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.

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?

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?

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.