tag:blogger.com,1999:blog-33227914228229652252024-03-13T04:05:09.197-05:00Paging for the AgingAnonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.comBlogger49125tag:blogger.com,1999:blog-3322791422822965225.post-6043499749997633282015-04-16T11:52:00.002-05:002015-04-16T11:52:41.029-05:00Between Geriatricians"Isn't she like 96 years old?"<br />
"OH NO, NO! She's only 89. . . But, she's a very old 89 year old."Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-54606836631358385562014-11-14T15:03:00.001-06:002014-11-14T15:03:33.613-06:00Cheers to the PCP!Specialty expertise others provide is at times invaluable, but I will always have great respect for the kind of (maybe old fashioned) doc who takes care of the whole patient. I feel that in our era of super specialty medicine, the primary care doctor does not get his or her due. Here is why the general doc should be respected and applauded . . .<br />
<br />
<ul>
<li>When you bring up a problem to a PCP, you will rarely hear her say that problem is not under her care. She won't say, "I am a ____ doctor. You should ask your primary care doctor." She will do her best to take care of it.</li>
<li>She takes care of 10 problems at each visit, often for less reimbursement than your specialist who manages one or two medical issues.</li>
<li>The PCP takes care of a person, not a heart or a kidney or a bone. She appreciates that adding a medication for one organ may have impact on another. </li>
<li>The PCP knows your values and preferences. She doesn't practice one-size-fits-all medicine. She will do her best not to prescribe medications or interventions that don't fit with your values or are impossible. She knows that since you can't possibly take in a low sodium, low carb, low protein diet without wasting away and so doesn't require this of you, whatever your medical conditions. </li>
</ul>
<div>
People go into primary care medicine because they care about people. They place less emphasis on being an expert on one thing and more emphasis on the big picture. Doing so isn't always easy, but it is rewarding. For these reasons, I hope that the primary care professions receive the kudos they deserve.</div>
<br />
<br />Anonymoushttp://www.blogger.com/profile/16703665116655557671noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-67797323969095564992014-06-13T10:38:00.002-05:002014-06-13T10:38:33.686-05:00"Happy for today"<a href="http://www.today.com/health/happy-today-carrying-when-alzheimers-strikes-early-2D79797508">http://www.today.com/health/happy-today-carrying-when-alzheimers-strikes-early-2D79797508</a><br />
<br /><br />
This article emphasizes that life goes on even after getting an undesirable diagnosis. Hope this helps people think about the possibility of finding happiness in the moment.Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-30401713429887966852014-05-01T10:25:00.001-05:002014-05-01T10:25:22.858-05:00Not a "sexy" specialty?When I tell lay people I am a geriatrician, I often get a quizzical look and need to explain that I am a doctor for older adults. When medical students come to work with us, I often find they are not enchanted by our field, which is among the least flashy of them all.<br />
<br />
So, imagine my surprise to see this . . .<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ3zK9IA1HFopDFqIiqEJK3bFgKc7b6MHBy1y04RL727RMS5iobSkrctVkS47-XTlI4uDync_dC9IseejKHAwgRZo5hWxXxjREHipRg7ufzOXRzD0zE2eDuutxRYmKCLqCk7gLW3xMIhc/s1600/photo.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ3zK9IA1HFopDFqIiqEJK3bFgKc7b6MHBy1y04RL727RMS5iobSkrctVkS47-XTlI4uDync_dC9IseejKHAwgRZo5hWxXxjREHipRg7ufzOXRzD0zE2eDuutxRYmKCLqCk7gLW3xMIhc/s1600/photo.JPG" height="240" width="320" /></a></div>
as a DJ set up for the night at a local restaurant. A friend actually pointed out to me that he was DJ [Dementia]. I guess we may be hipper than we realize. <br />
<br />
<br />Anonymoushttp://www.blogger.com/profile/16703665116655557671noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-49670857236662510572014-04-23T17:44:00.000-05:002014-04-23T17:44:04.179-05:00Middle of the Road<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;">Too much money to qualify for Medicaid,
not enough money to qualify without it. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;">Looking, searching for a facility, a
place to live until you die.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;">The fancy place says no. You can’t prove
your monetary worth, can’t prove you will give them a check every month… until…
eternity. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;">The modest place says no. You will cost
them too much. You have too many needs. And you can’t prove you will give them
a check every month… <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Until
you have no more money to give and the Government<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Takes<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Over.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;">So you wait. Without a home to go to.
Without a place to live. Moving between rooms and buildings, between facilities
and hospitals. <o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Until
you are broke<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Or
you die<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-size: 12.0pt;"> Whichever
comes first.<o:p></o:p></span></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-82078800020716511272014-04-18T11:00:00.002-05:002014-04-18T11:00:46.062-05:00When the best medicine is less medicine<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A majority
of our medical education is devoted to the rote memorization of medical facts
and than later to the practical application of that knowledge. As an internist
this commonly involves the use of various medicines for treatment of ailments.
