SUDDEN DEATH

Here today, gone tomorrow.  The older I get, the more often I get the call: “This is the ER at Any Hospital, can you hold for Dr. X?”  Dr. X then comes on the line and tells me my patient had a catastrophic event, that the paramedics and ER crew did everything possible but that the patient expired.

My patient had no reason to die.  He was relatively young and healthy. Life had been good to him and he had been good to his body.  He didn’t die in an auto accident or on a ski slope.  He died at home and apparently, from nothing.  I can’t describe the feelings of loss, frustration, curiosity, and wonderment that accompany such an unexpected call.

Yes, people die from nothing.  In my world, it’s not uncommon to lose perfectly healthy patients.  Usually they die in an accident; but, occasionally, they just die.  Sudden death is a mean foe.  Sudden death gives you no time to react and is almost always permanent.  Sudden death also denies family and friends a chance to prepare for the loss.

As a doctor, the tsunami of emotions accompanying “the call” begin with loss.  He was one of those patients who always made me smile.  Even when he was miserably sick with a cold, he always had something nice to say.  When his life’s stresses mounted, he always found the positive side.  Yes, his death is a tremendous loss to my practice and the community.

When patients get it right, cares for themselves, follow the rules and still die from nothing, it’s frustrating.  I believe in preventative medicine.  There are healthy habits and there are those habits that are unhealthy.  Eliminating unhealthy habits, eating right, stressing less, enjoying life, and exercising should be rewarded with long life.  When a patient who does it right just dies, it makes me want to drown myself in hot dogs and chocolate cake!  I think I’ll go to Portillo’s and throw my own wake.

Curiosity strikes next.  Why?  Everyone wants to know why?  The pathologist is the doc who answers that question.  The pathologist is the doc who knows everything.  Unfortunately, the pathologist knows everything; it’s just too late.  Autopsies help answer the question why.  Hopefully, by answering the “why,” families can mourn in peace and docs can accumulate wisdom that can help them become better docs.  Unfortunately, there are times when even the best pathologist cannot answer the “why” and everyone has to accept that, in death as in life, there are questions that will never be answered.

Did “wonderment” seem like an inappropriate emotion when I listed it above?  It’s not.  I am always awed by how precarious life really is and how much people take it for granted!  If today is your last day, are you going to enjoy it or are you going to waste it worrying about tomorrow?  Do you have an “attitude of gratitude” or are you so involved with life’s stresses that you forget to give thanks for what you have?

If today is your last day, did you contribute to your demise by neglecting your health?  Did you waste your time on earth or did you accomplish what you set out to do?  Are you proud of what you’ve accomplished?  Did you make others smile and bring happiness to those you met?

I believe in preventative medicine; yet sudden death seems to make a mockery of it.  My patient died much too young.  Would he have died sooner if he had not played by the rules?  I have to believe he would have.  I have to believe that taking care of your body adds years to your life.  I know that “an attitude of gratitude” adds quality to your life.

stress

One of my friends said, “Everyone hands me shit.  It’s my choice whether to smell it or step in it!”

I thought her wisdom should be shared with you, my reader.  It seems everyone I see these days is stressed.  Many feel like my friend, buried in excrement; yet most don’t realize that how you deal with stress is your choice.  She has decided not to step in other’s “shit” and I suggest you do the same.

I have written many articles on stress and stress management.  In “Blessing List,” I suggested looking at your half empty glass as if it were half full.

  • Your husband is out of work; you are blessed to have a husband.
  • You have too much on your plate; you have a table to put your plate on and food to put on that plate.
  • You have a full time job during the day and mom at night; you are lucky to have a job and blessed with children.
  • Your parents are getting old; your parents are alive.
  • Your house needs work; you have a roof over your head.
  • You have too many bills; I can spend less and live with less as long as I have a roof over my head, food on the table to feed the children and husband I love.
  • My children are too needy; they will learn the difference between wants and needs and learn to be appreciative of what they have.
  • Whiny kids are healthy enough to whine and they will grow up eventually.

