Here's another case of Adult Protection. An elderly couple is moved their home, many states away, to live near the daughter. The mother is wheelchair bound, the father arrives with a low hematocrit, nearly passes out and I diagnose colon cancer. After a partial resection, peri-operative atrial fibrillation and a long recovery, he finally goes home. He is also diagnosed with Parkinson's.
Once home, either the mother, who has CLL, or the father is in and out of the office or ER for fevers, falling, etc. After multiple visits the couple and the daughter are implored, in no uncertain terms, to either hire 24 hour help or move them into assisted living. They refuse stating that "a man should not have to live out his days in a nursing home". Adult protection is called. By the time they call back, he is once again in the hospital after a fall at home. They take away the family's power of attorney and place him in a nursing home, 2 towns away.
Its the right thing, right? The last visit with the daughter and the woman broke my heart. But... I believe we did the right thing. What's nagging me is this: he can fall anywhere.....
Monday, June 11, 2007
Monday, May 7, 2007
Wrong Drug
A patient I've treated for many, many years. Suffers from mild Atrial Fibrillation. Makes him feel tired. Takes digoxin and coumadin. Has mild COPD, makes him tired, hasn't smoked in years. Former lobster man. Getting progressive senile dementia. Wife may not be "tracking" so well, either. They called in today asking for a refill on generic coumadin 5 mg tablets. They secretary okayed the refill, called the pharmacy and orderd Aricept 5 mg tablets. Aricept appears at the top his printed med list. The error was not discovered until the patient and his wife got home. They called the pharmacy and were told that medicines could not be returned. Unponed bottle, reliable patients. The secretary called and explained it was her mistake. The pharmacy agreed and said they would not reimburse the patient 150 dollars for the wrong script.
I spoke to the pharmacy manager. She was insistent that it was not "fair" that 150 dollars should come from their "bottom line". I asked if she thought the answer was for my secretary to pay the patients 150 dollars from her salary and should I fire the secretary? She simply said it was not her fault and gave me the 800 number for "corparate headquarters".
Questions: Do we fire the secretary? Do we reimburse the patient? How to we improve patient call-in refill requests?
I spoke to the pharmacy manager. She was insistent that it was not "fair" that 150 dollars should come from their "bottom line". I asked if she thought the answer was for my secretary to pay the patients 150 dollars from her salary and should I fire the secretary? She simply said it was not her fault and gave me the 800 number for "corparate headquarters".
Questions: Do we fire the secretary? Do we reimburse the patient? How to we improve patient call-in refill requests?
Saturday, April 28, 2007
Smoking...
A new patient. In a wheelchair, gaunt. Cigarette smoke smell so bad it stunk up the waiting room. Beautiful, toothless smile with a gleam in her eye. 72 years old, looks 90. In a wheelchair. Daughter in law brought her - I'd say early 40s, overweight, smokes has pharyngitis. Patient smokes 2 PPD "I'm not going to lie to you, she smiles". She didn't like the doctors she got assigned to after her old doctor retired. She fell (loss of conciousness - never documented), went to ER "worked up" and sent home. A few days later fell again, had a seizure and a stroke. Left hemi-body, due to fall and "missed" subdural hematoma. Neursurgery, evacuate clot. Rehab. Home to live with the kids. On several blood pressure meds. No lipid meds. 2 PPD. Has document Carotid disease, amount unknown. Has seen a vascular surgeon who says no, and yet another who says go for it.
I tell her I would be surprised if any vascualr surgeon would take her with current active Emphysema. "What emphysema" she asks, while rolling around mucous in her lungs in a sort of cough.?
She is a sweetheart. Born in a nearby town, lived and smoked nearby and never went anywhere, did anything. Seems warm, and has a good sense of humor. O2 sats on room air are between 96 and 97 and her BP and pulse are fine.
I make a plan. Stay on current meds. Get copies of old records. She agrees. I suggest, while smilling, that she think about doling out 10 or less cigarettes I day. Okay, she says, I'll try. No you won't. I laugh back. She looks up gleaming and says I'm right. I feel that we've bonded, and I'll see her soon.
