Overwhelmed

I need to start writing again. I need the outlet. Running has sucked badly for the past year. I just can’t get the mojo back. I’ve gained 10 lbs, I feel sluggish and gross. Running doesn’t feel good when I do it. I feel slow, out of breath and everything below the waist hurts at some point or another. I am too hard on myself. It’s okay if I walk a minute or two for every 3 minutes of walking, it’s better than nothing, right? Right. I know. Sure.

My brother is going through a health issue. It could be a lot worse than it is and I know that, but I’m still freaked out for him. He needs surgery and a reconstruction and I wish he didn’t have to go through any of it. We went through a tough time last year when my dad moved into the Retirement home and I was in the height of my depression. I couldn’t help my brother the way I was supposed to. He spent weeks packing up my parent’s condo pretty much all by himself while I sat paralyzed with depression and tried to make excuses as to why I couldn’t help. I still carry that guilt. I’ll live with it for the rest of my life. He says he’s gotten over it but I worry he harbors resentment. So now that he is going through his own health issues, I am trying to make up for it. I’ll support his wife through his surgery and recovery. I’m checking in on both of them daily. I guess it’s the least I can do.

Emotionally I’m okay. I’m not depressed anymore. But I’m worried for what the future holds for my brother. I feel overwhelmed with life … again. I know this is what happens with age. I don’t think I like it very much. I just get no relief from it. It’s happening to my family now, to my patients. It’s everywhere.

I know I need to take care of myself first. I need to run. I need to write. I need to be okay.

Inevitable.

Tonight, somewhere, someone is dying with family by their bedside.

A cool cloth is placed on his forehead.

A mouth is wiped dry.

A hand is held.

A tear is shed.

A story is told.

Someone laughs.

I left you surrounded by your family. I was honored to have seen you one last time.

Death is an inevitable journey for us all.

I hope yours is peaceful.

To treat… or not.

My dad was diagnosed with prostate cancer on his 82nd birthday. I expected it when his PSA test started increasing. He had a biopsy.  I couldn’t attend the appointment for the results but asked my mom to make sure she found out his Gleason score. When she called me on his birthday, I heard it in her voice before she said the words.
Cancer.
It’s considered an intermediate- risk tumor.  There is no metastasis. But given his advanced age and other co-morbidities, namely the Alzheimer’s, surgery is not recommended.
At his age, hormone therapy and radiation is recommended. Without treatment, he has perhaps 10 years.  But that means the tumor will get larger, he’ll have more lower urinary tract symptoms of obstruction and likely bone pain from metastasis.   Radiation is not easy.  It involves daily trips to the hospital for weeks;  20-39 radiation visits. That’s 20-39 days that my mother has to drive him to and from hospital and pay exhorbitant fees in parking. My mom went through  radiation treatment for her own breast cancer 15 years ago. She still remembers how hard that was on her. How difficult now will this be on my dad? He asks her several times a day what the next doctor’s appointment is for. Because he forgets. How difficult will this be for my mom to take him to the hospital day in and day out,  in his already semi-frail and de-conditioned state?  Is it cruel to put him through treatment? Is it cruel not to?
After meeting with his radiation oncologist and learning about a new treatment protocol involving only 5 weekly visits for radiation therapy, it looks like we will be embarking on treatment for my dad.  He seems to understand the side effects of treatment and that it means weekly visits to the hospital.  Of course, he’ll ask many times why he’s going but that is okay for now.  Five weekly visits is going to be much easier for my mom.  If and when it gets to be too much, we’ll make a decision to stop.  But for now, he/we are going to fight this.

The Grim Reaper

December is not a good month to be a family doctor, or any doctor for that matter. I have lost count the number of bad diagnoses I have had to give before Christmas.  What an incredibly shitty way to end a year.

“I’m so sorry to have to tell you this, but that lump in your groin is lymphoma.” 

“The biopsy has confirmed it’s malignant melanoma.

“Unfortunately, your baby stopped growing around 9 weeks of pregnancy.” 

