Monthly Archives: December 2011

Thank God for My Ass

–Therese Zink

I am not referring to my backside, although I do have a well developed gluteus
maximus due to my stocky German build and fifteen miles of running every week. My ass is Jimmy, a shy miniature donkey (think Shrek’s pal) who has been the companion of my horse, Indy, on my twenty-acre farm for almost four years. Recently Jimmy saved my ass. Please pardon my crass language, but it is the truth.

At about eight one evening, my cell phone chimed as I was driving home.
The local nursing home needed help with an elderly gentleman who had been
admitted three days earlier. My partner had given him some furosemide late
that afternoon for congestive heart failure, but Mr. Olson was still edematous
and very short of breath. “The family is upset and wants me to do something,”
the nurse reported. “His hemoglobin is four and his potassium is six. Will you
talk with the daughter?”

A hemoglobin this low would require a transfusion of several units of blood,
and the potassium suggested kidney failure. “Sure,” I responded. Not wanting
to be the student who lost her homework, I said, “But I don’t know him. Please
read me his diagnoses and tell me what meds he’s on.”

It took the nurse several minutes to tick off the list, which included some
dementia and repair of a thoracic aneurysm seven years ago.

“How old is he?” I asked wishing I was not the one on call.

“Eighty-eight,” she informed me. “He’s very sick. DNR-DNI. The family is
pushing me to do something. The daughter is really upset.”

As I drove in the darkness toward home, I took a deep breath and readjusted the
phone next to my ear. My new challenge flashed like a neon sign—the distressed
family of a new patient who I didn’t know. “Any thoughts?” I asked the nurse.

“The daughter is a handful. Good luck.”

“Put the daughter on,” I said and prayed for inspiration.

“This is Janet,” the voice said. “You know me. My husband and I borrowed
your donkey for our church’s Christmas nativity pageant.”

I thanked God for the connection, some place to start this conversation. “Of
course, Jimmy. That was a cold day.” I said and remembered that the shepherds,
kings, even Mary and Joseph, wore snowmobile suits under their cloth costumes. Thick Sorel boots peeked out beneath their flowing robes. Jimmy was insecure without his buddy, Indy. So this manger scene had had a horse and a donkey. Janet and her husband had given me the digital photos that I had cut and pasted into my Christmas letter to family and friends. “I am glad to talk with you again, but I am sorry about the circumstances. Tell me your understanding of what’s going on with your Dad?”

Janet cleared her throat. “My mom cared for him at home for six years. He
started having trouble walking two weeks ago, so I started coming every day
to help her. We decided he needed more than we could do and looked for a
nursing home. There was an opening here, so we moved him last Friday. He’s
gone downhill since.”
I heard the frustration and recrimination in her voice: Why was he doing
worse, not better at the nursing home? “The nurses tell me he has a lot of fluid in his lungs,” I said. “We can help him breathe easier.”
“Can you help him get better?” Janet asked.
Read the rest of the story

First published in JAMA,299:16 (2008):1879–80, used with permission in The Country Doctor Revisited (Kent State University Press, 2010)

Building trust is an important ingredient to the doctor-patient relationship. In the 4 habits model, Dr. Frankel ARTICLE  presents a very practical model for thinking about how to approach the patient. Sometimes trust must be built rapidly, such as in an emergency or crisis. In this story, I was faced with the angry daughter of a patient I did not know. Luckily my miniature donkey gave us a place to start the conversation. If you are on a rural rotation, what have you observed about how doctors and nurses build trust with patients?

DINE: Navajo, People

–Maureen Connolly

Tsaile is cool at five thousand feet,
little snow, lots of space.

Weekdays I rise in the dark, watch the sun
bleed across the Lukachukai Mountains
out my kitchen window.
I see patients in the Indian Health Center:
pregnant women, diabetics, old women
in long skirts and velvet blouses, infants
brought in on cradleboards, injured men.

I learn how to speak some Navajo
how to listen to what is not said.
At the end of the day I walk outdoors
to where I sleep in the compound
near the dwellings of the other doctor
and the nurses. On the other side
of my little house, the sun bleeds
purple and orange over a pearled sky.

Once a week, I drive a winding road
into the dust and mud of Chinle
to a tiny emergency room bulging
with people. This winter babies
on the reservation are having trouble
breathing. There aren’t enough beds.

Friday nights at the trading post,
I look at axes in a barrel, consider
popcorn versus pretzels, pick up
a free copy of the Navajo Times.
Weekends I hike the canyons.

In Window Rock I go to a rodeo
for the first time, sit on rough
planks in the stands, a white
woman alone among the Navajo.
Mothers put fry bread in toddler
mouths. Prepubescent girls eye
cowboys walking to the chutes
spurs glinting on their boots.
Boys enter on bucking calves
then grown men clinging to huge steers.