I tell her I would be surprised if any vascualr surgeon would take her with current active Emphysema. "What emphysema" she asks, while rolling around mucous in her lungs in a sort of cough.?
She is a sweetheart. Born in a nearby town, lived and smoked nearby and never went anywhere, did anything. Seems warm, and has a good sense of humor. O2 sats on room air are between 96 and 97 and her BP and pulse are fine.
I make a plan. Stay on current meds. Get copies of old records. She agrees. I suggest, while smilling, that she think about doling out 10 or less cigarettes I day. Okay, she says, I'll try. No you won't. I laugh back. She looks up gleaming and says I'm right. I feel that we've bonded, and I'll see her soon.
Thursday, April 5, 2007
Adult Protection?
A woman is in her eighties. I've known her nearly 20 years. She developed significant progressive dementia. She had never been compliant with her blood pressure medications. In addition, her B12 level was quite low. We tried to get her regular B12 shots, but her presentation to the office was spotty (maybe 8 times a year at best). Her children are not fully supportive due mainly to their own personal problems. She has an old umbilical hernia and several times over the years became convinced she was pregnant, and would make an appointment to ask how a woman her age could be pregnant. She was always clearly skeptical of my answers.
During her annual physical, which required us calling the taxi for her and calling her at home to get ready, she would not recall her medications and it was clear she was not compliant.
Her son never returned our phone calls. An ex-daughter-in-law became involved and helped get her to the office. She is frustrated because no one in her family will listen to her, regarding the woman's dementia. On the last visit she reports wandering out into the street and urinating on the floor. She has lost weight from lack of attention to food.
We are told that the son "will call" us by tomorrow. If he doesn't, was it my obligation? Does a woman have the right to refuse care, even if she is demented? If she sets her house on fire, it will only kill her. If she wanders off into the night and dies, it will only affect her? Or do I HAVE to call Adult Protective Services? The police?
During her annual physical, which required us calling the taxi for her and calling her at home to get ready, she would not recall her medications and it was clear she was not compliant.
Her son never returned our phone calls. An ex-daughter-in-law became involved and helped get her to the office. She is frustrated because no one in her family will listen to her, regarding the woman's dementia. On the last visit she reports wandering out into the street and urinating on the floor. She has lost weight from lack of attention to food.
We are told that the son "will call" us by tomorrow. If he doesn't, was it my obligation? Does a woman have the right to refuse care, even if she is demented? If she sets her house on fire, it will only kill her. If she wanders off into the night and dies, it will only affect her? Or do I HAVE to call Adult Protective Services? The police?
Tuesday, April 3, 2007
A Thorough Work Up
A 44 year old woman is discharged from the nearby major medical center after a 48 hour stay. She underwent an uncomplicated left thyroidectomy for suspicious cells. Once home, her throat was sore from anesthesia and it hurt mildly to swallow and to take a deep breath. She tried to contact her primary care doctor over the weekend, thinking she needed a refill of a very old asthma inhaler, but got the covering doctor who told her to go the local emergency room.
The ER doctor heard "post-op" and "short of breath" and ordered a d-dimer test and chest x-ray looking for a pulmonary embolism. The d-dimer was slightly elevated, but this would be expected post-op. Her chest x-ray was clear. The rest of her work up, including complete blood work and an EKG were normal. He told her to go home but by then, 6 hours into her ER visit, she became increasingly anxious as she had become convinced that maybe she really was sick, perhaps with a blood clot. She cried, became a little hysterical and became more short of breath.
She was transferred by ambulance back to the major medical center where the operation had taken place. She was admitted to that hospital by the surgeon who was covering for the surgeon who had operated. This weekend surgeon did not know her case. She was kept overnight and felt better in the morning and was discharged home. That day, Monday, she called her primary care doctor who prescribed the refill for the asthma inhaler she wanted in the first place and felt better.
How much did this work up cost? Was anybody listening?