“The lump in your breast is suspicious for cancer.” 

January is sometimes even worse. Who wants to start a new year with bad news?  

Every year I feel like I’m back here lamenting the fact that it’s supposed to be a magical time of year, these “holidays”, and I’m forced to give more people more bad news.  Can’t I just have one year where everyone is healthy? Is that really too much to ask for?

No Breaks.

Day 28. National Blog Posting Month

I am actually looking forward to the weekend. It has been a hellish week at work (see my earlier posts).  I’ve been insanely busy with appointments and double bookings and it seems like everyone’s lab tests are abnormal. I was supposed to have a meeting with my colleagues at dinner last night but I felt unwell all day and had to cancel.  I thought the stomach virus was coming back but I think I just needed some sleep. So this colleague and I have not actually spoken about the issue that came up this week and rather than hang around this afternoon to do so, I am going to get the hell out of here while I still can.  I have no one booked this afternoon, so I am finally going to get home before 6pm which is so nice for a change.

I got to work this morning thrilled that no one was booked after 1 pm and dug in to clear my inbox. And that’s when I found out a patient (60 years old) has had a 20+ point drop in their hemoglobin over the past six months. This patient has other serious problems, a degenerative neurological disease, and really doesn’t need me to call and tell him he’s now anemic and we have to find out why.

For those not in the know – a significant drop in hemoglobin, the molecule in the blood that carries oxygen and is a marker of the bleeding status of a patient, in an individual over the age of 50 is a red flag for a gastrointestinal malignancy until proven otherwise.  This patient has not had any overt bleeding events in the past 6 months.  The bowel pattern has changed but was being blamed by the medications used to treat his neurological condition.  This patient has been declining rapidly with respect to his neurological status but now I can’t help but think there was something going on all along this past year that we are only just now seeing.  Could this patient have cancer?  I fear the answer may very well be yes.

And why the hell does this have to happen on a Friday and a month before Christmas?

Really? What the F—!?

 

 

 

F is for Cancer…. as in .. FUUUUUK, it’s cancer.

I saw my colleague’s patient the other day as I was covering her practice for a few days. It’s haunted me ever since. She was diagnosed with a bladder infection last week and I got the culture report back just before the weekend. I had to change her antibiotics. I spoke to the patient on the phone and told her if she still wasn’t better after the weekend to come to see me.

Well she did. While the bladder symptoms appeared to be improving she also mentioned how light-headed and dizzy she was and “oh yeah, by the way, I’ve lost about 10 lbs in the past month.”

Fuck.

I looked through her chart at her recent blood tests. Hemoglobin was normal but compared to 2 years ago, there’s been a 20+ point drop.

Fuuck.

Upon further review of her chart, I noted a family history of colon cancer in her mother and stomach cancer in her father. Both deceased.

Fuuuck.

Oh and she repeatedly refused to be screened with colonoscopy or fecal occult blood testing.

Fu—-

You get the drift.

She’s got cancer and it could have been caught early with a simple screening test.

First, do no harm …

Yesterday, a news story came up on my FB feed.  I’m still thinking about it and trying to figure out how I feel about it.  I decided to write about it, hoping it might help me process my thoughts.  It’s about a 29-year-old woman with stage 4 brain cancer (glioblastoma, the same kind of tumor that Dr. Greene (Anthony Edwards) on ER had) and she is going to die on November 1.  She lives in the U.S., in a state where, apparently, there are laws in place that allow patients to take their own life when terminally ill.  She states she’s not committing suicide, rather, she is taking control of her illness and deciding when and how she will succumb to it, not the other way around.  Most of the comments posted after the article are all like, “Wow, what a brave woman”, “Good for her”, “I’d do the same”.

Really?  I was kind of surprised that no one seemed to question the ethics here.

I can’t even begin to imagine what this woman is going through. To be diagnosed at such a young age with terminal cancer, it’s truly heartbreaking and tragic. One of my colleagues said she’d probably do the same if she were in that situation.  I’m really not sure I would, to be honest.  Or maybe I would? How can one ever know until faced with the reality?