Clowns open gates, tempt belligerent
animals away from fallen riders,
know that elusive thing, when
to step out of the line of danger.
I leave early, fearful of livestock
or a drunken driver wandering
into my headlights on the dark
journey through the mountains.

I attend mass in a hogan-shaped
church, its curved inside walls shared
by St. Francis and the corn goddess.
Statues of a medicine woman and man
stand alongside the Nativity crèche.
I discover the Irish and Navajo have
nearly the same word for “people.”

The night before I am to go home
it snows for hours into the quiet.
By morning the mountain passes
near Tsaile are closed. I head my
rented sedan the opposite direction
from the airport in Albuquerque
in hopes of circling back.

In Navajo country a milk-blue sky
blurs into rich cream land,
rust-red canyons claimed
by the snow. A brindled horse,
breath foggy in the air, stands still,
ears erect, against the horizon.
The landscape, impossibly, expands.

Two jeeps appear, one before
me, one behind, angel me
a hundred miles, no other
vehicles in sight, past scattered
Navajo villages, above the timberline,
over a mountain. I slide
onto the interstate, the jeeps are gone.

Near Gallup I stop at a convenience
store, dizzied by its repleteness.
Albuquerque can only be entered
from the west, they say, the snow.
I am coming from the west. I aim
for Albuquerque, home, my lover.

Then the airport and a plane that will fly.
More people, things, speed, sound.
A prayer forms itself.
I continue to move in and out of danger.

Dr. Connolly describes her time working on the Navajo reservation. She is aware of her foreignness, her otherness, in that setting, a different culture, with strange traditions; she describes her awareness of being different. At times she senses danger due to her unfamiliarity with the setting, but she has some resolution.

Today in many rural settings the provider may be from an ethnic group or race different from his/her patients. In some settings, international medical graduates, who were raised and educated outside the US, provide care to patients quite different from themselves. In other communities immigrants from outside the US have settled, drawn by connections with a church or seeking employment opportunities. Some communities and medical settings do a good job of integrating cultures different from the people who settled there over a century ago. Local businesses welcome the immigrants; schools have special programming for immigrant students; clinics and hospitals hire translators and immigrants as support staff, place signage in other languages. In other communities there may be tensions between the different races and cultures.

If you are in a setting where a variety of cultures are learning to live and work together, notice how they have or have not negotiated their differences. Has the majority culture welcomed the minority? What more could be done?

End of life decisions–becoming your grandfather’s physician in rural Tennessee

–David McRay
Dr. McRay tells the story of helping his grandfather decide to end dialysis and agreed to be his physician so he could die at home. ..

As his creatinine level rose, his hematocrit fell, he had no choice. With the itching worse and the fatigue incapacitating, if he wanted to feel better—in fact, if he wanted to continue to live—he needed to begin dialysis. He did not understand what was being offered, how it would work or how it would make him feel. The therapy was never described as a form of life support
with all the customary conversations about indications, alternatives, ethics, and options for withdrawal. It was simply the next step in the management of his illness; a step he felt forced to accept but never really did.

The nearest dialysis center was in a town forty-five minutes north. Three days a week, my grandparents would leave home early in the morning and make the trip to greet the staff and submit to “misery,” the word he used to describe the way dialysis made him feel. Miserable though he was, he made the best of the situation, as he had always done with every hardship he encountered in his life and for two and a half years, he drove himself to dialysis most of the time.

A stroke changed everything. He awoke that morning with some troubling weakness and numbness in his right arm and leg. An ambulance trip and brief evaluation in the local hospital emergency room were followed by a transfer to the major medical center in Nashville where my grandfather remained hospitalized for two weeks. He was discharged to a rehabilitation hospital and then an extended care facility. He never suffered from a severe loss of function, but he became dependent, unable to attend to his most basic needs. His dignity was under attack; his spirit broken.

When his wife of sixty-one years passed away in her sleep, he asked, “What will happen if I don’t go back to dialysis?”

“I don’t know” was the only answer I could provide. I had never encountered this circumstance before. I knew he could delay his treatment a day, maybe two. A few days later, I spoke with a nephrologist in my community. She seemed very uncomfortable with the conversation and described the difficult deaths of two patients who chose to stop dialysis during her fellowship. Beyond that she offered little.

