from Alsace, fluent in English, French, and German, sat next to me.  Peter served in the military in Europe, helping MPs get American soldiers out of trouble.  Speaking three key languages fluently allowed Peter to serve his country well.  He corrects my German gently.  Peter nudged me, nodded towards the young man, and said in German, “He has his whole life before him.”  I agreed.

“But I wouldn’t trade with him,” Peter quickly added.  I also agreed.  Yes, to be young, multilingual, good looking, healthy, with your adult life and the world before you, is great.

Unless you drive too fast at night, leave the road and hit a tree.  Or have really bad luck.

If possible, I would do over much in my life.  But I can’t change the past, only apologize, make amends, and then move forward, dealing with current circumstances.  I grew up in a wonderful time, being white, male, straight and middle class.  I had good parents, who taught me to be curious, to read, to love animals, and to treat the outdoors as a place to enjoy and to take care of.  We got dirty, bored, made up our own games, and enforced our rules.

I had pressure in school, but I never slept fewer than six or seven hours at night.  I read recently that some are taking a new stimulant allowing them to work longer in order to advance.  “Sleep is an option,” said one.  Wow.  I had summer jobs, and huge student loans were unknown.  I was a partner in a medical practice;  I now know highly qualified physicians who are looking for work, not even partner track, just work.  I never had that problem.

There were good times for the right people, but hardly idyllic.  “Negroes” were discriminated against, lynched, and we equated homosexuality with pedophilia.  Interracial marriages were illegal, and gay meant happy.  Smoking was considered cool, plane crashes were common, kids died from polio or measles, rape was considered a woman’s fault, wages for men were higher, “because he had a family,” doctors were God, and we dealt with cans in the wilderness by throwing them on the ground or sinking them in the lake.  The “good old days” were hardly that.  By the way, rape is still considered a woman’s fault in many places, gender wage equality isn’t, and racism is still prevalent.

I would not want to be in my 20s in this competitive world.  I am content with my age, hopefully wiser.  It is my world, too, one where I want to give back: volunteering tutoring math, learning a language or two, showing kids the night sky, leading hikes deep into the wilderness, seeing special places, volunteering at the crane migration every year, and living in my mid-60s.  No, the 60s are not problem-free.  Not at all.  Then again, in the obituaries virtually every day, I read about those who didn’t get to their 60s, 50s, 40s, or 30s.

Mark Edelson didn’t get to Medicare age.  What a loss.  When good people die, the rest of us have to make up for their loss.

Time for me to get back to work, and be glad I am alive to do so.

PASSING IN A SCHOOL ZONE

March 10, 2015

The sign said “20 mph between 7 and 5 on school days.”  Oregon has two types of 20 mph school zones: that and “20 mph when children are present.”  I was doing 20, when a guy behind me pulled into the center turn lane, accelerated, passed, pulled in, driving far more than the 35 mph speed limit after the zone.

I caught him at the next light.  So, to save a few seconds, the guy broke a few laws, wasted gas and brakes.  For nothing.

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“Why didn’t you call a neurosurgeon?” The plaintiff’s lawyer asked me in a deposition, back in 1978.

“I and my attending did, Sir,” I replied.

“Why didn’t you hurry and do it sooner?  The patient might not have been paralyzed.”

“He already was when I first saw him, Sir.”

The patient, with ankylosing spondylitis (AK), a bad disease that fuses bones of the spine, had fallen and had cracked his spine.  Unfortunately, an orthopedist tried to move the neck, producing spinal cord injury and partial paralysis.  I resented being blamed for the catastrophic outcome, and it would be the first of a long number of bad encounters I had with the legal profession.

Technology now allows non-radiologists to view many images before the radiologist.  This increase in speed of transmitting information occasionally comes with a cost.  Recently, an individual with AK and a neck injury was felt to have a normal C-spine X-Ray, according to a physician’s reading in a trauma center. The reading was wrong but fortunately did not cause a similar catastrophe.  Radiologists should read these images before anybody moves the spine of a patient with AK.  I’d make it mandatory.  It doesn’t guarantee a good outcome, but it improves the probability of such.

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A Chance Fracture has nothing to do with luck.  Or maybe it does.  Formerly called seatbelt fractures, before shoulder harnesses, they occur with violent forward flexion of the thoracolumbar spine.  The anterior or front part of the vertebra flexes and compresses, the posterior elements fracture.  It is highly unstable, and the proximity of the fracture to the nerves in the spinal canal means paraplegia may occur.

A patient was seen after an automobile accident, and a physician noted free air under the diaphragm on one image.  This means a perforated viscus, usually the bowel.  The patient was quickly taken to the operating room, for speed matters, and the “bowel was run,” meaning that all of it was checked.  The radiologist, in the meantime, looked at the images, noting no free air but saying there was an Chance fracture.

Oops.  In 100 yards, the speed limit will be 35. Did you have to pass?

The patient now has an abdominal scar, is at increased chance for adhesions and a bowel obstruction as a result, and was fortunate not to be paralyzed after having been moved.  Waiting a few minutes for the radiologist’s reading would have avoided an operation.  Free air requires immediate attention, but surgery may be delayed until the diagnosis is clear.

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A third patient had a dislocation of the hip, a bad injury, and was taken to the OR before the radiologist reported a clot in the iliac vein.  Such clots are a risk for pulmonary emboli and complicate surgery, something the surgeon must know pre-operatively.  There was time to think; fifteen minutes wouldn’t adversely have affected the outcome.   Like the guy passing me, hurrying may save time, waste time, or cause a bad accident.