The ER doctor heard "post-op" and "short of breath" and ordered a d-dimer test and chest x-ray looking for a pulmonary embolism. The d-dimer was slightly elevated, but this would be expected post-op. Her chest x-ray was clear. The rest of her work up, including complete blood work and an EKG were normal. He told her to go home but by then, 6 hours into her ER visit, she became increasingly anxious as she had become convinced that maybe she really was sick, perhaps with a blood clot. She cried, became a little hysterical and became more short of breath.
She was transferred by ambulance back to the major medical center where the operation had taken place. She was admitted to that hospital by the surgeon who was covering for the surgeon who had operated. This weekend surgeon did not know her case. She was kept overnight and felt better in the morning and was discharged home. That day, Monday, she called her primary care doctor who prescribed the refill for the asthma inhaler she wanted in the first place and felt better.
How much did this work up cost? Was anybody listening?
Sunday, April 1, 2007
Insomnia
"Sales of Ambien and Lunesta exceeded $3 billion in this country last year, and nearly 60 million prescriptions for insomnia medications were dispensed"
This is a quote from the NY Times, March 29, from an article on a failed insomnia drug in development. That's a lot of money and lot of prescriptions. The real number of prescriptions is probably higher, as some drugs, like older, generic tranquilizers probably aren't counted, or are older tricyclic anti-depressants, like doxepin or trazadone, which are also widely used.
What's up with insomnia? In year's past, alchohol was the primary drug of choice to help people sleep. My guess is that it, too, is still fairly widely used.
I'm a realist, so I don't assume that there is one tidy answer about the "rise" in insomnia, but the question is worth asking. A related question is why are drugs like Ambien and Lunesta so expensive? Are we so unable to sleep that we're willing shell out 3 or 4 dollars a night for a pill that wears off in 5 hours, is mildly addicting and not without real side effects?
Hospitalists
An 83 year old woman presents to the emergency room complaining of stomach pain. She is not very bright, but very sweet. She lives with her equally uneducated and mostly deaf husband. With the new system of "Hospitalists", her primary care doctor, who she has known for nearly 20 years, is not called. Instead she is admitted to the hospital under their "Hospitalist" system.
The consult a gastroenterologist who passes an endoscope down into her stomach and finds "non-specific" gastritis. They then pass a colonoscope and find nothing. In the emergency room her heart rate is noted to be in the mid 50s, so a cardiologist is called in. The cardiologist orders an echocardiogram, several electrocardiograms and can't find anything, so they discontinue the heart medicine she's been on for the past 20 years and order a new, expensive one.
After 4 days she is discharged home. Her care is considered "thorough". Her primary care doctor gets a copy of the discharge summary and asks her to come to his office and bring all of her medications with her, in a bag.
Going over her medications, he finds a huge bottle of Ibuprofen which she was taking for sore back and knees. Apparently the hospitalist was unaware of this. This is what likely caused the gastritis. In addition, in her bag of medications was her husband's heart medicine, which is known to slow the pulse. She did not know how it got in with her medications, but she admitted she had been taking them for some time.
So, a 4 day hospital stay, with 2 specialty consultations and nearly 8 thousand dollars was all due to 2 medication mix ups.
Could her primary care doctor have prevented this, had he been the admitting doctor?
The argument for hospitalists is that they can streamline hospital care. The experience so far is that they are making more opportunity for specialists to consult and do procedures.
The consult a gastroenterologist who passes an endoscope down into her stomach and finds "non-specific" gastritis. They then pass a colonoscope and find nothing. In the emergency room her heart rate is noted to be in the mid 50s, so a cardiologist is called in. The cardiologist orders an echocardiogram, several electrocardiograms and can't find anything, so they discontinue the heart medicine she's been on for the past 20 years and order a new, expensive one.
After 4 days she is discharged home. Her care is considered "thorough". Her primary care doctor gets a copy of the discharge summary and asks her to come to his office and bring all of her medications with her, in a bag.
