Resident Post: Brad Scheu

"He would never have wanted this." Through the tears, my patient's family were clear their father would never want a breathing machine to sustain his life, if even temporarily.

The endotracheal tube was secured 25 cm at the teeth. It had been that way for about 2 hours, but I'm certain it seemed like an eternity to the two daughters of Mr. S. when they walked into the ICU room that morning at about 7:30am. Although Mr S. had previously been well sedated, he quickly started coughing upon his daughters entering the room. Their tears echoed his disdain for the situation.

As a former high school teacher and coach, Mr S had lived a full life. The ripple effects of this were evident in the love his daughters were showing for him. He had undoubtedly touched the lives of many through his teaching, in and out of the class year. As the years went on, however; so did his mind. Although his body was relatively young at 92, his mind was not. Alzheimer's, a difficult disease and form of dementia, had sent in some years ago. The disease progressed, as it normally does and activities of daily living became more difficult. About 2 weeks ago, he got out of bed quickly to use the restroom, had a mistep, heard a pop, and fell to the ground. After family had brought him to the emergency room, it was discovered that the pop was in fact a broken bone in his left hip.

Several days later, the patient was having difficulty with pain and confusion. After undergoing a surgical repair for a broken hip, his post operative course was proving to be more complicated than the procedure itself. Days after the operation, his groggy mental status and severe pain led to difficulties eating and swallowing. This common set up for aspiration leads to more problems. Unfortunately, he developed respiratory failure in the middle of the night, and was transferred to the ICU. In an emergent response, the patient was intubated so that a mechanical ventilator could assist his breathing.

Although family had been contacted in the middle of the night prior to their father going on the breathing machine, nothing prepared them for the reality of the situation when they walked into the room the next day. Hours later, the patient passed comfortably after family members elected a comfort care approach.

Unfortunately, this is not an uncommon situation in today's healthcare system. Healthcare providers performed quality care. The family was present, caring, and supportive of their loved one. The patient, perhaps the most vulnerable, presented for help in a time of need. So how did Mr. S. find himself in a situation he would never have wanted?

Mr. S. had never filled out an Advanced Directive.

Resident Post: Jessica Lee

Front-Temporal Dementia:  Losing your humanity before your life.

She used to be a librarian.  She wore business suits to work every day.  She never left home without her panty-hose or her make-up.

Hope for the Hopeless

She moved to be closer to family 18 months ago.  Mrs. U and Mr. U lived independently for 70 years together, but at the age of 94, Mr. U was falling and needed more help from family.  So they packed up and moved closer to their son.  Mr. U continued to have the same problems: heart failure, COPD, frequent falls.  Initially, things were pretty much the same.  They lived in assisted living and there were meals provided, medications given, social activities to attend.  Mr. U enjoyed Bridge and Mrs. U watched and chatted.  Mr. U still had frequent visits to the local hospital, and with each one, he was a bit more frail.  Mrs. U was less able to care for him.  They stopped attending social events & Mrs. U started to have more health problems of her own.   It started with a short hospitalization for an infection.  She had increased confusion during that hospitalization and there was initial concern she might not be safe to go back home.  She was given a diagnosis of Alzheimer’s and started on some medication.  She was told “you are doing great”.  She went back to the assisted living facility that she shared with Mr. U (when he was not in the hospital).  She no longer wanted to attend meals at the shared dining hall.  She previously walked the halls passing the menus, and now could hardly find the energy to get out of bed.  She had dizziness with standing.  She had twelve medications when she previously was on three.  She stopped coming to her son’s for dinner.

Mrs. U’s son was quite concerned and brought her to the geriatrician.  Her answers to questions were quite simple. 

“What do you feel like is going on with your memory?”

“I am becoming nothing.  Everyone keeps telling me that I am doing well, but I am becoming nothing.  Please help me.”

“Do you feel you might be depressed?”

“No.”

“Do you feel sad more days than not?”

“Yes.”

“Do you feel worthless?”

“Yes.  I can’t even get to Mr. U when he needs me.”

“Do you feel satisfied with your life?”

“No.  I am becoming nothing.”

Mrs. U scored nearly perfect on her memory test.   Her medications were simplified with discontinuing five of them.  She was started on anti-depressant and before she left, she smiled a hopeful smile.  Time will tell if this regimen will work, but the simple thought that something might help already seemed to have a positive impact.

Resident Post: Eyad Reda

Geriatrics was my first rotation as an intern. The feedback that I got from some of my friends whom are doing residency here in the states was that it is an easy rotation to start with, and that it will help me to smoothly blend into the “residency” lifestyle. Although this was true, none of them mentioned how important “Geriatric medicine” is, and should be, to our future practice as physicians.

 

By 2030, the percentage of people >65 years old will be around 20% of the general population here in the US, that means one in every fiver of our patients. With this, comes the need that every physician should know the common health problems that are unique in this age group. Things that we do not pay attention to in our general patient population, like the number of stories in the patient’s house, might pose a major health risk for an elderly patient living alone.

When I look back now at my first month, I can say that I am thankful that Geriatrics was my first rotation. With the help of highly passionate attendings and fellows, I learnt how that with the elderly patient, there should be different approaches to the medical encounter compared to younger patients. Asking simple questions about their daily lifestyle, habits, fun things they do, (things we do not usually focus a lot on), will give us tremendous details about the risks and the possible interventions that we could do to improve the quality of life of our elderly patients.