However we must always be vigilant of when stopping medicine may be the best
approach. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I recently
established care with a 87 year old woman who had recently moved to the area to
be closer to her daughter. By outward
appearance she was a healthy highly functioning individual. After a brief
discussion she handed me her medication list, which included 18 different
medications and vitamins, many of which are scheduled three times a day or four
times a day. After a brief discussion it became apparent the woman was under a
tremendous amount of distress from the expense of the medications and
difficulty of keeping medications straight. Additionally on review of systems
she voiced many complaints that could easily be related to several of her
medications.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<br />
<div class="MsoNormal">
Although to
any practitioner it was very clear that the patient needed to have some of the
medications stopped this discussion can be much harder than expected. After getting
push back from the patient and her daughter on stopping any medications we were
able to stop only one medication at that visit with the plan to follow-up next
month and evaluate if she noticed any changes.<o:p></o:p><br />
<br />
-- Andrew Illif</div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-33568446388086835712014-04-03T11:10:00.002-05:002014-04-03T11:10:25.419-05:00Discrepancy between percentage of time Residents spend in the hospital training and percentage of time patients spend in the hospital
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I have been thinking about the discrepancy between
percentage of time Internal Medicine Residents spend in the hospital training
and percentage of time our patients spend in the hospital. </span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">My patient with the most hospitalizations this year is Mrs S.
She has had 8 hospitalizations adding up to about 1016 hours in the hospital. She
is definitely an<i style="mso-bidi-font-style: normal;"> extreme</i> outlier in
terms of frequent hospitalizations and yet she has spent 88% of her time OUT of
the hospital. <span style="mso-spacerun: yes;"> </span>This is in contrast to the
resident who has spent 75% of his training IN the hospital this year
(approximately 2304 hours in the hospital and 768 hours training in the
outpatient setting). His inpatient learning is intense and he is well equipped to
take care of the very sick patients in that setting. <span style="mso-spacerun: yes;"> </span>But our patients (with rare exceptions) spend
proportionately very little time in the hospital.</span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Would patients get better care if residents had more
exposure to the patients’ out of hospital environments? Here are a couple of
examples where knowledge of the patient’s environments would probably decrease
unnecessary interventions and cost. </span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">We couldn’t seem to keep Mrs B out of the hospital. She had
repeated asthma exacerbations and was hospitalized 11 times in one year. Each
time, she was treated appropriately and sent home but the scenario repeated
about every month. <span style="mso-spacerun: yes;"> </span>When we thoughtfully reviewed
her home setting, we discovered her twenty-something year old grandkids would come
over and smoke in her house. After having them stop smoking in her house, the
next year she was not hospitalized once!</span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">When doing a home assessment, I found Mr G compliant with
all of his meds but the only food he had in the kitchen was some neck bones
stewing. He said he couldn’t afford more food because his medications were so
expensive. We realized that he really didn’t need all of the meds he had been
prescribed and others could be switched to less expensive formulations. </span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Then there was the lady with advanced dementia who during an
admission for urosepsis, was deemed to have a high aspiration risk and ended up
with a feeding tube. In retrospect, she was always in bed in the hospital and
attempts at feeding were made when she was in this suboptimal position. When I
visited her at home after the hospitalization, she was up in her chair bright
eyed and smiling after finishing a whole breakfast of ooey-gooey pancakes and
maple syrup. Instead of making a decision about tube feeding in the hospital
while sick, it would have been preferable to have her go back to her own environment
to assess. </span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Have you ever seen a home set up like a nursing home? We
just saw one today—the daughter has a bedroom set up PERFECTLY with a bed,
supplies, shelving unit and pictures on the wall but free of clutter. As we
watched her, we saw that she has trained herself to be as good as any practical
nurse I’ve ever seen. The patient has been very stable so she doesn’t qualify
for hospice care though we are still giving her palliative/hospice-like care. </span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">While financial incentives push us to teach in the hospital,
I but I think residents could be better doctors by exposing them to where the
patient spends most of their time and helping them to consider this when they
are in the hospital. <span style="mso-spacerun: yes;"> </span></span></div>
Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-86115086956330135602014-04-01T15:16:00.001-05:002014-04-01T15:16:46.372-05:00Understanding the disease<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;">How many times have you been at church or social
functions and witnessed that “little old lady” that is running the show? From
party planning to organizing the Christmas plays to cooking dinners for 30+
people, my grandmother has always been that person. I often compared her to geriatric patients in
my medicine clinic and thought, “how does she do it?” No one in my very large family was prepared
for the day when she suddenly was no longer able to juggle it all.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;">My grandmother had a very difficult 2013 that all started
with her having back surgery. She had
undergone multiple back and other joint surgeries in the past and always seemed
to be back on her feet within days (so everyone thought this time would be no
different). Unfortunately, following a
very lengthy procedure, my grandmother woke up and really didn’t know
anyone. Her husband of 50 years, her 4
children, the multiple grandchildren, and even great grandchildren that she
often babysat, were only intermittently recognized. At first, I assumed (from 100s of miles away)
that she just had hospital delirium. I
received calls almost daily from my very distraught mother asking “what is
wrong with her?” and “is she going to get better?” The longer my grandmother was hospitalized and
as the confusion persisted, the less clear those answers became. The decision was made to take her home after
about 2 weeks as we all hoped that she would improve after being back home in
her normal environment. This unfortunately
was not the case, she actually declined – screaming all night in pain, became
incontinent of stool and urine, and completely exhausted my poor grandfather
that was trying to take care of her.
There was no medical background in the family and this situation with my
grandmother was not being handled well.
Some blamed my grandmother – they felt that she was “faking”. Others blamed her pain medications (to the
point that they essentially took all of them from her). Everyone started to fight, cry, and many
stopped visiting or communicating. My
grandfather on multiple nights took my grandmother to our local hospital
because he did not know what to do with her.
The last night that he took her she was septic and transferred back to
the original surgeon who did her surgery.
She was found to an abscess at the level of her new spinal hardware so
AGAIN had to go back to surgery. On one
hand, everyone was relieved that maybe the infection was the problem all along
and she would now to cured!! On the other hand, here she was going through
ANOTHER surgery. Following the surgery
my grandmother’s memory did improve some, but she is certainly nowhere close to
the person she was before this all started.