I don’t practice any more.  I wasn’t a trauma doctor, but as a neurologist I saw plenty of trauma long before we had Level 1 centers.  I am out of date.  But I know the ABCs, airway, breathing and circulation, which were and are essential to deal with immediate survival.  Here, seconds and minutes count.  Otherwise, I palpated the entire patient, looking for injuries that weren’t obvious, but might become significant problems.   It’s easy to see an obviously fractured femur and immediately want to fix it.  A wise radiologist said, “The first thing you must do in an emergency is take your own pulse.”  By that, he meant to stop and think for a few seconds.  If you don’t have a few seconds, it’s probably too late.

Time.  It is about time.  Knowing how much time one has matters.  Knowing how much time one has to think matters more.  Time.  Is it worth doing 45 in a 35 zone?

Technology has revolutionized medicine.  Improved communication would as well, if we actually did it.  If several people with significant injuries arrive at a trauma center, they must be triaged.  Some need help more quickly than others.  For some, it is sadly too late.  Many may require the same test; the order in which they get it must be established.  Communication means telling the radiologist the history of the patient, what the clinical concerns are.  It improves the reading of the image.

Ask a radiologist sometime how good clinical histories are.

Today, we do whole body scans.  These take time to perform, valuable time. Taking extra minutes to scan the entire body may delay doing an important test on a second patient. These scans deliver much ionizing radiation and are expensive.  Neither of the latter two is an immediate concern, but they are issues.  Radiologists read hundreds of images quickly, and that requires…..time.  Anything that limits the number of scans is good.  Clinical evaluation does just that.  Patients with free air under the diaphragm likely have a rigid abdomen.  Chance fractures produce severe back pain.  This information helps the radiologist immensely.

When I was responsible for caring for many sick patients, I triaged them, trying to make best use of time, an important commodity in my life.  I needed time to eat, sleep, think, see patients, and summarize my thoughts.  I had only so much of time, and only I could prioritize it….until the day came when I realized I could no longer fit what was expected into what time I had.  Hurry is both dangerous and stressful.  Kids suddenly jump out into the street.

Television makes it appear that speed saves save thousands of lives, that everything must be done in a hurry, and that death is prevented with seconds to spare.  That simply isn’t true.  Time is important, because waiting can be deadly.  But there must be time to think, to reason, and to plan approaches, too.  Or people will die.  We all make mistakes.  We can prevent many with better standardization, lessening fatigue, fewer interruptions, ordering only what needs to be ordered, giving information to radiologists, allowing them time to read images before people are rushed to surgery.

Once one is beyond the ABCs of resuscitation, there is time to think and plan care.  That time must be used.

The next light will likely be red, anyway.

“IF I AM STILL AROUND”

March 2, 2015

I just know the man was younger than I.

And early last summer, he was healthy, or at least so he thought.

Today, I read his obituary in the paper.  He had been diagnosed with “brain cancer” (a glioblastoma, likely) six months earlier.

It gave me a moderate jolt.  These sorts of things do.

There is death, and there is death.  For those who are demented, death is a release for them and their families.  It is sad, but it is a release.  Society often doesn’t allow us to say that, but many of us think it.  When my mother-in-law died at 94, one niece cried for hours.  My wife and I just said, “It’s finally over.”  My mother-in-law had been widowed twenty years earlier, was never the same, moved out of her house to assisted living 8 years later, had become slowly demented and had been ready for death for years.

I have seen too many who did everything they could to forestall death, when it was not only going to be the outcome, it needed to be the outcome.  I wasn’t popular, but I had the respect of nurses who dealt with these issues first hand.  When I practiced, I once had eight dying patients simultaneously in an ICU.  I had to deal with eight families, each of whom had members who were dealing with a family death for the first time.  I don’t remember what I got paid for it; suffice it to say that my total bills for the entire 8 were less than an average inpatient surgery at the time.  Surgery takes skill; dealing with death?  Well, that is another story.  That’s just talking to patients or families, not taking a knife and curing them.  Talk is cheap, and talking about death isn’t paid for at all.  Remember Death Panels?  That was just paying for the discussion with people about how they wanted to die.  You’d think from the uproar that elderly people had never thought about the concept before.  I submit talking about death is far more important ultimately than a good deal of procedures Medicare does pay for.  Perhaps if it were reimbursed better, the discussions would be better, but I am out of date.

Here in Oregon, people who are competent and terminal can choose the time of their death, not passing, for passing is a euphemism that makes us think that the non-existence of a former sentient being is something other than non-existence.  About seventy-five people choose that option here every year, not many.  These individuals know full well what they are doing.  They know they are dying soon, and they don’t wish to go through the indignity, often painful, to reach the end result—death.  Some use “assisted suicide” to describe this law, but suicide has a different connotation in our language, and “planned death” is a better term.  The individual is dying soon from a disease, not a medication, and they don’t wish to go through the whole disease process to the bitter end.  There are strict controls, and people die when they are ready, having had for some time the knowledge that they could choose or not to choose to use the drugs that would allow them to die.  A third never use the drugs.

A death from a bad disease in a younger person is a particularly bad tragedy, even if it is were not preventable.  It is a message to those of us who hear about it to be sure we are doing what we want with our lives.  It is a message to end estrangements, if possible, to fight only those battles that are meaningful, to leave behind something good, to live and to be able to say to yourself or even aloud, “I am alive!!!!”