In “Jugglers,” I described juggling your stressors as if they were brass and glass balls.  I pointed out the fact that brass balls (everyday stressors), when dropped could be recovered relatively undamaged but that glass balls (family, friends, health) often shatter upon hitting the floor causing irreparable damage.

In “Stress,” I wrote “Stress can actually make you sick.”  In an earlier article, “Worried Sick” on December 21st, 2010, I described a patient who literally made herself sick worrying about an illness she did not have.  Pure stress can lead to ulcers, phobias, palpitations, high blood pressure, stroke and more.  I also reminded my readers that stress is a fact of life.  My patients have taught that the best stress managers are often the most successful and happiest individuals.

In “Laughter Is Good Medicine,” I reviewed the positive effects of laughter.  When I heard “Everyone hands me shit.  It’s my choice whether to smell it or step in it,” I laughed out loud.  I needed a good laugh! It was a very stressful day and my friend provided a dose of the medicine I needed.

The world seems to be more stressful than ever. This New Year, strive to laugh a little more, smile a lot more, and refuse to step in other’s shit! HAPPY HOLIDAYS!

ELECTRONIC MEDICAL RECORD

In the beginning, there was paper and pen. The EMR (electronic medical record) did not exist.  Everything was written by hand at the time that you were in the office. While I often found it difficult to read my handwriting, what was important was clearly spelled out in block letters.  Documents, lab and x-ray results and assorted material resided in the chart on the paper they arrived on.  Charts became thick and cumbersome and to share them with other offices required either copying and/or mailing the records or faxing them.  There was a high cost incurred in managing those records (and the space needed to store them). This was the golden age of medicine.

When the EMR finally arrived, it promised to make life easier and lower expenses. It promised to streamline everything while improving medical care.  In essence, the EMR was a beautiful seductive whore that, while promising to make your wildest dreams come true, gave you HIV, Gonorrhea, Syphilis and a host of diseases not previously named and completely incurable.

I fell head over heels for her.  The first EMR we brought into the practice was designed by a programmer who quite literally went insane.  My love for my new EMR waned quickly as glitches pitted the programmer against the IT company.  Glitches often denied everyone access to the medical chart while money literally flowed out the window. You’ve heard the saying “in for a penny, in for a pound.” Well, this was more like “in for a penny, in for your life.”  Eventually, a second EMR came along promising to rescue us from the first.

The second EMR promised to be more friendly, more sophisticated and cost efficient and provide all kinds of nifty bells and whistles. I was no longer in love but not yet in the hate stage.  Once again, promises were not kept, and we went further into the rabbit hole.

True hate came with the third EMR.  It would not talk to the second EMR despite the promise that it would.  It did most of what it promised to do, poorly.

The EMR was supposed to store all of your information in one easily accessible area. All physicians’ offices, hospitals and other medical entities were supposed be able to easily share data. It was designed to share your valuable information with others who are important in your medical care but, unfortunately, it failed. Greed killed it as its creators recognized that they could sell patches that did communicate with other programs.

In the 4 years I’ve retired, the EMR has improved.  If you can remember all of your passwords for the many EMRs your docs use, you can actually access most of your records. As hospitals buy more practices and private practices come together in mega groups, several EMRs have become the clear leaders in the market place. While things have improved and the EMR is fulfilling its promises, other problems have developed.

Does the practitioner in the room with you look at you or the computer?  Is he/she listening to you while their fingers fly across the keyboard.  To get paid an appropriate amount, there are boxes to check; and, in some offices, it appears that checking those boxes is of paramount importance.  Several of my physician’s office do it right. The physician does very little computer input allowing his/her assistant to do the bulk of the clicking. More offices are installing kiosks, enlisting the patient in the click the box derby. In all the offices I visit, the computer sends out forms to be completed prior to an office visit. Ultimately, the patient will become better acquainted with his/her own history and medications if the patient agrees to input is/her information.