The more I talked with my mother about this case; there were subtle
things that had been missed – like the fact that my grandmother had been
forgetting places and names long before her initial surgery. She likely did have some mild cognitive
impairment that certainly did not help her in the recovery phase – especially
with delirium (and superimposed infection).
My grandmother knows our family members now and is functioning quite
well at home, but constantly has to be monitored and requires quite a bit of
assistance. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;"><br /></span></div>
<br />
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;">This story is just one example of the impact that
cognitive impairment can have on someone and their family. It is important to accept the process of
aging and understand cognitive decline. My
family has learned a lot this year thanks to my grandmother, and finally has
taken the initiative to start learning about cognitive impairment and dementia
and how to prepare as things continue to change throughout both of my
grandparent’s lives. Educating family
members and patients about what to expect is clearly important in the case
above, and something that I have noticed to be emphasized often during my month
on geriatrics. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "Arial","sans-serif"; font-size: 10.0pt; line-height: 115%;"> -- Lindsey Prochaska</span></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-10386796014860486092014-04-01T15:14:00.003-05:002014-04-01T15:14:38.593-05:00Tweaking the discharge process<span style="font-family: Tahoma, sans-serif; font-size: 10pt;">During
my inpatient months I had not thought much about where the patients end up
after their stay. I know many are going to SNFs and rehabs, but I mostly
just imagined a hospital-like setting with a focus on rehab and PT instead of
on medical issues. However, during my first week of geriatrics I realized
how vastly wrong my ideas had been. The care of patients in
SNFs seems to be a cross between a hospitalist and a PCP. You get to see
the patients several times, in their normal clothes I might add, over the
course of several weeks and are able to build a relationship with them and see
(most) improve and able to return home. You also realize all the things
that fall through the cracks on discharge. The person has diarrhea? It's
good to know they don't have C.diff, but it might also be helpful stopping that
BID sennakot-s. Oh, yea lets remove that rectal tube at some point as
well. They were taking Benalopril prior to admit, lets change them to
lisinopril b/c it's formulary on discharge. They are confused, but we
don't know what the baseline is, so we cannot justify hospitalization, so lets
get them someplace where someone can keep watching
them instead of dc'ing home, it's in the best interest of the patient
after all. All of these issues, and so many more, seem kind of oxy-moron
after discharge, but while you are getting paged every 5 minutes you lose focus
on the fine-tuning. Being responsible for the discharged patient made me
so much more aware of my discharging process, and I wish I had had that
experience from the beginning of my residency. <o:p></o:p></span><br />
<span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><br /></span>
<span style="font-family: Tahoma, sans-serif; font-size: 10pt;"> -- Kellie Wark</span>Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-29370035711792196112014-04-01T15:13:00.002-05:002014-04-01T15:13:31.594-05:00A change in perspective... <div class="MsoNormal">
<span style="font-size: 12pt;">I’ve
spent years in clinic putting patients on medications to lower cholesterol,
lower blood pressure, and improve blood sugars in hopes of extending their
life. I’ve pushed for dozens of colonoscopies, mammograms, and stress
tests in hopes to prevent disasters. </span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">Now, I’m
in Geriatrics Clinic taking people off medications and forgoing screening
because, well, it’ll probably be something else that kills them first.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">I’ve
spent the other part of my three years on the General Medicine inpatient teams
and ICUs trying to cheat death, halt death, or revive persons from near
death. </span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">Now I’m
in a Geriatrics Clinic and it feels like I’m actively planning for someone to
die.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">…But before
you think I’m morbid, let me explain<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">It all
started on my first day in Geriatrics Clinic when I was shown a chart of life
expectancies for elderly persons in America. The concept was simple
enough, using a person’s age, gender, and overall health to determine how long
they were likely to live. It took more than an instant to digest that
even a rather healthy woman in her 70s may only have less than 10 years
to live on average. It made me afraid to be in my 70s.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">With this
information, however, came a new sense of purpose and a new outlook on what I
was doing in this clinic. It was easy to
feel as if we weren’t “being aggressive” enough or that we were “being passive”
but what it really showed was how at all ages in Medicine, the focus always remains
on the patient. With every decision I’ve
made for every patient, every day in the past several years, the common focus
is doing the best to provide benefit with the lowest possible risk. While it initially seemed different than what
I had been doing on before, it was the exact same.<o:p></o:p></span></div>
<br />
<div class="MsoNormal">
<span style="font-size: 12pt;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: 12pt;">So as we
sat there, taking medications off her list which were unlikely to provide her
any further benefit, it felt liberating.