Going over her medications, he finds a huge bottle of Ibuprofen which she was taking for sore back and knees. Apparently the hospitalist was unaware of this. This is what likely caused the gastritis. In addition, in her bag of medications was her husband's heart medicine, which is known to slow the pulse. She did not know how it got in with her medications, but she admitted she had been taking them for some time.
So, a 4 day hospital stay, with 2 specialty consultations and nearly 8 thousand dollars was all due to 2 medication mix ups.
Could her primary care doctor have prevented this, had he been the admitting doctor?
The argument for hospitalists is that they can streamline hospital care. The experience so far is that they are making more opportunity for specialists to consult and do procedures.
Monday, March 26, 2007
Do You Share this Information?
An elderly man presents with his wife to the practice. They are new in town, having moved in order to be closer to thier daughter. He has significant dementia, is on Namenda, and is extremely well cared for by his wife. She is very bright and says that she can't really see that the Namenda has done much good. He's a delightful man. He smiles, drums on his knees and whistles the entire time he is in the exam room. He doesn't care if you are talking to him or about him. He's kind of funny, and its awkward, but pleasant to be in the room with him and his wife. I ask her how extensive his work up for dementia had been by their previous physician and she's not entirely sure. I ask if it would be okay if I ran a few tests. She agrees.
His B-12 level comes back at 160, which is extremely low. He is not on a vitamin supplement and she does not recall this issue being discussed. It is clearly too late to reverse his dementia, but I advise them to begin monthly B-12 injections along with a mulitivitamin.
Here's the question: is there any value in reporting this finding to their previous physician? She had spoken of him in glowing terms when I first met her and sounds as if he had been caring and gentle with them. Should he be told or "reminded" of the role of Vitamin B-12 deficiency in dementia, or will this information make him feel bad? These are not litiginous people, by the way.
Does a physician have an obligation to let another physician know of a missed diagnosis? A wrong diagnosis?
My experience is that we just pick up and go on and are often "too busy" to share this type of information. Any thoughts?
His B-12 level comes back at 160, which is extremely low. He is not on a vitamin supplement and she does not recall this issue being discussed. It is clearly too late to reverse his dementia, but I advise them to begin monthly B-12 injections along with a mulitivitamin.
Here's the question: is there any value in reporting this finding to their previous physician? She had spoken of him in glowing terms when I first met her and sounds as if he had been caring and gentle with them. Should he be told or "reminded" of the role of Vitamin B-12 deficiency in dementia, or will this information make him feel bad? These are not litiginous people, by the way.
Does a physician have an obligation to let another physician know of a missed diagnosis? A wrong diagnosis?
My experience is that we just pick up and go on and are often "too busy" to share this type of information. Any thoughts?
Terminology
Autonomy
Patients have the right to choose actions consistent with their values, goals, and life plan, even if their choices are not in agreement with the wishes of family members or the recommendation of the physician. Choices should be free from interference and control by others.
Beneficence
Beneficence refers to acting in the best interests of the patients. This concept often is confused with nonmaleficence, or "do no harm." Doing what is best for the patient often involves serious risks.
Confidentiality
Respecting a patient's privacy and maintaining confidentiality allows people to seek treatment and discuss their problems frankly.
Futility
The term futility may be used in several situations, including the following: The intervention has no pathophysiologic rationale. Maximal treatment is failing. The intervention has already failed. The intervention will not achieve the goals of care.
Informed consent
Informed consent is the process by which a patient receives all pertinent information necessary to make a rational autonomous choice. Disclosure standards, comprehension, voluntary action (free of control of others), competence, and consent are the 5 elements of informed consent.
Justice
Justice refers to fairness in the allocation of healthcare resources.
Veracity
Veracity is truth telling and honesty; recognize that it is not uncommon for healthcare providers to misrepresent a situation without technically lying.
Patients have the right to choose actions consistent with their values, goals, and life plan, even if their choices are not in agreement with the wishes of family members or the recommendation of the physician. Choices should be free from interference and control by others.