I don’t live in a perpetual state of angst about death, but I find myself discussing events in the next 1-2 decades with the caveat, “If I am still around.”  Mind you, accidents, which can occur at any age, can cause sudden, unexpected deaths.  In one’s 60s, however, there are a lot more things that can kill.  Pneumonia is suddenly not just a minor inconvenience; it is life-threatening.  One nurse told me a two years ago that a cardio-thoracic surgeon we both knew developed leukemia at age 60 and was dead 6 weeks later.  I probably had my mouth open for a couple of minutes.  Suddenly, the problems of the world don’t seem so pressing.  Indeed, Oliver Sacks, who recently admitted he has cancer metastatic to the liver, has stated just that.  He no longer watches the news.  I can’t say I blame him.  I don’t watch it much, either.  I try to deal with the things I can control, not worrying about the many over which I can’t control.  I wish I could stop worrying about the weather and climate change.  I can’t change it, but it still hurts to see it happening.

That means I support the Humane Society, but I turn off commercials and don’t look at posts that show animal abuse.  I simply do not have the time, resources or energy to deal with every needy individual in the world.  Further, the sheer volume of these requests overwhelms me and shuts me down.  I feel like a failure that I can’t fix the world. I am not going to try, and if that makes me a bad person, so be it.  I try to choose my battles, decide where my money, time, effort should go, and am glad I am in a position to do all of these.  I have my own list of things to do; another list, much shorter, are those few things I have done in life that I believe have defined me as a person who existed and which have mattered the most.  The first list is written down, not ordered.  I discuss it should people ask and make it a point to do the things on it when I can.  The second is far more private, and it is very much ordered.  I am deeply clear what those items are.  Others may have seen me as a different person, but this list describes how I see myself.

I don’t know how much time I have.  I just know that every year needs to count for something, and something on one of those two lists needs to be part of every year.

THE “GIANTS”

February 17, 2015

A woman my age recently died at a hospital because she was given an intravenous paralyzing agent rather than the ordered anti-convulsant.  Ironically, she came to the hospital to discuss her anti-convulsants and anti-anxiety medications.  She had a brain tumor removed a month earlier.

We thought we are going to give one medicine, and we gave another medicine.”

You see, a drug got mislabelled in the hospital pharmacy and a paralyzing agent was put in the IV bag instead.  She was being monitored, but unfortunately, a fire alarm went off, so the nurses were distracted closing sliding doors.  Concatenation of problems.  The patient stopped breathing, nobody noticed until she had a cardiac arrest, and she was then taken off life support three days later.

Concatenation of problems, 1985.  Delta 191 coming in to land at DFW.  Thunderstorm in vicinity.  New Doppler Radar not ready.  No weatherman on duty.  Lightning strike ahead and rapid intensification of the storm.  Plane hits updraft and accelerates.  On the other side plane encounters a downdraft, driving it downward, altitude too low to recover, 137 died.

The hospital had now implemented several steps “to ensure that an error of this kind will not happen again in our facilities.”

If I hear “to ensure that an error of this kind will not happen again,” one more time, I will scream.

Or maybe die, if it happens to me.   What about other facilities?  Any other facility going to learn from this?  We learned from Delta’s disaster.

They include the creation of a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions and the implementation of a new checking system for paralytic drugs.  Airline pilots have long had “sterile cockpits,” where nothing but the aircraft is discussed below 10,000 feet.  A decade ago, I proposed the same for radiologists, who are interrupted frequently.  I think clinicians should do the same.  Very few phone calls are so important that they are worth disrupting a clinician’s concentration when seeing a patient.

Three enemies of good medical care: hurry, fatigue, interruptions or distractions.  In my training, I heard the “giants” could work 36 hours, when I couldn’t.  I dreaded days on call, knowing I might be awake for 36 hours.  The “giants” could work without eating, too.  I couldn’t. The “giants” could take phone calls while seeing patients.  I would be called out of the office, pick up the phone, and hear, “hold for the doctor” (who had initiated the call).  Some of those doctors were my partners.  The call disrupted my consultation.  I said this lifestyle was unhealthy and bad and told to suck it up.  I wouldn’t and left.  I was proven right.  Being awake for 24 hours is equivalent to being drunk.

Medication errors are common; twenty years ago my hospital, where I was medical director, were dealing with them.  How does a paralytic drug, rarely used, get into an IV bag? That’s a system that needs to be fixed quickly.  Move these drugs far away from all others in the pharmacy.

People are fallible.  We all screw up.  We are hurried, fatigued and interrupted.  We multitask; far too much is expected from too few personnel in many hospitals.  I interrupted radiologists.  Nurses are frequently interrupted, often by false alarms and incessant beeping, which is distracting. We live in a noisy, fast-paced world, dealing with huge volumes of information simultaneously.  But our brains have not equipped to deal with such.  I am a slow processor; I shut down when encountering questions from two or three people simultaneously.  When everything is urgent, nothing is.

But the “giants” dealt with that.  I couldn’t.

Very old people may hit the accelerator mistakenly, not the brake.  But you can’t shift a car into reverse without having your foot on the brake. Is that perfect?  No, but it is a good safety mechanism.  Compare that with the history of Vincristine, used to treat leukemia.