 

I will not say that I will miss searching for information about my patients in the “huge” paper charts in the nursing homes I went to, but I definitely will miss learning from physicians whom practicing medicine for them is not only about diagnosing and prescribing medications, but rather, taking a further step into analyzing the psycho-social dynamics of the diseases that an elderly patient have and trying to work on addressing these issues in the same  level of importance as their diseases’ pathophysiology and treatment.

Resident Post: Hieu Doan

Aging exempts no one. Unfortunately, some of the elderly developed more health problems and physical declines than others.  Elders with such significant impairments required various types of assistances included their basic activities of daily living.   These tasks were not always being accomplished safely at home especially when their sons or daughters had children and a full-time job.  Despite this concept, in a way, society continues to be biased about the placement of one’s parents into a nursing home as a disgraceful act.  Being a medical student then a resident in geriatrics rotation, I learned to acknowledge the burden of caring for the elderly rather continued with my previous superficial judgment.  Ability to care for one individual with multiple medical problems and functional declines beyond the financial burden, it included physical and emotional obstacles.  Dressing, eating, ambulation, transferring, hygiene, medication management and etc.  could be beyond one’s person ability.  Thus, the only best available option for some family in caring for their parents or other immediate family members was placement in long-term nursing home.  Such decision was not easy as one may expected.   I struggled with this idea as imagined placement of my immediate family members in nursing home.   I saw closed doors along the sides of the hallways and the empty lounges with occasional one to two occupants in a facility. In concurrent with complaints of not being heard, not being assisted promptly and the abuse in the long-term facility demonstrated in the media worsened the objectivity of this topic.

 I am hopeful for changes or resolution in some of these concerns.  The business of long-term nursing home should be asked to increase the ratio of nursing-staffs to long-term care residents in its facility.  This is the initial step to improve care and fulfill the rising demands of our growing elderly population.  

Resident Post: Colleen Brown

My patient took obvious pride in her appearance, displaying on her right hand a beautiful diamond ring. She wore hosiery and her hair was carefully curled, her blue suit pressed. 

Her daughter sat next to her, exhausted from the preparation for the doctor's appointment. "She wouldn't leave the house until we found her brown and white purse." They searched high and low, eventually finding it in the kitchen cupboard.

Tears brimmed in the patient's eyes as she struggled to answer the date, the season. She did not recall the apple, table, or penny.  She raised four children while working as a registered nurse, delegating responsibilities in a busy surgical unit. Her daughter had taken her on tours of assisted living facilities. She had also taken her mother's car keys. As the appointment was ending, we discussed the most likely diagnosis and agreed on a trial of medication. 

 

The patient resolutely completed her sentence, long after the test was over, and handed it to me.

It read "I have faith."

Resident Post: Maharshi Bhakta

I did Geriatrics last month as an Intern and I am elated for having this rotation earlier on in my Residency. Topics and discussions that we had in Geriatrics were unique and separate from rest of the rotations I did as an Intern. For example, when seeing a patient in the clinic we automatically assume everyone is going to live to be 100 years old. This is certainly not true however when considering screening test it rarely comes to mind to evaluate the life expectancy of the patient and whether the patient will be able to get the treatment if screened positive. Also, after completing Geriatrics, I find myself evaluating patients ADLs and IADLs not because I never learned them in medical school but I never grasped the importance and relevance of that affecting the patient's health and social situation.  During the clinics with Dr. Hayley and Nursing home visits with Dr. Kalender-Rich, I had opportunity to focus on issues pertaining to geriatrics such as driving ability, dementia and incontinence. I feel like I became more clinically astute in assessing and managing those issues.  

Resident Post: Cipporah Gordon

The reality of Aging

 The realization we are all going to be “old” someday, G-d willing, is usually a thought placed under layers of other more eminent and relevant ideas. However, when walking through a nursing home this thought quickly surfaces faster than the speed of light. One notices each resident’s room is adorn with photos of the very lives they created generation upon generation. There most always is a black and white photo of a man in military uniform that catches your attention, and can be used as a starting point for conversation.

 

The elderly individual varies in their ability to interact with you; some diagnosed with Alzheimer’s dementia and are unable to accurately answer questions, but some elderly individuals are in good health and can give you their whole life story, whether you ask for it or not. Strangely enough both of these individuals impact you the same. The deep wrinkles on their face are indicative of the many expressions felt in their lifetime from happiness, sorrow, fright, to excitement, and you truly begin to wonder what kind of life they had prior to coming here; how many kids? Homemaker or serviceman? Do they remember the depression and WW2? the Holocaust? They become a non-published version of a history book in their own right.

Further, the elderly person with Alzheimer’s dementia gives you a few extra thoughts to ponder. Thoughts such as, what a challenge for their family to see their loved one without the very memories that makes them who they are… and what if this would happen to me? Or someone dear to me? This is truly a hard disease not only for the patient but for those who love them.

 
It is the circle of life to age and to die, yet feeling like one is going to “get old” one day seems unreal and I am certain it did to the very people I saw. Maybe living our life like we are “aging”  each day would afford us the perspective of doing the “things” that really matter to us,  and with those that matter to us most. For certain, we are all on a time clock never knowing when the alarm will go off, only hoping it will not be today. So to age is a blessing- It was an invaluable experience to have met  these individuals over the course of my geriatric rotation and I can confidently say the realization I will be “old” someday does not have as many layers covering it as it did 4 weeks ago.