I have three children.  This young woman has none.  Would her decision change if she had kids?  How would you explain to your children that you are going to end your own life before the cancer gets a chance to?

Death is a natural part of life – granted, dying at 29 doesn’t seem all that natural.  Dying at 90 on the other hand, does.  Still, we are all going to die, none of us can ever know when or how, that is, unless we are diagnosed with a terminal illness and even then, no one really knows how long we have.  Last spring, I visited a patient dying of prostate cancer. I saw him about 12 hours before he passed, peacefully, at home, surrounded by his family. When I spoke to his wife the following morning, she struggled with the fact that she was asleep when he died.  I wondered if it would have been easier for her to witness his death? I’m sure it would have been difficult regardless.  To the very end, my patient hoped and prayed for a miracle.  It was never stated, but you could see it in his eyes. He didn’t want to die; he didn’t want to leave his wife and children. He should have had more time. He kept fighting to the very end.  I admired him for that.

I have a hard time knowing that this young woman is going to actively end her life. That she picked the day she was going to do it, much like one picks a wedding day.  It’s two days after her husband’s birthday.   She has been told there is no cure, that her final days will be spent in pain, perhaps with multiple seizures and it’s not something she wants her family to witness.  I understand that, I really do, but there are ways of helping dying patients be more comfortable in the final stages of life.  It’s the whole reason Palliative care exists.  The process of dying has to remain a natural part of life, once we start helping patients to die, we no longer adhere to the Hippocratic Oath, in my opinion.

First, do no harm.  A physician, in good conscience, cannot be a party to the death of another human being. I can already hear those on the other side of the argument – NOT assisting a patient to “die with dignity”, causes harm.  I don’t believe it does and I don’t think this is what Hippocrates had in mind when he wrote the Oath.  I don’t wish for any individual to suffer on their deathbed, far from it. Medicine has come a long way in the past 150 years – expected death can be painless for the vast majority of patients.  I think we are actually inviting more harm to patients, their family, and society as a whole if we decide that assisted suicide, euthanasia, dying with dignity – whatever you want to call it – is okay.

It’s just not.

 

Through the valley…

In the next few days, a family is going to lose a parent, a sibling, a friend, a partner, a lover. This is a family who has come together at the end, in grief and in love.

I witnessed a small piece of this today.

With a heavy heart I knocked softly at the front door, taking note of the “No Smoking, Oxygen in Use” sign.

Upon entrance into the home, the sound of the oxygen tank was heavy in the air.  A hospital bed could be seen down the hallway in the living room, and lying in it, my patient.  I forgot how one looks during the final hours of life. It caught me by surprise and a lump formed in my throat.  I approached the bed and touched my patient’s hand.  I said hello, as the personal support worker washed my patient’s feet.  I am not religious but was instantly reminded of Mary Magdalene washing the feet of Jesus as he hung on the cross dying.   The living room was transformed into a makeshift hospital room.  Bedpans, sheets, syringes, bottles of medications, all visible on the bookshelf and lined up meticulously, within easy reach. But this was someone’s home – unopened mail on the coffee table, hospital brochures on dying at home scattered underneath.  Half-read books on the couch, an afghan and pillow rested in the corner.

Surreal doesn’t even begin to describe it.  The family and I talked, mostly about their loved one and the events of the past few weeks, but also about their plans after the funeral;  the trip they will take this summer, to scatter the ashes; the arrangements for the funeral.

I walked for a while after the visit.  Trying to clear my head. Trying to imagine what that family is going through, watching their loved one dying in front of them. I wished, for just a moment, that I was religious.  Maybe believing in God would help me understand this process of death, what it means and what it leaves behind.

Yea, though I walk through the valley of the shadow of death, I will fear no evil: for thou art with me; thy rod and thy staff they comfort me.

 

House Call.

