Facing the Void

My brother and I had a long talk the other day about our parents.  He has positioned himself to be their power of attorney for finances and I am their power of attorney for personal care.  In the past year, it has become evident that we may need to start exercising our roles.   I can’t tell you how sad that makes me.

Growing up, my father was larger than life. He was a tall, formidable man with a deep voice but he was for all intents and purposes, a gentle giant.

Over the past year or so he’s become impatient, occasionally verbally aggressive toward my mom and is forgetting things.  He was diagnosed with mild cognitive impairment last fall but his condition seems to have deteriorated in the last 3 months.  He has a much shorter fuse now and asks my mom to repeat things several times a day.  He denies feeling depressed but we all think he is. Thankfully his family doctor suggested a trial of a low dose antidepressant and he actually agreed.  

He will be having an brain scan soon. I fear it will be normal.  Why? Because the thought of watching him continue down the road of dementia is heartbreaking. It would frankly be much easier if he was diagnosed with a brain tumor. I don’t think I could bear the day he forgets his grandchildren and then me. I don’t think I can watch him become aggressive and angry and frightened at his memory loss.  I see it already happening with my maternal grandmother. 

And there’s the kicker: dementia on both sides of my family? What does that mean for my brother and me? Are we destined for the same end?

We talked about all of it. Dad won’t want to go into a nursing home when the time comes. Will I have to have him declared  incompetent and take over as POA?  If dad moves into a nursing home, mom won’t be able to stay in the condo; will she live with me or my brother or alone in an apartment?  How long are we going to have to watch him deteriorate? He would never want to live like that. I certainly wouldn’t. 

I fear the road ahead. 

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.

 

Letting Go.

It’s been a difficult day.

One patient whose wife has terminal lung cancer came to see me today.  I plan on doing a home visit later in the week.  He came for his own medical issues, but we talked about his wife.  He put on a brave face but he is devastated.  Married for 36 years, second marriage for both, this wasn’t supposed to happen to them.

Another patient, in a long-term relationship, just isn’t “feeling” it with her partner anymore.  She hasn’t for a long time, yet remains in the relationship and complains regularly of episodic pain which has been investigated more times than I can count.  Her tests always come back normal.  She left her partner last year for a time, actually started dating someone new but then returned to the long-term relationship.  It would appear that the break really didn’t do much for her.  She still doesn’t know what she wants, yet isn’t ready to take the final steps.

Both of these people have to let go, in different ways.

At some point in all of our lives, we have to let go of something, or someone. Whether it is in death, or simply a parting of ways, it’s not easy.  I struggled to find the words for the gentleman whose wife is dying.

And I just got word another patient has likely entered the final stages of his journey and is now actively dying.

All of this in one day, within a few hours.

I need a drink.

I feel completely overwhelmed with my job today.

I need to let these people go.  I can’t take this home with me.

Husband is coming to pick me up. He won tickets to see an early screening of Godzilla. I need mindless entertainment tonight.  Thank goodness my mom can stay with the kids.

 

Bad News Bear.

There’s an aspect of being a doctor that never gets easy and that is delivering bad news.

In medical school we take a course called “Breaking Bad News“, but nothing prepares you for actually having to do it.

I’ve had my family practice for 7 years and have been practicing medicine for almost 10. I can still remember every single time I’ve had to give bad news.

  • While working at a walk-in clinic, over the Christmas holidays, I had to tell a woman she had pancreatic cancer.
  • In my first year of family practice, I told a woman she had cervical cancer.
  • In my second year of family practice, I felt a pancreatic mass in a 55-year-old woman; she lived for 4 years after that. I attended her funeral.
  • Three years ago, I felt a very abnormal prostate gland and new instantly the patient had prostate cancer.
  • A young woman, believed to be about 3 months pregnant came in for an unrelated matter and asked if we could listen to the heartbeat. She’d seen her midwife the previous week and they couldn’t find it.  Neither could I.  An ultrasound a few hours later confirmed what I already knew.  She’d suffered a miscarriage but didn’t know it.
  • There was an older woman who came to see me for chest pain. She had been coughing from a cold and had a lot of chest wall pain. An x-ray showed multiple rib fractures. Spontaneous rib fractures.  A week later, after sending her for a series of blood tests, I diagnosed Mulitple Myeloma.
  • Sometimes a diagnosis of chlamydia can be devastating.  It certainly was in the 31-year-old married woman who came in for a routine Pap.  Sadly, my bad news was instrumental in her later ending her marriage.
  • My first week back to work, I told a man he most likely had kidney cancer.  Welcome back!