While I no longer hate them, I certainly don’t love them.  Simply put, they have become a fact of life. My only advice is that you do not trust them.  After every visit, review notes (on patient portal) for accuracy.  Mistakes in the computer notes are often copied from note to note, eventually becoming facts.

I’m computer literate and find the portals and kiosks difficult to deal with.  I wonder how the computer illiterates are going to do in the new world of medicine?

Today’s joke is funny, or is it?

 How many programmers does it take to change a light bulb?

None because it’s a hardware issue.

ANXIETY

It’s never too late to learn!  Yesterday, I saw Mr. X.  Mr. X has been seeing me for the past 20 years.  He is in his 70s and had been diagnosed and treated for a major anxiety disorder for as long as I have known him.  Despite the best my profession had to offer him, the best medicine, counseling and behavior modification techniques, Mr. X continued to be anxious and worry about everything.

“My knee hurts.  Do you think it could be cancer?”  Mr. X has seventy-some year-old knees and they are worn out.  “My shoulder hurts.  Do you think it’s a heart attack?”  Mr. X carried some heavy boxes from the garage to the attack over the weekend.  “I had a headache two days this week.  Am I going to have a stroke?”  Mr. X’s worries have gotten worse over the years.  In retrospect, the harder I try to alleviate his fears, the worse he gets!

It’s never too late to learn!  Yesterday, I had an epiphany.  Mr. X is a professional worrier.  He worries the way some people play golf, shoot pool or play bridge.  He is the Tiger Woods of worry.  Worry is woven into every facet of his life.  It is part of his social being.  In his younger years, he worried about work, paying the bills and his children.  His worries were less threatening.  As he aged and retired, his worries turn inward, focusing on his physical wellbeing.  His worries have become increasingly more threatening over time.  It’s one thing to worry that your painful knee is arthritis; it’s quite something else to worry that your knee pain is cancer.  

My mistake has been trying to take away his worries.  Doctors are trained to alleviate pain and suffering.  When a patient’s knee hurts, we are taught to diagnose the problem, treat it and provide for future care.  When a patient worries excessively, we do the same thing.  We try to remove the worry.  In the case of a professional worrier, when you say, “Don’t worry, it’s not arthritis.  It’s just your age.  It’s just  a minor sprain,” you take away a benign source of worry and open the door to a malignant worry.  “Could it be cancer?”

Live and learn!  I should have told Mr. X he has arthritis.  He would have been much less threatened by arthritis than by cancer.  I’m learning!  I talked to Mr. X about his worrying and his need to focus on less threatening worries.  I suggested that he buy a lottery ticket and worry about whether or not he would win.  I suggested that he should worry about what winning would do to his life.  I suggested other things he could worry about.

Not being a psychologist, I consulted with Dr. Lapporte, one of my colleagues.  Dr. Lapporte is one of the psychologists who has treated my patients for decades.  I wanted to make sure my new treatment approach was valid and safe.  He concurred, stating that “distraction” was a viable approach.  I think I will prescribe more “distraction” in the future.  It’s cheaper with far fewer side effects than medication.

For those of you who are professional worriers, find something harmless to worry about.  “Will it snow today,” is an excellent place to start.  As you become better at choosing less harmful things to worry about, work on developing healthy worries.  “Will I have time to exercise today?”  

Most of all, be happy and healthy!

Here’s today’s joke:

I actually had anxiety for so long I went to a psychiatrist. And I said to the guy, ‘I’m constantly anxious. What do I do?’

He told me I had obsessive-compulsive disorder.

I was shocked. I had to call him nine times to make sure he was certain.

WALK-INS

Most of my original patients were someone else’s patients who came to my office because they could not get into their own docs for weeks. People are funny. It wasn’t uncommon for me to have an hour or two wait.  My patients rarely complained. They knew I would see them on the day they needed to be seen. The complaints came from the new patients whose docs couldn’t see them for 2 weeks.