It was not as I felt earlier, a sign of defeat, but rather a celebration
of a life lived to its best. And as we
continued to talk, it was just like my usual clinic, continuing with every
visit to make sure that everything we are doing is focused on living a longer
and better life. <o:p></o:p></span></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-17453051967705239432014-04-01T15:12:00.002-05:002014-04-01T15:12:18.130-05:00What a Wonderful World<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;">“And I think to myself, what a
wonderful world”, sang the volunteer to the group of elderly individuals
encircling her. As she continued to sing to the group, I found myself,
pen resting on the table, listening and reflecting on the aging population
around her. I was on my second nursing home visit and the geriatrics rotation
had taught me two great lessons, the elderly population is complex and the
goals of treatment are often different.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;">Medicine’s complexity has always
interested me, the chance to investigate someone’s history, their multitude of
symptoms, analyze the collected laboratory data, and formulate a plan. The
geriatric population amplifies this process due to their atypical presentations
and innumerable psychosocial factors, all in the face of a population with
differing goals of care.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;">As a patient ages, the recommendations
for screening and treatment change. The evidence based medicine I have so
devotedly learned has been broken on this rotation. Each patient requires an
individualized plan based on their physical illness, psychosocial components,
and their personal goals. For example, is it truly beneficial to pursue
colorectal screening in a patient with a terminal illness? More than once, I
have had the opportunity to expand my medical thought process.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;">This rotation not only taught me to
enjoy another multifaceted aspect of medicine, but also provided me with a
renewed perspective on life; what are the most significant aspects of life and
how to define quality of life. Watching the volunteer move throughout the
crowd, I caught a glimpse of what my future might be like and reflected on what
is most important. What a wonderful world it is indeed.</span><span style="font-family: Tahoma, sans-serif; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;"><br /></span></div>
<div class="MsoNormal" style="text-indent: .25in;">
<span style="font-family: Verdana, sans-serif; font-size: 10pt;"> -- Leanard Riley</span></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-37013750665896789792014-04-01T15:10:00.000-05:002014-04-01T15:18:03.565-05:00Dementia, the bigger picture<div class="MsoNormal" style="background: white; mso-margin-top-alt: auto;">
<span style="color: #222222; font-family: Arial, sans-serif; font-size: 13px;">My experience in geriatrics has enlightened me on multiple levels. I came to realize the importance of looking at the bigger picture with older patients. It’s not just about focusing on medical problems but also aspects of daily living that may impact overall health. I discovered I can get to know someone very quickly simply by asking questions pertaining to ADLs and IADLs. These are items we as residents often overlook while training in the inpatient setting as we focus quite a bit on the acute problem. I also came to recognize the huge impact dementia has on a patient and their family. In my eye, it is a medical condition that doesn't get enough credit as it truly should. From a physician’s perspective, I realized I should pay more attention to this disease process as it has a multifaceted impact on a patient. In my opinion, unless a person has a family member or friend with dementia, the general public otherwise views this condition as ‘something old people get.’ I hope to educate people that it is much more than that. To look at this from a broader perspective, actor Seth Rogen recently presented a statement to members of congress to encourage funding for research into Alzheimer’s dementia. Despite his witty yet moving speech about his personal experience with a family member suffering from the disease, his presentation was made to a poor showing of congressmen. I have had the opportunity to see various types of dementia in person. I would hope that as time goes on that this condition receives more recognition to the general public's eye about its impact on overall health and ultimately lead to early recognition and appropriate management. Looking back now that I have come to the end of my experience with geriatrics, I do wish I could have had this experience during my intern year. I feel like it would have changed my practice with older patients. Nevertheless, I will definitely carry over what I have learned to the rest of my residency and into my career.</span></div>
<div class="MsoNormal" style="background: white; mso-margin-top-alt: auto;">
<span style="color: #222222; font-family: Arial, sans-serif; font-size: 13px;"><br /></span>
<span style="color: #222222; font-family: Arial, sans-serif; font-size: 13px;">- Arvind Satyanarayan</span></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-50149869477717747912014-02-14T11:23:00.000-06:002014-02-14T11:23:24.851-06:00Ode to the Caregivers, the unsung heros<div class="MsoNormal">
I was ashamed. After I had been whining about a page last
night disrupting my sleep, I met a most amazing woman. I made a house call to
see a bedbound lady this morning, Mrs. D. She has been essentially
non-responsive with end stage dementia for almost 4 years. And her <i>daughter-in-law, </i>Denise, has been caring
for her at home as they say, 24-7. Because Mrs. D is completely paralyzed, she
is at high risk of developing bed sores. But for 4 years in Denise’s care, she
has not had one bed sore. This could ONLY be achieved because every 2 hours day
and night Denise turns Mrs. D, changes her diaper and massages her skin. EVERY
2 hours for the last 4 years. That is 17, 480 times! (Ok, maybe her husband and
teenage kids have helped a few times a week, so maybe she has only done it
16,000 times.) That’s just <u>one</u> of the many acts of caregiving she
fulfills!<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The dedication to perform the physically exhausting and
repetitive tasks involved in this level of caregiving is clearly the outward
expression of an incredibly deep love and compassion. Denise’s husband is
thankful but she doesn’t get any thanks or any response really from the patient
or the patient’s other children. Don’t all of us deep down dream about being
loved that unconditionally? WOW!<o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The crazy thing is, there are hundreds and thousands of caregivers
like Denise. They are invisible to most of the world as they are confined to
their homes full time or working in institutions like nursing homes that most
people try to avoid at all costs. Just as you might not think about the