Every time I have to deliver bad news I am reminded how fortunate I am and how fortunate my patients are for living in a country where, when its required, they have access to timely health care.  None of the above patients waited for more than a week or two to see a specialist.  Sadly, not everyone survives after being given bad news. I haven’t had to do it very often, but when I do, it affects me personally.  Often I can’t sleep for a few days.  Sometimes I worry (often unnecessarily) that I missed the boat and should have caught the illness at an earlier stage.  Anything else going on in my life suddenly seems not to matter for a while.

Bad news bear.

Sometimes that’s me.

 

 

Higgledy Piggledy

Higgledy piggledy
Wiggledy wump,
I met a man
Who caught a mump:
With his left cheek lumpy
And his right cheek bumpy –
Higgledy piggledy
Wiggledy wump.

Higgledy piggledy
Sniggledy sneezle,
I met a man
Who caught a measle:
With his chest all dots
And his face all spots –
Higgledgy piggledy
Sniggledy sneezle.
– Alligator Pie, Dennis Lee, 1939

I read this book to the kids the other night.  My daughter loves the illustrations and this one in particular.  She asked me what a mump and measle was.  I explained that they were illnesses caused by germs (viruses) but that most of us don’t get them anymore because of vaccines. She kind of understands what vaccines are, I explained how it’s a needle that she gets that protects her from illnesses like the one described in the story.  She seemed satisfied with that, so we continued reading the book.

But my mind stayed on Higgledy Piggledy, primarily because of the news recently.  There have been outbreaks of measles in a few Canadian cities, mostly in communities where the vaccination rates are frighteningly low.  In the nation’s capital, Ottawa, a young boy contracted measles after returning from the Philippines, a trip he took with his parents.  The child wasn’t vaccinated.  Upon returning home, he became ill and went to not one, not two, but three different walk-in clinics (including an emergency room) before getting diagnosed. Meanwhile, the child was infecting his classmates at school, not to mention a potentially vulnerable population in the ER.  Within a few weeks, another four cases were confirmed.  Another outbreak is also happening in British Columbia.

I’ve written a lot about vaccines.  I’m not going to belabor the point, I believe vaccines work and I believe they are safe.  I don’t believe they cause autism and I believe that, in the end, after all is said and done, vaccines save lives.

Back in 1939, Dennis Lee was born. Decades later he wrote a poem about mumps and measles.  He likely had the illnesses as a child.  He probably recovered.  Not everyone he knew would have been that lucky.

Please vaccinate your children.

Cancer Blows.

Prior to my maternity leave, one of my patients had been diagnosed with pancreatic cancer.  She was set up with specialists, I reassured both her and her husband that they were in excellent hands with my locum and promised to be in touch with them as soon as I could.  My locum has been keeping me up to date on this particular patient as well as a few others.  This patient had major surgery a few weeks ago to remove the tumor and reportedly has been doing well.  I read the operative report today.  She had a procedure known as the Whipple.

The Whipple is a complicated procedure.  I saw one performed once as a medical student and all I remember is holding a retractor for a very, very long time.  Generally speaking, pancreatic cancer is not a good cancer to be diagnosed with – I mean, no cancer is, but this one in particular can kill a patient very quickly if it’s not caught early.  Thankfully, I believe my patient’s tumor was found early and according to the operative report, the Whipple procedure was considered curative.  Curative!! If I believed in God and Angels, I would say she definitely has an Angel looking after her.

Cancer is one of those illnesses that, I believe, touches all of us in one way or another.  My mother had breast cancer, diagnosed 12 years ago while I was still in medical school.  My mom was one of those women who always did self-breast examinations because she was prone to developing cysts.  I remember when I was a lot younger, she went in for day surgery to have a lump removed.  It was benign, but ever since then I always remember her feeling her breasts, always checking for something.  Well, on one of those checks, she felt something different.  Her family doctor couldn’t feel it; the radiologist couldn’t feel it; the breast surgeon couldn’t feel it.  But my mom did and the mammogram proved it. She had a lumpectomy about a month later and it was proven to be contained within the breast with no evidence of spread to the lymph nodes.  She had 5 weeks of radiation therapy, took Tamoxifen for five years and is considered cured.  Her having breast cancer does not necessarily increase my risk as she was post-menopausal at the time of diagnosis, but I still plan on being vigilant and likely will get my first mammogram next year when I turn 40.