Patient “X”: I’ve been waiting 1 hour, how much longer is the doc going to keep me waiting.”  When I finally entered the exam room, I got a mouth full. “Mr “X”, I’m sorry I took so long but the patient before you was sick enough to require hospitalization.  By the way, one hour is a lot shorter a wait than a couple of weeks. Now, let’s see what we can do for you.  Most patients agreed with my logic and eventfully became my patients.

There were those patients who designated a Pediatrician or other primary physician as their MD of record, even though they had not seen him/her for years.  The pediatricians were not happy with this arrangement and often drove the patient into my arms.  The internists were less vocal but did not like sharing patients either.

By the time I retired, almost all of the docs in the community had open- hours during which patients could be seen without appointments.

When I started in medicine (in the early 80s), almost all docs wore ties.  Ties never made sense to me. Wearing a tight noose around your neck while making life altering decisions has always been nuts. I gave up on ties in the early 90s. Since then, studies on the wearing of ties have been shown to carry bacteria and spread disease.

My favorite silly statements are:

Patient’s wife – He said he would never talk to me again if I called the paramedics!

Doc- Did it dawn on you that if he died, y”all would never talk again.

Then there was the obese mother of 4 who had remnants of Oreos under her breast.

Women – My kids are such slobs. They leave crumbs everywhere- They never clean up their mess.

Alcoholic – But doc, I only had 3 drinks!

Doc – What constitutes a drink?

Alcoholic – about 6 ounces of vodka per drink

Doc- Your limit should be none and you need to get into AA

Patient -I don’t smoke. Well, I’ll occasionally have a few.

Doc – How often is occasionally?

Patient-5-6 days a week.

Doc – How many cigarettes are a “few”?

Patient – I meant a few packs a day.  OK, you got me. I smoke 1 ½ cartons a week but I am cutting down.

Finally, while delivering an eighteen-year-olds (crowning female) baby in the ER, both the patient and her parents were yelling at me that she WAS NOT pregnant.

IN THE BEGINNING

“Slowly I turned, step by step” is how an old Vaudeville routine starts.  I remember the Three Stooges performing the skit.  As I watched it on the computer today, I was struck by how violent the act was.  The Three Stooges were great at turning violence into humor.  So, what does an old Vaudeville routine have to do with my current writings?  The answer is complex.  On the one hand, when writing about the past, the perspective may change radically.  My memory of “Slowly I turn” was one of humor and belly laughs while now the predominant emotion surrounds violence and anger. The other answer to my question may be nothing at all.

I promised myself I would write a book and my articles of late have been part of the forward to that book. Today, I realized that I knew what I was doing, but I forgot to inform my readers, leaving many of you in the dark.  Medicine will have changed so radically that by the time I’ve finished writing this book, it may only be of interest to people that love reading about dinosaurs, my generation of doctors being the dinosaurs.

Anyway, I’m up to the opening of Lake Zurich Family Treatment Center (LZFTC).  LZFTC was such a radical idea that everyone was sure we would bankrupt quickly.  Good Shepherd Hospital’s administrator told the banks I would belly up.  Other Doc’s in the community were on the one hand sure I would fail and on the other hand afraid of my model.  Remember, this was the early 80s and medicine by appointment was the standard.  By the time I retired, most docs allotted at least part of their schedules for Walkins.

Anyway, two young bankers (Ron and Jack) and an open-minded executive at Hoffman Estates Medical Center managed to help me get a loan and construction started in LZ.  One of my professors at UVA had once told me that to be successful at anything all you needed to do was to be the first to open next to a new McDonalds.  And so, Lzftc was opening next to a new Burger King and a new McDonalds. My prof was right. LZ was a rapidly growing community (fertile).