Granddad approached this decision in his usual careful and thoughtful manner. We continued our conversation and I tried to answer his many questions. We referenced the Christian Scriptures, talked about his relationship with God, and spoke of the confidence with which he felt he could approach the end of his life. We discussed other situations in which patients make decisions to withdraw life-sustaining medical care such as mechanical ventilation and tube feedings. He concluded that for him discontinuing renal dialysis was similar to discontinuing mechanical ventilation in the face of an irreversible, terminal illness. His kidneys had failed and would not recover. His life was without joy and now devoid of the experiences that had given it rich meaning for almost eight decades. Existence was limited to restless sleep on the bed or the sofa with painful, exhausting, and embarrassing trips to the bathroom.

Dr. McRay’s grandfather was enrolled in hospice and Dr. McRay agreed to become his grandfather’s physician so he could die at home. ..

The morphine and the hypoxia-induced sleep kept him unaware of the fluid that was filling his lungs. “I’m ready. Let’s go home,” were his final words. He slept and did not arouse again. His son held one hand and his daughter the other. I moved across the room and sat in a chair, watching with quiet reverence. This location provided my parents, aunt, and uncle enough space to be at his side. Perhaps the move was symbolic as well. My grandfather was dying on the couch, but he was also my patient. I needed to maintain some space, to hold on to the equinimitas I had found. Until my task was completed, I wanted and needed to protect my objectivity.

The end came quietly. Some of those present had never witnessed a death before. Startled, they looked to me for an interpretation, a diagnosis, a verdict. My solemn nod unlocked the door to their grief. Together we—his family and friends, his church and community, and me as his grandson and physician— allowed my grandfather to go home and stay home. With grace and courage, he overcame the obstacles presented by the rural location where he lived. With
hesitation and gratitude and with some sense of urgency and necessity, I overcame my uncertainty about the dual roles I was asked to play. I was honored and humbled by the privilege of helping my grandfather write the final chapter of his story. I believe he wrote it well.

Dr. McRay explores a number of important issues: ending life sustaining treatment such as dialysis, managing the dual roles—grandson and physician, the value of religion in exploring the big questions in life. In today’s world technology creates benefits and burdens. We can extend life, but those days and months are sometime more quantity than quality. Dr. McRay helped his grandfather decide to quit dialysis. Have you witnessed or been part of such discussions and decisions with patients? What did you learn? What will you take away from this essay as you help patients explore how they want to die and make decisions about resuscitation, intubation and advanced directives? How is religion and spirituality helpful to patients who have a faith?
Dr. McRay negotiates his dual role more carefully; this is explored more fully in part of this essay that is not included in the blog. What are important considerations for managing the dual roles?

Published in The Country Doctor Revisited (Kent State University Press, 2010) used with the permission of the author

Welcome to Elma–21st century changes in rural practice

–Mitchel Cohen

Hey, you must be our medical student for the day. Short white coat gave it away.
Did you find the office OK? Good, directions aren’t too difficult. There’s only one light in town and I always tell people if you just look for the funeral home and the liquor store we’re just past that. People often drive right past the building though. Most think it is just a one-floor rambler style house. They really have no idea of the history of what’s happened here.

Come down the hall this way; let me show you this picture. This is a drawing
of this office back when it was a hospital. It was built in 1898 by Dr. Blair. There
were two beds for men, two for women, and a surgery/storage area. The nurses
lived in a house attached at this end. Did I mention there was no running water or electricity when he opened his hospital? He put that in ten or twenty years later.

Here’s the mini-library we’ve built and a computer that you’re free to use. We’re still fairly technologically challenged out here. Our IT department consists of whatever we can figure out or con friends and family into helping us with.

Information technology is certainly one of the biggest challenges of being in a small, rural practice. There’s so much potential yet so many barriers. Purchasing, implementing, and maintaining an electronic health record is an expensive proposition. Telemedicine could help bring specialists in for virtual office visits, but again, who can afford to set that up? There’s admittedly some element of technophobia in here. Much of our staff, as wonderful as they are, still are not comfortable with some basic computer functions. There’s a certain conservatism that comes with small-town life, and while this is often a good thing, technophobia is probably not good.

Dr. Cohen addresses the tremendous changes that have occurred in medicine in the last century. As a child of the computer age, you may not fully appreciate the shift the electronic health record brings to patient care, especially for physicians who thought typing was for their secretaries and not for them. The organization of health care into health systems and coops brings resources and economies of scale so that adopting telemedicine and the electronic health record might be a little easier. With that physicians lose some autonomy. The productivity treadmill, which is part of medicine today, removes some of the “fun.”  You may rotate with physicians who have adapted well to the IT age of medicine and others who are moving like dinosaurs.

Dr. Kurt Stange and colleagues have spent a lot of time thinking about how practices adapt and keep up with the rapid changes in medicine today. This 2008 on-line article in the Journal of Family Practice: A survivor’s guide for primary care physicians, examines what works and doesn’t work about practice change. ARTICLE Give it a read, see what you’ve noticed in the setting where you’ve been spending time.