Husband’s father was diagnosed with bladder cancer at the age of 62. Like most individuals diagnosed with bladder cancer, he presented to his doctor with gross hematuria (frank blood in the urine).  His tumor was small, localized and initially treated with an immune-stimulating drug called BCG (made of the bacteria that causes Tuberculosis).  It seemed to work at first but several months, maybe a year later, he developed acute renal failure and it was discovered that the tumor had spread outside the bladder wall and was blocking one of the ureters that drains the kidney.  I believe he underwent chemotherapy at that time, as surgery was no longer an option due to local spread.  Sadly, he died about a year and a half after the initial diagnosis. His risk factors were his age (>40) and his sex (male).  He never smoked, but he did work in the pharmaceutical industry as a pharmacist for many years back in Scotland, so it’s possible he was exposed to some chemicals back then.  We’ll never know.   As husband has just turned 40, I remind him periodically that he needs to go for his check up.

I remember a particularly difficult case I worked on during my family medicine training.  I spent two months on the Palliative Care unit. Palliative care is end of life care. More than that, it is medical care and treatment during the process of death and dying, not only for the patient, but for the family as well.  Difficult under any circumstances, but brutally awful in this particular case,which was a 44-year-old mother of two children, dying of colon cancer.

Colon cancer is one of those illnesses you think happens to a man in his sixties.  At least it was for me, as a medical student and resident.  But those two months on the Palliative care ward taught me otherwise.  Almost 10 years later, I don’t remember the details of the case, but what I do remember is that cancer can strike anyone, at any age.  My job as a family physician is to be suspicious and cognizant of that fact.  Anyone with symptoms of anemia, weight loss, change in bowel habit, vague abdominal pain/cramping, night sweats, regardless of their age – these are all red flags that need to be paid attention to.  Sadly for this woman, her physician lacked a certain amount of imagination and her tumor wasn’t discovered until it was too late.

I recently visited the RateMyMD website and looked myself up.  I was pleasantly surprised to see several new comments, and yes, they were all positive. (Giving myself a pat on the back right now!)  One in particular stood out.  This patient was new to my practice, having seen her husband’s physician for many years.  This physician was retiring and she sought out a younger, female doctor.  She got me. Apparently, at her first annual physical exam with me, I asked her about colorectal cancer screening.  She had never had a colonoscopy – it was never brought up by her previous doctor.  She had the “home testing kit” done every few years.  These fecal occult blood tests (FOBT) are designed to detect microscopic blood – blood not visible to the naked eye.  The thing is, not all tumors bleed, so the test might miss one.  Colonoscopy is the gold standard test for detecting colon cancer.  Guidelines for screening state that all patients > 50 years of age should have one every ten years.  However, this usually doesn’t happen because of wait times and cost to the healthcare system. Thus, the FOBT became a test to do in between colonoscopy.  Despite the guidelines, most physician will still recommend for all of their patients to have at least one colonoscopy.  Apparently, I talked about it enough at this woman’s appointment that she agreed to have one.  Turns out, I saved her life.  She had several precancerous polyps which were removed during her colonoscopy.

It’s a no-brainer, folks.  Screening tests work, be it mammography for breast cancer or Pap smears for cervical cancer.  If anyone reading this has a family history of cancer, or is of the age that a screening test is recommended, please get your screening done.  It really might just save your life.

Too Close For Comfort

Day 21. National Blog Posting Month.

Every now and then, I get an email from my son’s preschool about an outbreak of Hand, Foot and Mouth disease, or Fifth’s disease.  These are viral infections that are generally self-limiting and not a whole lot to worry about.  Except if you’re a pregnant woman exposed to Fifth’s disease.  In that case, there is an increased risk of miscarriage if exposure occurs in the first trimester and if exposed after 20 weeks there are certain biological effects to the fetus, in particular a life-threatening form of anemia.

Last night, around 1am, while I was nursing the baby, I decided to check my email.  In my Inbox is a note from the preschool announcing that there has been one confirmed case of Chicken Pox.

And so it begins ….

At this point, my son has already been exposed and has likely exposed all of us, including the baby.  Thankfully, both my husband and I have had the infection in childhood, our daughter was immunized and got a booster last year, and the toddler was immunized at 15 months.  My first thought was to get my son his second dose immediately, if for any other reason than to protect the baby.

Where I live, children are given one dose of the Varicella vaccine at 15 months of age and again at age 4.  According to the CDC, one dose of the vaccine is “85% effective against any form of varicella and close to 100% effective against severe varicella.” However, two doses of the vaccine is 88%-98% effective at preventing all varicella disease.