“We must be certain that there never is a 14th patient who receives vincristine intrathecally (into the spinal fluid) by mistake.”  I am not be exact in the quotation, and I can’t find the article in the literature, but such injection, completely preventable, is almost always fatal, often in children whose leukemia was curable.  “It is unspeakable that this should happen in this day and age…”  That was said in 2001, long after the first quotation.  Google the issue now, and there is a recent case report of three children, two of whom were thought to have Guillain-Barre syndrome. The problem hasn’t been fixed, and it should never occur. Why?  In one article, twenty different system fixes were suggested.  What is wrong with medicine?

Stuff happens, yes, but this stuff needed to stop happening decades ago.  We’ve known about fixing bad systems for a long time.  Are we making progress?

Answer:  I don’t know.  We might review all hospital deaths using an ordinal scale to determine the role of medical errors.  Sample hospitals, and we have an estimate with a decent margin of error.  Do it over time, and we know trends, as well as numbers and types.

Those of us who study these issues believe in “root cause analysis.”  We also believe patient safety requires senior management’s seeing the data and acting upon it.  This does not happen in too many instances.  Reports need to be compelling and readable:  significant errors should be written up, the results of the investigation disseminated.  Delta’s crash made dealing with wind shear a major priority.  The American Airlines crash in Little Rock highlighted “get there-itis,” despite a thunderstorm’s intensification in the area, with failure to deploy spoilers, a combination of hurry, weather and fatigue.  Back then, two-thirds of pilots polled said they would land during a thunderstorm.  They no longer do so.

Medicine will never be perfect.  As technology changes, as medicines change; as illness management changes, there will be new challenges.  We need to face those challenges head on, anticipate them, have a safe way to report close calls as well as errors, and make these known to everybody in the field.  There should be no embarrassment, no hiding, but there must be an analysis as to what went wrong, as is done in aviation, what must change, and how to prove efficacy.  Top management must be involved and buy into these systems.  While we shouldn’t tolerate violation of safety principles, inherent system design must make it easier to do what is right, more difficult to make errors.

My ideas have been in the public domain for well over a decade.  Perhaps they aren’t good enough.  That’s fine.  I’m not perfect.  Offer better ideas.  Then prove it.

Just don’t tell me about the  “giants.”  They created the problem.

SCHÖNER TOD AND DEATH WITH DIGNITY

February 11, 2015

A friend of mine in another state told us his mother died about a month ago.  I met his mother once, and found her a lovely, friendly person.  But we all get old, and her old age was complicated by strokes and gradual deterioration.  For those who say age is just a number, it can be a crappy number.  She was a widow, too.  A great majority women over 85 are unmarried; half of men.  Just a number?  No, real numbers.  Sad facts.

When she went to hospice, after another stroke, she developed disordered breathing, hyperventilation, which could have been due to the stroke or early pneumonia.  To me, it really didn’t matter, because once a person is in hospice, they are to be kept comfortable until they die.  That may require morphine.  Yes, morphine, addicting morphine that slows down breathing, suppresses coughing, and might actually hasten death.

Can’t have that, say some.

Admittedly, the feds have a schizophrenic approach to pain management, because the medical profession failed to manage pain adequately at both ends of the spectrum.  We gave too much pain medicine to the wrong people for whom it was not helpful and addicting, and we under-treated others, who needed more analgesia than they received.  It is entirely possible one day to be in a hospital, where smileys for amount of pain are measured, and 1 smiley is good.  A day later, one may be out of the hospital and pain medication strictly controlled so he doesn’t become a medication abuser. I may exaggerate, but not much.

Pain or agitation control, when a person is dying, should be easy.  You give whatever it takes to control it.  This lady, mother, grandmother, wife, was dying.  Her life was ending.  She, like my late mother-in-law, lived far too long.  Yes, that happens to many people.  Hey, it’s just a number, right?  Life is sooooo precious, until when one is ready to die and won’t.  Sort of like Dustin Hoffman in “Little Big Man.”  But this is real.

Or won’t be allowed to, naturally.  We say that not treating a pneumonia is “playing God,” but we resuscitate people who don’t want to be resuscitated.  I’m not a believer, but if I were, I would say that is much closer to “playing God.”  The Bible and the Qu’ran don’t say 300 joules to shock the heart, when a person with dementia suddenly has a heart arrhythmia.  My friend’s mother would have liked to have lived a long, healthy life, but the second adjective was not to be.  She was ready to die.  She had nothing left to live for.

I hope I am that brave, should I reach that situation.

I hope I don’t end up in a hospice where morphine is “metered out,” in small amounts, because someone fears they might be accused of killing somebody, by making them comfortable in their final hours, even if the final hours were shortened.  If that is wrong, then the world is wrong. Fear of the patient’s dying as a result is NOT a contraindication to give morphine.  Addicted?  The person is going to die, not seek drugs.  They are going to cease to exist.  It is the way of the world.  The verb is “to die”; the noun is “death.”  Use them, not euphemisms.

A sick person in hospice should never, and I repeat never, be denied medication to keep them comfortable.  If hospice workers do not agree, they should work elsewhere. Sadly, this is too often the case in America today.  Ask Barbara Mancini, who was prosecuted for having handed her father morphine, when it wasn’t even clear he was suicidal.  Because that particular hospice was a place where “death is an option in America” occurred, her father suffered hospitalization for four more days before he died.  He didn’t even need to go to the hospital.  Naloxone reverses morphine.  Indeed, I used it in the Navy in the Gulf of Thailand once, and it was the only clear life I ever saved. Ms. Mancini was arrested in the hospice and put through hell for a year and $100,000 by a prosecutor who may be in Congress, now.  The judge who threw the case out of court wrote a scathing 42 page report, if I remember correctly.