components of your car that keep it functioning, you likely don’t recognize the
importance of these caregivers—they may not be very visible but they really are
the cogs in the engine of love and life. <o:p></o:p></div>
Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-6936413874701863242014-01-25T09:30:00.000-06:002014-01-25T09:44:20.245-06:00Inspiration from Old Hippocrates<div style="text-align: center;">
<span style="font-family: inherit; font-size: large;">"Cure sometimes, treat often, care always."</span></div>
<div style="text-align: center;">
<span style="font-family: inherit; font-size: large;"><br /></span></div>
<span style="font-family: Georgia, Times New Roman, serif;">I've seen this quote attributed to the Father of Medicine and to Dr. Edward Trudeau (1800s), but I suppose it doesn't matter who said it. </span><br />
<span style="font-family: Georgia, Times New Roman, serif;"><br />What matters is that it is a poignant reminder that despite medical advances over years, decades, centuries . . . our calling as physicians remains the same.</span><br />
<span style="font-family: Georgia, Times New Roman, serif;"><br /></span>
<span style="font-family: Georgia, Times New Roman, serif;">There are still so few diseases that we cure. Perhaps we prescribe antibiotics that get our patients over infections, but much of our time is devoted to corralling chronic diseases, some more successfully than others.</span><br />
<span style="font-family: Georgia, Times New Roman, serif;"><br /></span>
<span style="font-family: Georgia, Times New Roman, serif;">When it comes to geriatrics, in particular, our patients face many conditions that march along becoming more debilitating over time - dementia, heart failure, Parkinson's disease, to name a few. </span><br />
<span style="font-family: Georgia, Times New Roman, serif;">Sometimes it makes one feel powerless when patients come to us seeking to "get better." However, that's when I remember the last two words of the phrase. Comfort always. When we put science aside and relate to our patients on a human level, we are always doing them a service. And perhaps we're doing ourselves as service, as well. </span>Anonymoushttp://www.blogger.com/profile/16703665116655557671noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-83836794576879957012014-01-22T13:15:00.001-06:002014-01-22T13:15:28.356-06:00Hello Sweetie
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span class="apple-style-span"><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";">"Hello sweetie." </span></span><span style="color: black; font-family: "Tahoma","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";"> <o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span class="apple-style-span"><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";">The common phrase that I'd heard since I was a child and the
typical greeting that she gave to anyone that came by to see her. No one
noticed that she couldn't remember anyone's names. It wasn't until we
were looking at pictures one day and she said, "Well, that's a
good-looking family. Who's that?" "That's our family, and
that's you right there in front," we told her.</span></span><span style="color: black; font-family: "Tahoma","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span class="apple-style-span"><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";">As time went by things became more apparent. The pots left
on the stove. The laundry started but not finished. The repeated
questions a few minutes apart. I remember shortly before she moved into
the long term care facility, I went to visit her with my brother. She
asked me how my grandparents were (her sister and brother-in-law who had passed
away about 8 years prior). I was only 15 or 16 at the time, and I
remember the sadness in her eyes as we reminded her that my grandparents had
passed. "Oh yeah, I remember," she said. A few minutes
later, she again asked about my grandparents. Knowing the distress it
caused before, we simply smiled, and said, "they're doing just fine."
"Oh, that's great sweetie," she said.
</span></span><span style="color: black; font-family: "Tahoma","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span class="apple-style-span"><span style="color: #222222; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Over the next several years, she had a slow and steady decline.
I was working at the hospital when she was admitted nearing her end
stages. She wasn't eating or drinking well, and she was having recurrent
episodes of dehydration and infections. She didn't even know her sisters
at the time. I remember walking into her room as a lab assistant to see
her smiling face and hearing, "hello, sweetie", and even though I
knew she didn't know me, for a short period of time, she was still the same
aunt I had known since childhood. Thankfully for us, dementia never took
that away from her. </span></span><span style="color: black; font-family: "Tahoma","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<br />
- Adam Merando, MDAnonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-39118002756373437352014-01-22T12:50:00.001-06:002014-01-22T12:50:16.064-06:00Why in the world does my patient need a Geriatrician?
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">Prior to my rotation on Geriatrics I always asked myself,
“why would I send my patient to a Geriatrician when almost all of my patient’s
in my Internal Medicine Clinic meet the age criteria as a geriatrics patient?”
This answer was quickly answered within one week on this rotation. I soon
realized how easily patients can hide their dementia with jokes, laughter,
wittiness or even compliments. I have performed mini-mental status exams in the
past, but most of the time it was on patient’s that clearly had dementia. When
I performed these tests on patients that appeared to have “normal cognition” I
was amazed how subtle dementia can be. It was then that I realized that some of
these patients are not getting the time and attention they deserve.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">One thing that really stuck with me after this rotation is
the realization that a full Geriatrics H&P will tell you more about that
that patient than three, or even four, Internal Medicine clinic visits will. I
had one patient in my regularly scheduled Internal Medicine Clinic that I had
seen about three times in the past. His vitals and labs have always looked good
compared to any of my other patients. On the surface there were no signs of
dementia or even mild cognitive impairment.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">However, I decided to ask about ADL’s and IADL’s and I
performed a mini-mental status exam on this patient. At that point I realized
that this patient had subtle, mild dementia and was requiring a lot more help
at home than I had previously expected. This made me reevaluate this patient’s
medication list. I asked myself, “do I really need his blood pressure at 120/80
while on HCTZ? What if he becomes orthostatic and he falls and breaks a hip?