Construction was not without problems.  It was a Union job and it was behind schedule.  One day, my landlord called stating that the union was going to walk off the job.  Someone had been working during the night and the union presumed that I had hired someone to speed things up.  I explained that Renee and I were broke and I had been working on the office at night.  When the union crew heard that the interloper was the doc and he was broke, they stopped complaining and finished working on the job.

One summer night, a family eating TCBY came in asking if I knew anything about the new doc.  I was covered in dust (I was putting in ceiling tiles) and explained that the new doc was young, well trained and would see their family without appointments seven days a week.  Then I Introduced myself.  They became patients from that night until I retired.

During my first weeks in LZ, I made a house call to a family who had gone to a Civil War reenactment. I got lost and had to stop at several houses to get directions.  At each house, I introduced myself and explained that I was lost, a doctor and trying to make a house call. The entire family had lost the war and gotten food poisoning with the exception of the youngest son who had an acute appendicitis.  The word spread that there was a new doc in town who not only made house calls but was a good diagnostician.  Can you believe that there were no GPS or cell phones in 1984?

LZFTC was open 7 days a week and I made rounds at three hospitals.  I furnished an office in my basement and made reverse house calls.  You found me in PJs, wet swimsuit, work clothes or whatever, whenever you showed up. 

Enough for today.  There are too many stories put on paper.  Suffice to say, LZFTC was destined to be a family, and it was growing.

OMG

OMG, I got a “C” in Organic Chemistry. My teacher’s nickname was “The Velvet Screw, and he lived up to it. A “C” was reason enough to commit Hari Kari.  Grades came easy to me (with one exception we will discuss later.)  My score was 85.7 and 86 was a “B”. The Velvet Screw held his ground explaining that in science, an 85.7 was clearly not an 86. While I argued that a “C” was the kiss of death, my professor reassured me that I would survive.

In fact, I stayed on the Honor Roll all 4 years in a row at the U (University of Virginia.  During my years in college, there were no learning disorders or ADD.  Even though I was never diagnosed with a learning disorder, I had one. While I did well with single subject short tests, I did horriblly with aptitude tests.  I scored in the 14th percentile in English on the MCATs.   The Dean I met with wanted to know how I passed my courses given that I didn’t speak English. I applied to the best southern schools (Uva, Duke, Emory) as I was sure I would get in.  Being cocky with less than stellar MCATs and a “C” was a formula for failure and so I found myself going home to work my AAA pool business and reapply again the next year.

My mother had other plans for me. She insisted that I stay in school and get a graduate degree.  There was no arguing with her, so I found myself teaching medical students in Anatomy.  My life as an anatomy student was untenable.  First, people moved away from me on the bus. I smelled like formaldehyde.   The Anatomy department reminded me of Hitler.  At the end of my first year, I caught a break.  The chairman of the department told me I wasn’t invited back.  I was as happy as if I had won the lottery.

My only problem was how I would approach the subject with my mother. I had heard about Mexican medical schools and soon was enrolled in La Universidad de Autonoma de Guadalajara, a 4 year medical in Guadalajara.  My mother took the news fine and a month later I found myself driving to Mexico.

Mexico taught me the one thing US schools would not have taught me, HUMILITY!  Oh, yes. I also learned how to survive with a military tank’s barrel aimed directly at me.  It was an eventful drive into Guadalajara. I was doing about 110 mph on a straight stretch through the desert when I noted what appeared to be a massive car coming towards me. Turns out it was a tank parked in the middle of the highway.  I stopped! The tank’s owner was the Mexican National Guard, and, for the cost of all of my underwear I got to continue on to the Big G. After that event, I placed all of my underwear in Nestle’s Quick chocolate powder AND COATED IT LIBERALLY. The boarder guard never took my underwear again.

Today’s joke (noy funny at the time):

Tank commander: “Hey, gringo.  I bet mine is bigger than yours.”

Gringo, as my bladder emptied: “Yeah, but I bet mine can water the roadside better than yours.


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