Beneficence
Beneficence refers to acting in the best interests of the patients. This concept often is confused with nonmaleficence, or "do no harm." Doing what is best for the patient often involves serious risks.
Confidentiality
Respecting a patient's privacy and maintaining confidentiality allows people to seek treatment and discuss their problems frankly.
Futility
The term futility may be used in several situations, including the following: The intervention has no pathophysiologic rationale. Maximal treatment is failing. The intervention has already failed. The intervention will not achieve the goals of care.
Informed consent
Informed consent is the process by which a patient receives all pertinent information necessary to make a rational autonomous choice. Disclosure standards, comprehension, voluntary action (free of control of others), competence, and consent are the 5 elements of informed consent.
Justice
Justice refers to fairness in the allocation of healthcare resources.
Veracity
Veracity is truth telling and honesty; recognize that it is not uncommon for healthcare providers to misrepresent a situation without technically lying.
Sunday, March 25, 2007
Medical Ethics
Attended a conference on Medical Ethics from a Jewish perspective. The discussion was flawed from the outset. No one had the courage to ask the hard question, namely, is there still a place for religion or personal religious belief in the practice of medicine? If we accept that medicine is a scientific discipline, shouldn't our goal be that of striving towards more precise science? And if so, how can we allow religion to dictate critical issues including birth, abortion, end of life, terminal care, palliative care, etc?
I don't intend to sound crass. And I am not against religion. But assume that you are an ethical Jewish doctor who believes strongly that life is for the living. You are treating a terminally ill patient who has no known scientific chance for any quality of life. You would consider it a favor and an honor to help that person die with dignity. If you were someone from a traditional Christian background you may be torn between "allowing God's Will" to intervene and helping that person move to a "better place", e.g. heaven. If you were involved with a Guru and practiced an eastern religion, you would be thinking that the "life force" is only temporarily in the body you are treating, and is perhaps only one stepping stone along the great path. The concept of reincarnation might be guiding your judgement.
Do you see how naive and/or presumptious it is to bring one's religious attitudes into a scientific arena? It is time we had the courage to park the mysticism at the door and attend to the illness and the patient with as full scientific objectivity as we are capapble of.
Newton stopped in his analyses because he was stumped in his mathematics, and so ascribed that which he did not know to "God". In fact, he spent a significant amount of his time trying to "figure God out". Subsequent scientists and mathemeticians were able to advance his ideas, once new concepts were understood, and "God" no longer was necessary to explain the missing phenomena.
We medical scientists must accept that just because there remain unknowns it is NOT "in God's hands". We must have the courage to practice our science and the strength, even if we are "of faith" to leave that faith at the door, and act as men and women of reason, when dealing with life and death.
I don't intend to sound crass. And I am not against religion. But assume that you are an ethical Jewish doctor who believes strongly that life is for the living. You are treating a terminally ill patient who has no known scientific chance for any quality of life. You would consider it a favor and an honor to help that person die with dignity. If you were someone from a traditional Christian background you may be torn between "allowing God's Will" to intervene and helping that person move to a "better place", e.g. heaven. If you were involved with a Guru and practiced an eastern religion, you would be thinking that the "life force" is only temporarily in the body you are treating, and is perhaps only one stepping stone along the great path. The concept of reincarnation might be guiding your judgement.
Do you see how naive and/or presumptious it is to bring one's religious attitudes into a scientific arena? It is time we had the courage to park the mysticism at the door and attend to the illness and the patient with as full scientific objectivity as we are capapble of.
Newton stopped in his analyses because he was stumped in his mathematics, and so ascribed that which he did not know to "God". In fact, he spent a significant amount of his time trying to "figure God out". Subsequent scientists and mathemeticians were able to advance his ideas, once new concepts were understood, and "God" no longer was necessary to explain the missing phenomena.
We medical scientists must accept that just because there remain unknowns it is NOT "in God's hands". We must have the courage to practice our science and the strength, even if we are "of faith" to leave that faith at the door, and act as men and women of reason, when dealing with life and death.
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