Does he really need his A1c at 5.7 while on Glipizide and Metformin and risk
him having a hypoglycemic event? What is wrong with a goal of 7 or even a
little bit higher for his age?” <o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">At that point I decided to really take a look at his
medication list and remove those meds that can actually do him more harm in the
short run than good in the long run. I was well aware at this point what the
life expectancy of a patient is who is 85 years old and I was also aware of the
mortality rate of patient with a broken hip after 2 years. I did not want to
contribute to this patient’s possible future suffering due to trying to overly
correct lab values and vitals. Sometimes less is more.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">I have always been trained to have a certain blood pressure
and certain A1c and as long as it falls within those ranges then I’m doing my
patient a great service. But this is not the case in the elderly population,
especially those with dementia which will undoubtedly progress, as the
statistics show. So thanks to this rotation I really feel that this new insight
and way of thinking will help me as a Hospitalist when I’m caring for my
patient and when I’m getting ready to discharge them home or to a facility.<o:p></o:p></span></div>
- Michael Gutierrez, MDAnonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-7706963468142399872014-01-10T10:46:00.004-06:002014-01-10T10:46:35.192-06:00California Memories<div>
<span style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">A small moment can evoke the most vibrant memory</span><div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
I just left the most amazing conference and I am inspired. Inspired to teach, inspired to learn, inspired to create, and even inspired to live. You might ask how attending a conference with a bunch of academic geriatricians could even come close to evoking this many positive emotions... but it was only the conference. </div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
This meeting was on the beach in Coronado. It's true, I love the beach. I even love the fact that I have to wear tons of clothing and sunblock to avoid a burn. It's the waves and the serenity. But more than that, this particular beach made me think of my grandparents. </div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
Pa is still at home in Kansas enjoying his endless and putrid cigars, but he really isn't able to travel easily and certainly not by himself. He and Grandma loved to travel, and travel they did. That is, until her stroke at age 59 left her paralyzed and functionally dependent. </div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
I imagine that they traveled well prior to that time -- Grandma was the type that got dressed everyday and didn't leave the house without lipstick, carried a fancy purse, and faced the world. And Pa, well he just wanted her to be happy. They would have loved this place together with it never ending beauty, delicious food, and places to sit down and smoke.</div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
I passed a man smoking a pipe on the beach yesterday. Normally, I would have been irritated by the smoke and hurried past. Instead, I stopped directly in the smoke's path and inhaled deeply, loving every morsel of the Cherry Cavendish... or whatever it was. And then I called Pa.</div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
<br /></div>
<div style="font-family: Tahoma; orphans: 2; text-align: -webkit-auto; widows: 2;">
And found out that he and Grandma had been to Coronado... and loved it. </div>
</div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-3532156194940419592013-12-18T08:49:00.001-06:002013-12-18T08:49:25.095-06:00Perspective is everythingIn my white coat<br />
Talking to a family<br />
About their options<br />
for discharge, for goals, for support at home<br />
Defining my expectations<br />
Directing them down a path<br />
<br />
In my white coat<br />
Reviewing the med list<br />
<a class="irc_mutl" data-ved="0CAUQjRw" href="http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=ggNJkRf2C93WuM&tbnid=5c6j6HWTSLZ6AM:&ved=0CAUQjRw&url=http%3A%2F%2Fsamuel-cantigueiro.blogspot.com%2F2009_06_01_archive.html&ei=g7WxUvrbL4apyAGot4CIBQ&bvm=bv.58187178,d.aWc&psig=AFQjCNEh8Y26XivGO8uTRoUPIkBzMEBZIQ&ust=1387464397468091" saprocessedanchor="true" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img class="irc_mut" height="320" src="https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTPM9hCK6Z6y_t3P4hnsb9BNIeOyS3VM3n4LiIFeO5ZzOznWLZt" style="margin-top: 0px;" width="268" /></a>Stopping and starting drugs<br />
without a backward glance<br />
Meeting criteria and guidelines<br />
Documenting reasons for not<br />
<br />
In my white coat<br />
Making medical decisions<br />
Based on my understanding<br />
of the patient's understanding, the family's<br />
Coordinating other providers<br />
Discussing with social services<br />
<br />
How different when you shed the white coat<br />
<br />
In my grey sweatshirt<br />
Listening to a doctor<br />
About <em>my</em> loved ones options<br />
for discharge, for goals, for support at home<br />
Hearing <em>their</em> expecations<br />
Disbelieving of the path<br />
<br />
In my grey sweatshirt<br />
Hearing the med list<br />
And it's many, many changes<br />
trying to remember, to understand<br />
Ignoring criteria and guidelines<br />
Stopping the intolerable side effects<br />
<br />
In my grey sweatshirt<br />
Making medical decisions<br />
Based on my understanding<br />
of the provider, of the person, of <em>my</em> family<br />
Coordinating care because<br />
As family and provider both<br />
<em> I know more than I want to</em>. <br />
<div class="irc_mutc">
</div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com1tag:blogger.com,1999:blog-3322791422822965225.post-16499241528138293662013-12-13T13:34:00.000-06:002013-12-13T13:35:33.608-06:00PLACEMENT--Arghh!!I have a love-hate relationship with euphemisms. There are times that it is nice (and even funny) to allude to something without having to say that ugly word, right? It took me a while to accept the euphemisms related to dying. But now I understand that as long as we say "dying" once clearly, euphemisms can soften the blow of a harsh reality.<br />
<br />
However, the use of "placement," when referring to a nursing home move disturbs me. It feels cold and in a disingenuous way, makes it seem as though this is happening outside of any one's control and maybe is even a special honor--"Her Placement." Perhaps this language perpetuates the negative perception of nursing homes, too. Of course, moving to a nursing home is emotionally difficult for all involved BUT as hard as it is to face, active supportive language such as -- "It looks like it is time to move your family member to a nursing home" might in fact be more loving and responsible than "she will be placed."Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-42346687345929126642013-12-03T00:29:00.002-06:002013-12-03T00:29:43.168-06:00COACH: a window into the home<div class="MsoNormal" style="text-indent: .5in;">
This part of the curriculum, though
short really stood out in my mind as a truly great learning experience. I had
started the night before doing a review of my assigned patient’s medications
and their discharge summary from their recent hospitalization. The medication
list was easy enough to review and jot down, though like many geriatric
patients the medication list, including vitamin supplements was extensive. The
next portion was the review of the discharge summary. Much like when we saw
patients who had been recently admitted the nursing facility the review of the
discharge summary allowed us to see what we would want in a summary by
evaluating one from the other side. This certainly provided insight into to how
to improve my summaries so that they contain everything I would want.<o:p></o:p></div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
When we got to the apartment
complex it was easy to see that the patient, like many of the patients we see
regularly in the hospital, was not wealthy. Furthermore, he was housing several
other family members in his small apartment complex, which was an added social
stressor. My patient, however, despite having multiple health problems, despite
having visual impairment, despite having social stressors, had managed to find
a means to succeed. His medication list was near identical to the one provided
by the hospital, with the few differences being conscious decisions due to
identified side effects from his medications. He showed us how he organized his
medications and how he managed to remember his upcoming appointments. He was
fortunate enough to have a daughter who is a pharmacy technician who appears to
be highly medically literate. The patient himself was also quite sharp, which
was certainly beneficial. I can imagine without his daughter’s help he would
have a much harder time keeping track of his medications, and would likely not
be doing as well clinically. The same would likely be true if his cognition was
not as good as it was.<o:p></o:p></div>
<br />
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
Because he was doing so well
clinically we were able to pare down on some of his medications, for which he
was very grateful. Despite this he still had a toolbox full of pill bottles to
take on a daily basis. We were fortunate in seeing a highly motivated patient
who despite having a tough home situation was able to overcome his adversities.