Fortunately, the medical profession is beginning to come around more and more to the idea that sometimes we need to allow patients to die.  We need to do whatever necessary to keep people comfortable, even if it means shortening their life.  And in five states, the patient who fulfills certain conditions can choose to shorten his or her final hours, because the end result is the same.

Let’s be clear about semantics, here.  This is not assisted suicide, Dr. Gawande.  Your book was well-written, except for the short shrift and the wrong term you gave to Death With Dignity.  This is an individual who is dying, soon, and does not wish to prolong the process.  This is a individual who is aware what is happening and chooses not to continue.  It is not assisted suicide. The disease is killing the person; they want to live.  But they want to shorten the agony of their final hours.

We can argue as to whether palliative care or hospice can deal with these conditions rather than a Death With Dignity Act.  Maybe they can, but in far too many places in this country, they are not.  That is a fact.  It may be religion, misguided, or financial.  I personally don’t think palliative care can deal with the conscious person with pancreatic cancer, sees the end in sight, and doesn’t want to live it out. I hope I don’t have to find out personally.  In my home state of Oregon and four other states, I don’t have to.

Any hospice that fails to give an elderly woman morphine, because her family members are upset by her breathing, should be closed down.  The lady is beyond knowing, but her family is left with a bitterness that will never heal.  I am both angry and astonished that addiction or “mustn’t give too much morphine to a patient” still exists in the 21st century, when somebody is dying.

It’s nice that Dr. Gawande and others are finally aware at the state of dying in America today.  Welcome aboard the train.  I boarded it 40 years ago in on the third floor of Presbyterian Hospital in Denver. I’ve been riding it ever since.  I’ve known when to quit, and I know how to do it.  I count things, and I think it’s high time we counted the number of people who die at home, the per cent who have living wills, the number whose living wills are violated, the per cent who used hospice, and how long before death they used it, and the number of “Schöner Tod” (beautiful death, a German term).  Everybody dies; on the death certificate there should to be a place for “Living will used,” “hospice,” “hospice at the appropriate time,” and since we are so in love with smiley faces for pain scales, whether the pain scale the last week of life was 1.  Dichotomous question.  Easy.

I wrote about it a decade before you, Dr. Gawande.  Did it in fewer words.  Here’s the link.  It’s in a reputable medical journal.  Welcome aboard.

I’ve been waiting.

BELIEVING IS SEEING

February 9, 2015

My wife read a CT Scan of the heart, done to look for coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer is nothing, and that is my point: we need radiologists to read films formally, not clinicians, and I say that as a former neurologist who read CT head scans well.  A medical group may own an X-Ray facility and clinicians may read the images.  But every image must have a formal reading by a radiologist, an unbiased individual trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have only one disease process.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.  We also are pattern recognizers, often useful, but leads us astray when some see Jesus on a pizza or the “The Face on Mars.”

A CT scan of the Chest has a side view.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow.  A CT scan of the heart is done for coronary disease, and two primary cancers are discovered.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, I was once asked by a cardiologist to see a man who had presented with a brief spell of unconsciousness, or syncope. Neurologists are frequently consulted for syncope, and it is usually due to a non-neurological problem.  The man had recently driven 1500 miles (2500 km) from Minnesota to Arizona. I examined him, noting his breathing was faster than normal. His neurological examination was unremarkable. I obtained an arterial blood gas, since we didn’t have pulse oximetry back then, and found pronounced hypoxia.  Thinking a cardiac arrhythmia might cause unconsciousness (strokes seldom do), thinking a pulmonary embolus could cause both an arrhythmia and hypoxia, I obtained a lung scan, since that was once the “gold standard” test. The man indeed had pulmonary emboli, likely because of venous clots in the legs occurring during prolonged sitting on his long drive.

It seems trite to talk about the “good old days,” when they were not always so good.  We didn’t have the technology we have today.  On the other hand, I think our physical diagnosis—history and physical exam—was a lot better than today.  We didn’t have scribes writing down findings and ordering a plethora of tests, many of which require a lot of radiation.  More than once, my wife has told me of head CT scans or MRIs with a specific lesion.  When I asked her what the history was, she usually answered:  “It was part of a complete body work up.”

That approach makes modern medicine foreign to me.  I ordered tests I thought I needed, and if I weren’t clear in what order I should order them, I called the radiologist.  I always wrote much information about the patient on the requesting slip, back when we used paper and still knew how to write, because a radiologist could give me a better reading when they knew the area of the brain or spine in which I was interested.  When I could, and I usually made sure I could, I would look at the films with the radiologist, when we still had films, so I could see for myself and learn more about reading images.  It made the radiologist better and feel more useful; I believe it made me a better neurologist.

So, when the MRI of my neck, done because of a concern about a pinched nerve, was unchanged from 9 years earlier, that was good news. I was chagrined, however, when the radiologist told me that I had a two thyroid nodules that were missed by even the radiologist back then.  It never occurred to me look for thyroid disease on my neck MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodules were definitely there.  Once I looked, there they were, quite obvious, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, if you haven’t ever noticed it.  The Moon is above the horizon half the time, and other than 2 days on either side of new, it is visible, day or night. You will discover a whole new world—literally, and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  If we learn to notice many things, it opens a door to a new world.

Sometimes, we notice a thyroid nodule.  Sometimes, we don’t.  I was lucky; the nodule was benign.  Had it not been, my thyroid cancer’s discovery would have been much later than it should have been.

Sometimes, life itself lasts longer when people notice things.