From the time of antiquity,  healers, physicians, medicine men have treated their patients in the home.  In the United States, up until a century ago, a visit to the home was the standard way of delivering medical care.  Today, things are much different.  A study published in the New England Journal of Medicine in 1997 looked at the frequency of house calls to the elderly.  Shockingly, less than 1% of Medicare patients received house calls from physicians.  I suspect that this remains the case.

And let me be clear, what I am addressing here are the home visits by a patient’s primary care physician, not the walk-in clinic doctor opening up a house call business.

 

The days of your family doctor coming to your home instead of you going to their office, are largely over, I think.   Although my colleagues still make house calls, mostly for their elderly and housebound patients, as well as those dying at home, it’s not very often, and I can usually hear them grumbling about it. “Ugh, I have to make a house call.”

I am proud to say that I have made a few house calls, albeit not many, but when I feel it would benefit my patient, I make the effort.  Granted, I have a much younger patient population than my colleagues, so the opportunities for home visits are few and far between.  I expect this to change as my patients age.  I was interested to find out what the state of house calls is in this country, so I looked it up.

In 2010, family physicians in British Columbia were surveyed about house calls. The sample size of physicians who completed the survey was small.  After all, who has time in their busy practice to fill out a survey among all the other paperwork?  In this study, 73 surveys were completed (250 were sent out).  Of those completed, 87.7% stated they had done at least 1 house call in the past year; 31.5% did house calls at least once a month and 16.4% did them at least once a week. What I found interesting was that when the study authors looked at the physicians in two groups – those who graduated from medical school before 1990 and compared responses to those who graduated in 1990 and after, they found:

The 49 physicians (67.1%) who graduated from medical school before 1990 were no more or less likely to have done at least 1 housecall [sic] in the past year than the 24 physicians (32.9%) who graduated in 1990 or later (n = 42, 85.7% vs n = 22, 91.7%; χ2 = 0.53, P = .47). However, 11 (22.4%) physicians who trained before 1990 did housecalls at least once a week compared with only 1 (4.2%) physician who trained in 1990 or later (χ2 = 3.92, P = .048).

Younger physicians are doing about half the house calls their older counterparts are doing and even less are doing them once a week.  The tide is turning, indeed.  Even more interesting, is the report from the National Physician Survey:

The National Physician Survey reported that, in 2010, only 47.8% of British Columbia (BC) family physicians offered their patients housecalls and 0.9% described housecalls as a specific area of focus in their practices.2

Family doctors seem to prefer to see their patients in the office, not in their patients’ homes.  I can understand why – it’s more convenient to stay in the office, travel time in the city can be a nightmare, and remuneration may leave something to be desired.  After all, in the time it would take to travel to visit one patient, a physician could see 5 – 10 patients in the office.

A lot can be learned from visiting a patient at home.  For example, an 85-year-old woman who has had multiple falls in recent months;  she can’t come to the office because she’s in a cast after having broken her ankle.  You, as her physician, decide to take the visit to her home.  Upon walking in the door, it’s quite evident why she’s falling a lot – the floors are lined with ratty carpets, even you almost trip on your way in!!  The patient’s daughter is also present for the visit and instead of discussing the fracture, the visit is spent discussing removal of the carpets!

I made a home visit this week to a patient who is dying of cancer.  I called her husband last week and asked if she was well enough to come into the office.  She has a team of doctors looking after her, one of whom is a palliative care physician who makes home visits every few weeks.  A visit with me at this point is purely supportive in nature as her palliation is being tended to by the specialists.  Her husband said that, while they do make it to chemotherapy appointments, and other specialist appointments, it takes a tremendous toll on his wife and he didn’t think she’d be up for an office visit in addition to their weekly outings.  I knew he wouldn’t suggest a home visit – most of the time the last thing a patient wants is to impose on their physician.  So, I gently asked if she wouldn’t mind a house call.  The pause on the phone was telling.  “That would be wonderful for her,” he said.  “She would enjoy that so much.” He sounded a little bit surprised that I would offer.