However this one patient might be more of an exception than a rule. How many
patients keep coming back to the hospital because they can’t understand how to
manage 20+ medications? Or lack the social support structure needed to take
care of themselves. Ultimately, what
made this visit memorable was not just the visit itself, but the multiple
permutations of possible visits and the multiple challenges each possible
permutation might present. <o:p></o:p></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-62159255382637509032013-12-03T00:26:00.001-06:002013-12-03T00:26:18.219-06:00Joys of Geriatrics<div class="MsoNormal" style="text-indent: .5in;">
Geriatrics is a crucial rotation to
have in residency training. I’m glad
that residents can start taking it earlier than their third year now. The rotation and the attending physicians
involved really make you step back and look at the whole picture. So often I think that we, as residents, get
caught up in the minute details and linguistic web of describing someone’s
coronary anatomy, or quantifying how much air they can blow out in one second
(which is still important); that we lose sight of looking at the patient and
their progression through a lifetime.
Geriatricians are emphatic about looking at the whole patient, which I
think is a quality any physician should aspire to possess.<o:p></o:p></div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal">
Not
only is this broad view incorporated; but also paying attention to the subtlety
of a patient’s presentation. The tempo
of their speech. The way that they walk
before sitting down. Small changes in
behavior patterns such as beginning to eat less. Presentation of common diseases is often
subtle, and not textbook when dealing with elderly patients. A good example of this is depression; which
is why it is so important to screen in this population. Physicians have to be thorough in this population,
otherwise treatable disorders can get missed.<o:p></o:p></div>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Overall,
I enjoyed my time spent on the Geriatrics rotation. Not only for the reasons and lessons above,
but I believe that it made me a more thorough and caring resident. There was an element of continuity in the
nursing homes that I enjoyed.
Regrettably, I will not be able to see how those patient’s do over the
next coming months. For a rotation that
I thought I was not going to enjoy, I was certainly both impressed and humbled;
not only by the physicians that I worked with, but also by the patients that
allowed me to participate in their care.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
-- Mitch Tener</div>
<div class="MsoNormal">
<o:p></o:p></div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-9179273348458853212013-12-02T13:50:00.001-06:002013-12-02T13:50:27.565-06:00Shocking news!I had a medical school gerontology professor who would always open his talks in a dramatic, hushed tone saying, "I have a secret to tell you . . . none of us are going to get out of here [this life] alive." It is an undeniable fact. The billions of humans who came before us all have had the same fate. What's surprising then, I suppose, is that the assertion sounds so bold and almost startles us. <br />
<br />
The comment could compel you to:<br />
A) Live in the fear of the unknown after our earthly bodies fail us, or<br />
B) Make the life you have as lively as possible<br />
<br />
I choose B, and I like to think that as geriatricians we choose B for our patients, as well, by championing for quality of life instead of single-mindedly waging war on death. With that in mind, my professor's declaration invokes not alarm, but a smile whenever it comes to mind.Anonymoushttp://www.blogger.com/profile/16703665116655557671noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-33959655653638598792013-11-19T00:11:00.003-06:002013-11-19T00:11:52.943-06:00When fixing it ain't worth it<div style="font-family: Tahoma; font-size: 13.63636302947998px; margin-bottom: 0px; margin-top: 0px;">
<span style="font-size: 13.63636302947998px;">Like most physicians, I was initially drawn to the field of Medicine due to the profession’s blend of compassionate care and the intrigue of very nerdy science (human physiology/pathophysiology). It is one of the only professions that allows one to apply scientific knowledge to relieve an element of human suffering. The majority of our training teaches us to identify a disease processes and "fix it" with the best "tools" available. Unfortunately, the "tools" we use as physicians all come with a long list of side effects and, at times, unwanted outcomes. During my Geriatrics rotation I experienced a different paradigm of practicing Medicine, which was refreshing. The ultimate goal remained the same; to alleviate a patient's suffering with the tools at hand. The difference in the approach was simple, "is it worth fixin'." Ultimately, a patients quality of life should always be the focus of our treatments. At times the possibility of fairly common side effects can outweigh the benefits, especially in the elderly.</span></div>
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While in clinic or visiting a NH, I found myself drawn to suggest an more aggressive therapy when presented with most clinical problems. I was able to recognized this near reflexive response I have developed during my training. It was nice to take a step back, evaluate the long term effects of the said therapies in the Geriatric population and ask the patient...... is this treatment worth it? Many times the standard treatment recommendation just simply wasn't.</div>
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-- Benji Mulloy</div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-36919590653310613512013-11-17T20:54:00.000-06:002013-11-17T20:54:03.300-06:00The resident made a save on house calls this week<div class="separator" style="clear: both; text-align: center;">
The patient was improving beautifully after back surgery. However, the object of our intervention ended up being a geriatric dog who appeared dazed and frozen in front of our car. The resident hopped out and picked up the gentle little fella. While it took the grateful owner a while to drive to our location, the refreshing pause in the crunchy leaves and warm autumn sunshine on a busy day offered an unexpected reward for making house calls. <a href="http://4.bp.blogspot.com/-A-dWfDWk464/UolMtC_LWJI/AAAAAAAAAEA/W-d51uevwaA/s1600/13+-+1" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://4.bp.blogspot.com/-A-dWfDWk464/UolMtC_LWJI/AAAAAAAAAEA/W-d51uevwaA/s320/13+-+1" width="240" /></a></div>