“MARKET FORCES”

February 5, 2015

I felt some queasiness as the plane descended to land in Tahiti, after a 4 hour flight from Auckland, New Zealand.  I’ve never been airsick, but I rationalized it that way.  After landing, we remained on the plane.  I felt worse, and then…..

When I awoke, having vomited all over my clothes, the seat, and myself, my wife asked me, “Are you all right?”

Obviously, I wasn’t.  My wife told me that I suddenly pulled “an exorcist,” threw up, had a seizure and became decerebrate.  That’s bad, and I won’t discuss the neurology, other than I briefly lost total function above my brain stem.  I didn’t feel too badly, although I threw away my shirt, the crew changed out the seat cushion, and I barfed two more times before we were airborne for LAX.  Those white bags are useful.

I got staphylococcal food poisoning from a cream pie I ate at the Auckland Airport.  A passenger in the row in front of me studied infectious disease and was thrilled to have a clinical example behind her.

That’s why food safety matters.  I probably should have been kicked off the flight.  But I lived. Food poisoning caused me to vomit, my heart rate and blood pressure fell, provoking a faint.  Children die here from bad food.  It makes the news.  Fifty-three people died in Germany in 2011; that epidemic cost $2.8 billion, so food safety regulations can save money, as well as lives, and are not government meddling.  Ayn Rand notwithstanding,  businesses don’t self-regulate.

Business has a friend in new Senator Mr. Tillis, (R-NC): ”I don’t have any problem with Starbucks if they choose to opt out of this policy (requiring hand washing after using the bathroom) as long as they post a sign that says ‘we don’t require our employees to wash their hands after they use the restroom.’  The market will take care of that.”

Mr. Tillis won a close election when a lot of people didn’t vote. Elections matter.  Now we have to deal with him for 6 years.  We have a standard requiring people in the food service industry to clean their hands after using the toilet.  They may not wash their hands, just like business can cut corners, but we require it and inspectors, too, to ensure cleanliness.  The Republicans would like to get rid of inspectors, too, because “the market will take care of that.”

Jesse Kelly, who almost unseated Gabrielle Giffords in 2010, shortly before she was shot, stated, “I would not require food safety inspections.” Voters liked his looks, his wanting to dismantle the ACA, which has insured 11 million people, apparently caring neither about food safety nor about insuring the poor.

It is difficult to know how many people are sickened by restaurant food, but we estimate 76 million cases annually with 300,000 hospitalizations and 5000 deaths.  That’s worse than 9/11.  We finally have a standard that doesn’t allow any E.coli in beef, but no such standard exists for chicken.  High rates of Campylobacter are in store chicken; E. coli are still in both products.  Left to “market forces,” does anybody think companies would worry about bacteria in beef if the government didn’t make them?  The NRA prevents the CDC from doing research on firearm violence; is Mr. Tillis going to introduce a bill banning research into food-borne illness?  Perhaps “the market” will sort it out.  Or the graveyards.

I volunteer in a school where peanut butter sandwiches, which I love, are not allowed, because of peanut allergies, a relatively new phenomenon. I can adjust my behavior, but I wonder why there aren’t signs that say “Unvaccinated Children in this Room.”

Ever had measles?  I have.  It’s the sickest I’ve ever been; 90% of my generation had it.  Measles is one of the most infectious viruses in existence, more than Ebola, with a 1 in 1000 chance of causing encephalitis, brain inflammation.  That is scary.

Pertussis?  My mother had that. Kids die from pertussis, or whooping cough.  Adults can get it, too, here and now.

How about Rubella, my generation’s favorite disease?  We got to stay home, and we felt fine.  Oh, one problem: if an unvaccinated kid gets rubella and the teacher, also unvaccinated, happens to be pregnant, the baby may be born with congenital rubella syndrome: mental retardation, deafness and cataracts. Rare?  My wife’s relative takes care of her middle-aged son, who has it.

Mumps?  There is a 40% chance of orchitis, testicular inflammation.  That is painful and might lead to sterility.  My brother had mumps meningitis.

Polio?  That killed 4000 Americans a year; some, paralyzed and in iron lungs, actually wished they were among the dead.  We stayed at home in summer, away from crowded beaches.  Jonas Salk’s injectable vaccine was so dramatically effective that the trial was stopped early.  Another brother had polio.

Herd immunity?  It exists, but what right do parents have to opt out?   Is it not child abuse to put children at risk for these and other diseases?  Ever see tetanus?  I have.  Should we let parents opt out of child care seats?  Should we let children play with guns? If that isn’t convincing, what happens when their child goes to a Third World country where these diseases are endemic? Have they thought of that?  Yes, polio is usually asymptomatic, and measles may not produce encephalitis, but why risk them when there is a vaccine?

To my generation, vaccines, including the one that decreased H. flu meningitis by 99.9%, were huge medical advances.  They occurred when science education was an American priority, when we believed in science and public education, not faith healing or for profit charters, made children get vaccinated and did it in the schools.

Ironically, my generation is getting vaccinated for pneumococcal pneumonia and shingles.  No, these aren’t perfect, but I’ve seen the misery of post-herpetic neuralgia, which has caused some to commit suicide.

Physician Ron Paul once spoke to an anti-pasteurization group.  I assume he knew something about brucellosis, otherwise called undulant fever.  Pasteurization made brucellosis rare. We now want to go backward and risk Typhoid, Listeria and Tuberculosis, too?