Don’t get me wrong, 85% effectiveness is pretty darn good, but is it good enough for me?  Especially having a 2 month old in the house?  My instinct as I mentioned was to bring my son (the toddler) to his pediatrician today for the booster.  Instead, rational heads prevailed and I called instead.  Our pediatrician assured me that my son’s immunity should still be strong enough to protect not only himself, but his little brother as well.

Phew.

Still, I can’t help but be pretty pissed off at those parents.  Given the type of preschool my son attends (okay, it’s a Montessori school in an affluent area of the city and quite frankly, not cheap), I have to assume these parents are well-educated and probably know that a vaccine against Chicken Pox exists.  But, I’m also quite sure they’ve heard all the “horror stories” on the Internet or from Ms. McCarthy herself and decided it was best for their child to skip the vaccine.  Right.  

Ugh.  I’m sorry if this offends any of my readers, but these kinds of parents are putting other children at risk.  As a mother, I’m not okay with that, but there is zero I can do about it.

As a doctor?  Well, you know where I stand on that.

End rant.

 

A Frightening Trend.

Day 12. This is actually a lot easier than I thought it would be, writing a post everyday.  I actually look forward to it!

And, yes, I’m back, despite my little rant yesterday, which in case you missed it, you can read here.

What’s on my mind today?  Vaccines.  I know, I know, it’s a volatile topic and I’ve discussed it before, but you see, the baby is 8 weeks old today (my goodness, when did that happen?) and he will be going for his first set of vaccinations next week. For me, it’s a no-brainer that he will be vaccinated.  All of my kids were vaccinated.  I didn’t even give it a second thought.  Now, that’s probably because I am a physician and a rational, logical human being.  Okay, that last part was a bit of a dig.  I am just so sick and tired of parents thinking that just because they’ve done their “research” on vaccines (ie. have read about Wakefield, everything that Jenny McCarthy has to say on the subject, and discussed it with their “friends” on countless message boards), does not mean that they understand the science and study behind creating a vaccine.  These parents haven’t seen the devastation that Polio caused, they haven’t seen what congenital Rubella syndrome looks like, nor have they had to tell their son that they may never be able to father children because the Mumps caused orchitis and has the potential to limit his fertility. And let’s not forget the risks of meningitis from certain strains of pneumococcal pneumonia, Measles, and rarely, chicken pox.

I was a resident in family medicine working on the Pediatric ward when a 15 month old girl was admitted with seizures.  She had been diagnosed with pneumonia 2 days earlier.  Blood cultures revealed a particular strain of bacterial pneumonia.  This strain is one that is covered by a vaccination available here, called Prevnar-13.  A review of this child’s medical records showed that her parents declined all vaccinations.  The seizures were eventually controlled, she was diagnosed with encephalitis and a few weeks later was found to be completely deaf.  Totally preventable had she only been vaccinated as an infant.

At least once every few weeks I see a news article about an outbreak of a vaccine-preventable illness.

It’s becoming so common these days, it’s actually starting to scare me a little bit.  If we continue down this path of non-vaccination, herd immunity is going to fail.  We will see the resurgence of illnesses we haven’t seen in twenty or thirty years.  I have never seen a case of measles but I’m sure one day, at this rate, I will.

What’s next?  A North American outbreak of Polio?

100!

I was saving this, my 100th post, for my 2 year blogging anniversary which is on the 12th of September, but I couldn’t wait.

I am 11 days from my booked delivery date.  I have 6 working days left, and yesterday, I, together with a specialist, mutually agreed that our patient could not travel on her European vacation with an obstructed biliary tract from a probable pancreatic tumor.

This is my 3rd maternity leave and I just wanted to leave my practice with no new ominous diagnoses.  Is that really too much to ask? Right before my first leave, a lovely 50-something woman was diagnosed with a pancreatic tumor.  Right before my 2nd leave, a 50-something man was diagnosed with a particularly aggressive prostate tumor, and now, right before my 3rd leave, a 70-something woman is being worked up for pancreatic cancer.

As I mentioned in previous posts,  I have a wonderful physician who will be covering my practice, but it feels awful leaving these people when they need their family doctor the most.  I especially like this 70-something woman as she reminds me a lot of my own mother.  Her husband is wonderful as well and if his wife does have pancreatic cancer it is going to destroy him – he all but told me that at his most recent visit for an unrelated matter.  My heart broke for him.  He really wanted this trip, but he knows full well how bad it might be if she does have cancer.  I wish I hadn’t been a part of taking that away from him. I wish I could be present for them as they navigate through the health care system.  I hope I see her next spring when I return.