<br />Anonymoushttp://www.blogger.com/profile/02912687446115214105noreply@blogger.com0tag:blogger.com,1999:blog-3322791422822965225.post-61855528881587778342013-10-29T08:56:00.000-05:002013-10-29T08:56:03.618-05:00Observations of Aging<div class="MsoNormal">
My mother had a friend who developed Alzheimer's. This
friend of hers was unmarried and had lived independently and was loosely in
touch with her one daughter. Somewhat strangely my mother's friend had
purchased insurance through a door-to-door salesman that covered long term care
facilities. It was fortuitous that she had purchased this insurance because
within a few years she had developed Alzheimer's disease and needed 24 hour
care. My mother drove an hour each way to take her friend to breakfast once a
week. She continued this tradition long after her friend did not remember her
name and did not know who she was. My mother continued this because she sensed
that her friend was at peace during these visits and it provided a change in
her day to day routine. She continued these until her friend was unable to
leave her facility due to physical decline and then brought breakfast to her
although towards the end she did not eat much. I know all of this because
sometimes I went with her on these visits and my mother's friend became dear to
me too.</div>
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<o:p></o:p></div>
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My own family has been touched by dementia and its hand has
often been heavy. My Grandmother showed early signs of dementia but was sadly
killed in a car accident before her disease progressed. Her sisters also
developed the disease which eventually took their lives. More recently one of
my uncles has developed dementia but through testing he was found to have
Frontal-temporal dementia. In his case my Aunt is his sole care-taker and this
has been a difficult role to fill for her. She has an amazing number of
challenges especially because my family are all very handy and have woodworking
and mechanical skills and thus there are many (now) unsafe items in their house
which of course my Uncle is drawn to as his tools have been an extension of
himself for all his life. My aunt works endlessly to redirect him when he
becomes frustrated often not sleeping well because he is active and restless
during the night. He has required more and more assistance with his everyday
needs. They live in a remote area and
one time she related to me that at times when it has just been the two of them
for a prolonged periods of time she wonders if they are both crazy. She is a
very dear person and it is difficult to witness this progression. <o:p></o:p></div>
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I am lucky enough to have also have family who have lived
into their 90's and lead productive lives. My Grandfather has led by example
his entire life. He was in World War II and was a pilot. He had been shot down
and his plane had landed in Switzerland. He returned home and obtained an
engineering degree and spent his career in architecture but was also active on
the water board in his community which is something he remained active in until
his last years. He was also very devout and played an instrumental role in his
church. He remained very sharp his entire life but he did unfortunately suffer
a fall and struggled with a weak heart and failing kidneys but remained
dedicated to his family, his church and to God his entire life. My Grandmother
had been his caretaker during his last several years and had needed to take
over the responsibility of driving at some point. She made all his meals and
managed his house for him. We all know if it had not been for her my
Grandfather may not have lived as long or as well as he had. <o:p></o:p></div>
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In my own community I became friends with a remarkable
gentleman. The day not so long ago I sat down next to an older gentleman who
had brought his grandchildren to the park. One of his grandchildren knew my son
from kindergarten and they began playing together. This led to a remark which
led to a conversation and before long I knew this gentleman's life history. He
has worked in "beverages" his entire adult life and he retired from
Coca-cola about 10 years ago. I asked what he has been doing in his retirement
and he replied that for the first 5 years he and his wife cared for his ailing
mother-in-law and that she had passed away 5 years ago. At about this time his wife had begun showing
signs of dementia and was diagnosed with Alzheimer's. He cared for her at home
until one year before she passed away. He had some very difficult times caring
for her as her behavior became more unpredictable and she suffered falls
leading to fractures and hospitalizations. He finally could not care for her at
home and she was placed in a nursing facility where he visited her every day.
He said it became more difficult as time passed to make these daily visits as
she became more withdrawn. She did die about one year prior. He was tearful as
he said this but he straightened and returned to watching his grandchildren
play. He said that in the last year he has slowly began traveling which is
something he and his wife had always wanted to do. He has remained active in
his community and cooked up award winning chili once a year for a boy scouts
fundraiser. He drove down to visit once every couple of months and stayed
active in his children's and grandchildren's life. Amazingly he is very
involved in my son's kindergarten class (despite the fact he lives several
hours away) - and most of the kids know him. <o:p></o:p></div>
<br />
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I have been so fortunate to be able to learn from those
around me about growing old gracefully or about living with disease. I am so
lucky to have all these people in my life and their experiences have deeply
influenced who I am today and for this I am so grateful.<o:p></o:p></div>
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Submitted by Casey Kimber, DO</div>
Anonymoushttp://www.blogger.com/profile/15345282517148009532noreply@blogger.com1