Perhaps we should consider that the chemicals we have dumped into our environment and our fetish with total cleanliness could be factors causing many childhood afflictions, instead of focusing on vaccines.  Perhaps instead of worrying about Ebola, which was limited, even in Africa, we ought to worry about measles, polio, E. coli, salmonella, and other scourges, all potentially treatable, which are microbial terrorists, with potential to do far more harm than two legged ones.

We haven’t become healthier by prayer.  We got healthier because of science, research, double-blind studies, good statistics, and legislating cleanliness, safety, vaccinations, and anything else that improved the public good, because we knew companies wouldn’t do it on their own.  The companies screamed it would put them out of business.

And the Dow keeps hitting new highs.  Market forces.

 

THERMODYNAMICS

February 2, 2015

The first month I was an intern in medicine, we had a person with congestive heart failure who was on fluid restriction.  Despite this and diuretic therapy, the patient did not lose weight.  Maybe, he was getting fluid from heaven.  Or was he?

I decided to ask the man some questions.  What did he do in the hospital?  He took walks with his wife.  OK, good.  “Did you stop by a drinking fountain at any point?”

“Oh yes, I often did.”

“What did you do.”

His wife answered, “He took a big drink.”

When we restricted him to his room, his weight dropped and his condition improved.

At the weekly Stammtisch the other night, I got more than a German education.  One lady was talking about fire walkers, and a guy was talking about a man in India who allegedly had lived for 70 years without eating or drinking. I was polite, simply saying extraordinary claims (the second) require extraordinary evidence.  Fire walking exists, and there are reasons why people can do it.  We understand the science behind fire walking.  Don’t run, make sure the wood is dry before burning, and don’t try it on metal.

Getting one’s nutrients from the air, or from heaven, is another matter, unless one is moss growing from a Sitka Spruce on the Oregon Coast.  I hadn’t heard of people’s doing that, but these days there are so many new stories that it is difficult to keep up with them.  I decided to check online.

Indeed, such a man has claimed this.  He was checked with CCTV for 15 days and indeed did not eat or drink.  Interestingly, he was dressed while being observed.  Supposedly, he had no urine in his bladder and had no bowel movements.  I say supposedly, because maybe somebody filming him had an agenda and lied.  People do.  In addition, I did not see results of daily weights, electrolytes, BUN and Creatinine, UUN (urine urea nitrogen), urine specific gravity, if there were any, all of which would have been necessary.  If he were indeed getting nutrients from heaven, which plants do, his weight should have stayed the same. This story is an extraordinary claim; it requires extraordinary evidence, which was not forthcoming.  CCTV for 15 days is not enough.  I want to see the above.  Why?

There was no explanation of the few times the individual was NOT on CCTV, having gone to meet with his supporters.   I wonder if there were water fountains. He was dressed and could have hid a lot of food under his clothes.  I didn’t argue with the individual who told me the story.  He was equating some of this to “My Spiritual Beliefs” with a few references to Jesus.  Those arguments are un-winnable.  I was a bit disturbed that somebody would take such a claim at face value, but people do that these days.  I’ve seen pictures showing a huge eclipsed Moon from the North Pole.  It doesn’t work that way, and I can prove it, but many still believe this sort of stuff.  The local paper didn’t know that the Harvest Moon occurred annually, simple to research, a weatherman in Tucson thought local noon was at 12 p.m., which it is not,* and a different weatherman once commented that the Sun was “already” setting later on Christmas, “only four days after the equinox.”⁺ These are easily observable with the eye.  Technology is a wonderful thing, but photoshopping is too often believed; film was harder to fake.  I suspected nothing I said would convince the man otherwise.  I did mention “thermodynamics” twice, and he looked at me with a quizzical expression.

Obtaining food from heaven is reserved for plants, whose pyrrole rings have magnesium and not iron.  We can’t do this; indeed, people who have tried have lost an extreme amount of weight, had incipient renal failure, and some even died.  In short, there is compelling evidence suggesting that not eating or drinking leads to severe physiologic compromise and even death.  At the end of life, VSED  (Voluntary Stoppage of Eating and Drinking) causes death.  Why are there not survivors in this transition stage, especially given that impending death is an extremely spiritual time?

I try to be a reasonable skeptic, but here, reasonable has requirements.  “Spiritual,” and “God” don’t cut it with me as proof.  People used to call a child’s death from acute lymphoblastic leukemia (ALL) “God’s will.”  Today, 90% survive 10 years and are considered cured; half a century ago, ALL was a death sentence.  Sounds more like science to me.

I want the individual naked on a bare bed in a bare room with no evidence of food or water present.  I want the trial to be at least a month, subject’s health willing, so that possible over hydration issues or medications that were given (antidiuretic hormone, for example) can “wash out” and not be a factor.  People fake things all the time; I did a grand rounds on this for many years as a neurologist, to show how people could fake dilated pupils, paralysis and a host of other neurological conditions.

How did I know?  People who have paralysis from a stroke or a tumor do not lose sensation sharply to the midline, they do not lose smell on one side of the nose, and they don’t lose vision in the eye on that side.  Our brain does not work that way.  Those who present with a dilated pupil and coma, where fakery is a real consideration, require two things:  Pilocarpine should constrict a pupil caused by oculomotor nerve paralysis.  Drugs placed into the eye to dilate the pupil will resist pilocarpine.  As for “coma,” ice water squirted into the ear is not only exceedingly uncomfortable, but the eyes move in a way that cannot be faked. Some people want to be ill, as strange as that sounds.  I carried pilocarpine in my medical bag.