Seeing a patient in their home environment is one privilege of family medicine I didn’t expect.  Once you step foot into their home, they cease to be “just a patient”.  You bear witness to their real life, to the home they have made, to their hopes and dreams, to their sorrow and sadness.  My patient and her husband welcomed me into their home, offered me a delicious cup of coffee and we talked.  We talked about her cancer and her pain; we talked about how chemotherapy was going;  we talked about the cat I saw roaming in the backyard; they told me how they met in Spain thirty-five years ago; and we talked about their four children. I saw the hope flicker in her eyes when she talked about the chemotherapy that helped her pain and maybe, just maybe, is shrinking the tumors. I saw the courage in her husband’s eyes as he tended to her needs and fluffed the pillow she had behind her back.  I saw the profound sadness in her eyes as she struggled to find the words to describe what it’s like to plan her own funeral.

Most family physicians don’t do house calls anymore.

I am not one of them.

 

When A Pet Has Cancer.

One of our cats is sick.  I think I mentioned in previous posts that we have two cats.  One is my husband’s and the other is mine.  It’s my husband’s cat that is not well.

Fizgig is the bestest cat ever.  When I first met him 11 years ago, he was a feisty guy who loved to play fetch with a string.  He was the perfect cat.  He was in the middle of the room at every party and even people who hated cats, loved this cat.  He is named after a character from the movie Dark Crystal.  Husband says he was a stray cat that just kept coming around until one day he let him in and became his pet.  For the past 11 years, Fizzy t has slept at my husband’s feet every single night.  When husband is out late, Fizzy will meow and meow and meow until he comes home.  I kid you not.  Husband isn’t really sure how old Fizzy is – best guess is probably 13 or 14 years old.

For the past two years, we’ve noticed a definite loss of weight.  Fizzy used to be big and heavy.  I’d say he’s lost almost half his body weight in the past two years, more so in the last six months.  We had him checked by our vet last year and he seemed okay despite the weight loss.  Blood tests then were normal.

Now, since the baby was born, we’ve noticed more weight loss and a new development: diarrhea.  Very occasionally there has been blood in the stool.  We thought it was stress related to the new baby, or maybe the change in wet food.  He’s always had a good appetite but lately he seemed to be a bit more picky.  Anyway, a few days ago husband noticed blood in Fizzy’s poop, so off to the vet we went.

Blood tests revealed elevated white blood cells, and more specifically, elevated lymphocytes.  Not good news.  The little guy has cancer, probably chronic lymphocytic leukemia (CLL).  It’s possible it could be lymphoma, so we are going to get some x-rays to make sure there isn’t a tumor in the chest.  The vet thinks it’s probably CLL.  Being a physician, I’ve seen CLL during my Heme-Onc rotation, and I have one patient in my practice with very early stages of CLL. It never occurred to me that it could happen to a cat.  Husband thought, given the diarrhea and weight loss, that we were dealing with colon cancer.  I guess if there’s any good news here it’s that CLL is a chronic condition which does appear to respond to treatment with prednisone and chlorambucil.  Prednisone is a steroid that suppresses the immune system, reduces inflammation and may help to increase his appetite.  However, there is a risk of developing diabetes, given that he’s an older cat.  Chlorambucil is a chemotherapeutic drug.  It is used in humans, as well as felines, in the treatment of leukemia.  Use of chlorambucil requires regular monitoring of blood counts, probably once a week, to make sure it isn’t suppressing his blood counts.

We will probably treat him with prednisone to start.  I’m not keen on chlorambucil given the frequent blood monitoring involved.  Let’s be honest, vet care isn’t cheap.  Fizzy doesn’t appear to be in any pain.  I don’t like the idea of taking him to the vet weekly for a blood draw.  It just seems too much for the little guy.

To some it might seem silly, but a beloved pet is a member of the family.  We always knew Fizzy wouldn’t be with us forever but that reality is setting in all too quickly today.