Thursday, May 28, 2015

Doing Everything Right

A few weeks have passed since my kidney stone attack and my visit to an Emergency Room.  Time brings healing and perspective: it brings the ability to reflect on the experience and to hopefully gain new insights.  The time since my suffering this “minor” medical bump in the road has given me a chance to think about how everything can be done right, while feeling wrong. 

When I teach, I often share my definition of a minor illness as an illness someone else has.  Everything I or someone I love has is major.  My point is that when we treat people who are suffering, we must put ourselves in their shoes and try to understand what they feel and how those feelings impact their lives.  We must see the situation through their eyes, understanding their story and their perception and not only their pathology.  Indeed a minor illness that impacts one’s ability to work and one’s ability to meet responsibilities can be very major to the person in need of care. 

I suffered my first kidney stone attack in 1977 when I was an intern.  I ended up needing surgery (minor surgery but major to me) to remove the stone.  Through the years, I have had episodic attacks of kidney stones, especially when I allow my water intake to fall down.  I force myself to drink water in order to keep free of stones and the renal colic that ensues.  I do everything right but the stones still occasionally  occur. 

My latest kidney stone attack began with the all too familiar severe cramping pain in the left side of my abdomen radiating to my flank.  As is often the case with my kidney stone attacks, it was accompanied by a shutdown of my intestines.  A common complication of kidney stones is that the normal peristalsis, or motion, of the intestines stops.  This is called Adynamic Ileus or Ileus and the resulting obstipation (defined as intractable constipation), bloating, nausea, vomiting and total abdominal pain that comes with it can be more distressing than the severe cramping stone pain. 
For the next two days, I drank as much water as I could, avoided food as my intestines were just not working, and watched my urine for signs that the stone might pass.  While the cramping pain was only occasionally severe, the obstipation, bloating and nausea were especially troubling.  The entire time, however, I was confident that this was another bout of kidney stones and the stone would eventually pass.  By the second day, the pain, obstipation, bloating, and nausea were getting worse and had me doubled over. I made my way to the Emergency Room when the pain and the severe obstipation became unbearable. 

I presented at the front desk, immediately telling the clerk that I was in severe pain and needed a specimen jar as I needed to use the restroom.  A sense of urinary urgency often accompanies kidney stones and I knew that a urine sample would be needed.  My sense of pain and my symptom of urinary urgency were not matched by the ER clerk’s attitude or speed of response.  I waited patiently and after about ten minutes had the specimen jar in hand and was able to use the restroom.  The ER clerk did everything right but it didn’t feel right to me, the patient. 

After about twenty minutes in the empty waiting room, I was taken back into a room in the ER where the nurse started an intravenous line, drew blood, and took my vital signs.  I was then seen by the nurse practitioner.  He took one look at my extremely distended, tight abdomen and became energized as he thought that I had an intestinal obstruction or a perforation.  He asked me if I wanted an evaluation for obstruction or perforation. At that point, while I was relatively certain that I had an Ileus and not an intestinal obstruction I believed that it was good to make sure that the more urgent problems were not present.  I also believed that I was in no shape to be my own clinician.  The necessary tests were done to ensure that I had not perforated part of my bowel, while we waited for the blood and urine tests to return.  The nurse practitioner was doing everything right.

When the labs came back, the results showed that my kidney function was impaired, a surprising result which, while possible with a kidney stone and with some degree of dehydration, was a bit worrisome.  Meanwhile, I was receiving intravenous fluids to counter any dehydration I may have had from my limited intake over the previous two days.  The nurse practitioner was asking my opinion for every decision often in an open ended manner.  What pain medications I wanted, what test I wanted done, how best to proceed were all asked at each step.  He was following a model of patient involvement and shared decision making: doing everything right.  The problem was that at that point I did not really want to be asked which pain medication I wanted or exactly what I wanted my diagnostic evaluation to be.  I just wanted the correct pain medication for my situation and the clinician’s expert judgment to assess and treat me.  While I am a true believer in shared decision making, that was not necessarily the right time to use it.  I was in pain, I was distended, and my bowels were functionally if not mechanically obstructed.  I was not necessarily thinking all that clearly.  The nurse practitioner was being respectful of my status as a physician which was the right thing to do….but possibly at the wrong time. 

With the lab results in hand, I was able to have my CT scan but without the contrast usually used to better delineate a stone.  In the face of renal impairment, contrast infusion can be dangerous.  The CT scan showed a small stone present, and also showed distention of my intestines consistent with an Ileus with no signs of obstruction or perforation.  With that result, all of the activity and interest in me as a patient came to an abrupt halt.  In the eyes of the nurse practitioner and the ER nurses, I was no longer a real emergency.  The door to my room was closed, I did not see much of my nurse practitioner and the alarms on the IV monitor, and the BP monitor seemed to go off regularly with impunity unless I pressed the button to call someone in.  All of this was consistent with the norms of emergency medicine.  The “true” emergency, mechanical bowel obstruction or perforation was “ruled out” in medical parlance so they saw their job as done. However from my perspective, I was still suffering.  I still had the stone, was still in pain, still had severe abdominal distention and obstipation with Ileus and had known renal function impairment.  But all interest in me had stopped since, in the eyes of the staff, I was no longer an emergency.  They were doing everything right. 

I had received about 2 liters of fluid and wondered, with some presumed dehydration, whether I should receive another liter as eating and drinking was still difficult, but the staff at the ER would have none of it.  I did not have a “surgical abdomen” so they wanted me out of their emergency room.  I was discharged and I left.  Two days later, on Monday, I was able to see my personal physician and my urologist and received the medication and counsel I needed.