I feel the same way about UFOs.  There are many things for which we do not have an explanation.  I try to look for natural causes, rather than to postulate UFOs, Poltergeists, alien abductions, and government conspiracies (amazing secrets kept by a group of people who are often labelled incompetent bureaucrats).  During World War II, Venus was fired upon by the US from Maine when its bright light appeared over the ocean.  Our memories are fallible, they change with recall, and perceived sincerity, looks, or voice of an individual do not constitute proof. People have strange ideas how the body works.  They hear tales from their friends, see newspapers at the check out line, and assume these must be truthful.  I’m guilty of magical thinking, too. The difference is I know I am hoping for things to happen that I have no control over.

I found it interesting that the man who was so willing to believe a person could survive for 70 years without oral intake of food and water was so unwilling to believe that fire walking could exist.

Thermodynamics.

 

 

 

*Local noon is when the Sun is highest in the sky.  Not counting Daylight Savings Time, this occurs at noon only at longitudes evenly divided by 15 degrees.  For example, Tucson’s longitude of about 111 degrees is 6 degrees west of 105.  Local noon varies around the mean of 12:24.  Every 4 minutes is one degree of longitude:  1440 minutes/day/ 360 degrees of longitude/day.

⁺The equation of time is the difference in Sun time from clock time. The Sun runs faster than clock time in December, but every day it is slowing down much more than its southerly movement is occurring.  The first delays the sunset, the second speeds it up.  This makes the earliest Sunset about 6 December and the latest sunrise in early January.  By Christmas, the Sun has been setting later for nearly 3 weeks and is quite noticeable…if one looks.

NOTICING THE WORLD

January 30, 2015

My wife read a CT Scan of the heart, done to look for coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer is nothing, and that is my point: we need radiologists to read films formally and not clinicians, and I say that as a former neurologist who read CT head scans well.  It’s fine for a medical group to own an X-Ray facility and for clinicians to read the images.  But every image must have a formal reading by a radiologist, an unbiased individual trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have only one disease process.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.  We also are pattern recognizers, often useful, but leads us astray so that some see Jesus on a pizza or the “The Face on Mars.”

A CT scan of the Chest has a side view.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow.  A CT scan of the heart is done for coronary disease, and two primary cancers are discovered.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, an internist once sent me a patient with leg pain, concerned it was due to a pinched nerve in the back.  The lady had pain near the knee, but it was point tender, meaning that the problem was where I was touching.  I obtained a bone scan, looking for a fracture and found a hairline fracture of the proximal tibia.  I got a lot of pleasure diagnosing something correctly out of my field.  Most specialists do.

Years ago, I was asked by a cardiologist to see a man who had presented with a brief spell of unconsciousness, or syncope. Neurologists are frequently consulted for syncope which is usually due to a non-neurological problem.  The man had driven 1500 miles (2500 km) from Minnesota to Arizona. I saw him, noting he seemed to be breathing a little faster than normal. His neurological examination was normal. I obtained an arterial blood gas, since we didn’t have pulse oximetry back then, finding pronounced hypoxia.  Thinking a cardiac arrhythmia could cause unconsciousness (strokes seldom do), thinking a pulmonary embolus could cause both an arrhythmia and hypoxia, I obtained a lung scan, since that was once the “gold standard” test. The man indeed had pulmonary emboli, likely because of leg clots occurring during prolonged sitting on his long drive.

Several years later, one of that cardiologist’s partners referred a patient to me on whom he had diagnosed an occipital lobe infarct, producing only blindness to one side, not out of one eye.  For a neurologist, that is not difficult to diagnose, but many non-neurologists miss it.  I was impressed the cardiologist had found it.  I’m sure he got pleasure from diagnosing something outside of his field.

It seems trite to talk about the “good old days,” when they were not always so good.  We didn’t have the technology we have today.  On the other hand, I think our physical diagnosis—history and physical exam—was a lot better than today.  We didn’t have scribes writing down findings and ordering a plethora of tests, many of which require a lot of radiation.  More than once, my wife has told me of head CT scans or MRIs with a specific lesion.  When I asked her what the history was, she usually answered:  “It was part of a complete body work up.”

That approach makes modern medicine foreign to me.  I ordered tests I thought I needed, and if I weren’t clear in what order I should order them, I called the radiologist.  I always wrote much information about the patient on the requesting slip, back when we used paper and still knew how to write, because a radiologist could give me a better reading when they knew the area of the brain or spine in which I was interested.  When I could, and I usually made sure I could, I would look at the films with the radiologist, when we still had films, so I could see for myself and learn more about reading images.  It made the radiologist better and feel more useful; I believe it made me better.

So, when the MRI of my neck, done because of a concern about a pinched nerve in my neck, was unchanged from 9 years earlier, that was good news. I was chagrined, however, when the radiologist told me that I had a two thyroid nodules.  It never occurred to me look for thyroid disease on my neck MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodules were definitely there.  Once I looked, there they were, quite obvious, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, if you haven’t ever noticed it.  The Moon is above the horizon half the time, and other than 2 days on either side of new, it is visible, day or night. You will discover a whole new world—literally, and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  If we learn to notice many things, it opens a door to a new world.

Sometimes, we notice a thyroid nodule.  Sometimes, we don’t.  I was lucky; the nodule was benign.  Had it not been, my thyroid cancer’s discovery would have been much later than it should have been.

Sometimes, life itself lasts longer when people notice things.