In the following two days, my pain, obstipation and distention continued as did my difficulty eating. After the third day of drinking as much water as my nausea would allow, my stone passed, my ileus and resultant obstipation cleared up, and I was back to work.  A CT scan two weeks later, and repeat lab data showed that the stone, the kidney impairment and the ileus were gone. 

There are those who would say that the care I received in the Emergency Room was perfect for the function they are charged with performing.  They gave me hydration, they diagnosed the problem, they “ruled out” a different problem that would have meant urgent intervention and they sent me on my way.  They paid strict attention to the medical facts and protocols.    

But I want more.  In an emergency situation and in an emergency room, while it is important to be in the moment, the truly great physician, or nurse practitioner should also think past the moment and see the situation through the eyes of the patient.  The ongoing uncertainty, fear and pain should be addressed even if addressing those concerns is a purely human and not medical science endeavor.  They must think and plan for the day after the ER visit and not only what happens within those four walls.  If all they do is everything right in the moment, they have become technicians and not the healers that our health professionals should be.  

Tuesday, May 19, 2015

Death is Inevitable but Fear and Loneliness Need Not Be: What Medicine Learns from the Humanities

Often the best way to understand health care is through fiction, religion and philosophy.  Ultimately, health care should improve the human condition and not only treat the biological elements of disease and pathology.  One can learn more about the human condition from stories as told in literature, in faith, and in philosophy than from research that is published in medical journals even as the medical journals enlighten the science behind disease diagnosis and treatment. As Andrew Solomon, in his review of Oliver Sachs new memoir, “On The Move”, writes in the New York Times Book Review, “Medicine is dominated by the quants.  We learn about human health from facts and facts are measurable.  A disease is present or not present.”   That is the current state which he calls, “arithmetical naiveté.” He describes Sachs career in contrast as being devoted to the “unfathomable complexity of human lives” and quotes from Sachs new book (which I must confess I have not yet read however I have read all his other books) “All sorts of generalizations are made possible by dealing with populations but one needs the concrete, the particular, the personal, too.”
My thoughts about medicine this week were triggered by an article from, of all sources, the on-line magazine, “Outside.”  The article entitled, “My Dad Tried to Kill Me with an Alligator” is a story of a father doing something that appears irrational and stupid.  In this true story, Harrison Scott Key’s father has him and his brother jump out of their boat to dive down to find a lost fishing rod and reel in a bayou filled with alligators.  That has the effect of helping his sons, especially his somewhat overweight, bookish son overcome fear and understand, in the words of the author that “safety should not be the defining virtue of a life.”  Analogously, while safety should not be the virtue of a life, addressing the biology of disease to avoid death should not be the only virtue of treating people who are ill.  While avoiding death is a virtue it is not the only virtue and for some, may not even be the most important at a particular stage of life. 

Yet in today’s medical world we seem to approach all health risk and all illness as being removed from the elements of life that may make life worth living.  Mass media suggests that science has an answer for everything and that taking a certain pill, or enrolling in the right diet or exercise program will make all your health problems melt away, the implication being that illness and death are optional.  Science, according to the medical reports on the news and the commercials we watch will have your believe that we can live forever and avoid or easily cure all illness.  They don’t acknowledge the reality that the wonder of living inherently involves taking chances and making autonomous choices in a complex world full of uncertainty. 

As physicians and health professionals, we know the reality of disease however we fall into the trap of believing that a person’s biology is the most important element of their life when in reality, it often is rather low on the list, even in the face of devastating illness.  The most important elements of life for most people are related to the values they have, the social environment in which they live and the people they care about.  When we ignore the complexity of the human condition, and when we focus on the medical only, and not the joy of life, then we lose the ability to help our patients truly heal. 

Interestingly enough, the “quants” can even show this with data.  For example when you study why people are readmitted to the hospital, it is related to their lives more often than it is related to their disease.  Living alone is the number one risk factor for being readmitted to the hospital in those over 65 according to a recent study in the Journal of the American Geriatrics Society.  That is not something you can see on a pathology slide but it is part of a person’s story.  Another review compiled research on the marriage health connection.  Married people are healthier than unmarried people and have lower health care costs.  Interestingly enough this is despite the fact that they have more obesity which some point to as the root of all health care cost problems. 

We see this understood quite well in the 23rd psalm, The Lord is My Shepherd, perhaps the most famous of all the psalms.   In Harold Kushner’s book interpreting the 23rd psalm, he speaks of the protagonist as being someone in despair.  Rabbi Kushner writes, “The psalmist cried out to God and this miracle occurred.  The miracle was not that the man’s fortune was reversed, but that he was not alone.”  Thus the data on readmissions and the one chapter of the bible that many in the English speaking world seem to know by heart give the same message – that being alone worsens the pain and despair that illness can initiate and that by having someone at one’s side, healing is more likely  to occur.  As Harold Kushner states it, “God’s promise is not that we will be safe but that we will never be alone…We will hurt but we will heal.”  While having a spouse by one’s side is a bit different than having God by your side, the point of loneliness being associated with poor outcomes when in a time of stress was well known before the scientific quantitative studies were done and was even published!  (This relates to a joke told by Israeli academicians asking whether God could get tenure at an Israeli university.  The answer is “no” because he only had one publication and it was not in English.)   

None of this is to suggest that the medical aspects of care are unimportant, only that the human elements are just as important as the medical.  Thus the humanities, as our window to the human condition are important in the understanding and treatment of people who are ill.  Just as Harrison Scott Key writes of facing up to and overcoming fear and the 23rd Psalm talks of God as helping us not feel alone, we as health professionals have to find ways to help us understand people with all their complexity and make health care into something more than purely scientific ways to avoid the inevitability of death.