Medicine From The Trenches

Experiences from medical school, residency and beyond.

Seeing Purple! International Alzheimer Disease Month and World Alzheimer Disease Day (September 21)

Alzheimer Disease (AD) is the leading cause of dementia in older adults at this point.  With no cure, no specific cause identified and little available to slow the progress of this disease of progressive cognitive degeneration/impairment, it is very likely that no matter what specialty in medicine one chooses, AD patients will be in your patient cohort. Since AD patients can present at any course in the development of their impairment, it is imperative that all physicians (and health care workers) be aware of AD presenting signs (memory impairment, behavioral symptoms and psychological symptoms)  and most importantly, not to marginalize these patients. Loss of memory, judgement and other cognitive functions do not mean that the AD patient is lost by any stretch of the imagination.

My Mum suffers from AD, residing now in a memory-care unit; casting myself and my sisters into the role of distant caregivers. While the course of her disease has slowed somewhat in the past couple of years, at first, it was disheartening for her children to watch an independent, vibrant, high-functioning woman who managed a 90-acre horse farm, become dependent on others for her care. When she became unable to walk to her mailbox and wander along the back roads of our farm, we knew that keeping her at home was no longer an option even with 24-hour caregivers.

Along the way, we have discovered that my Mum has much of her wittiness; can always tell my sisters and me apart over the telephone and has produced many sculptures (always was artistic) that line her room at her residence. Her spirited nature has resulted in a couple of “run-ins” with other residents but she is well-cared for albeit not in her home as she had wished.As a physician, I no longer look at what my Mum has “lost” in terms of cognition but what she gives to us.

What I have learned from Mum is priceless in terms of keeping our relationship. She still critiques my style of dress, surprising since I have been dressing myself independently since age 4 or 5 years. “Are you going to go out in that,” she will admonish and it’s precious to me now. She will hold my small white chihuahua for hours stroking and chatting softly, something she didn’t do very often before AD. She pushes my sisters to be more patient with their respective spouses. In short, while my Mum has lost her short-term memory and some of her profound cognitive abilities, she has gained a patience that she didn’t display very often.

Along the way in my role as caregiver to my Mum, I have learned to appreciate what other caregivers undergo. As a surgeon who treats a population of patients who have been severely injured (burns, trauma and chronic wounds), I have placed more focus on caregivers as well as their loved one. There is increased emphasis, on my part, in making sure that caregivers see the relationships that still remain rather than focus on what may be lost. In most cases, a richness of interaction can remain and develop if one is able to adjust and adapt to a new reality for interaction with their loved one; something that health care practitioners can appreciate in not “writing these patients off” as lost.

Cathie Borrie, a gifted author (“The Long Hello: Memory, My Mother and Me”- Simon and Schuster.ca) in a Question and Answer presentation with the British Columbia Alzheimer Society illustrates the richness of relationship here: British Columbia Alzheimer Society . Ms Borrie who is a nurse, attorney and holder of a Master of Public Health has written a delightful book of caring for her mother with AD and the  wonder of wisdom from her Mum who was deeply into the progression of AD. Even more profound is that as one reads this Q & A session, one comes to see how much caregivers can receive from their loved ones and no how much is lost.  I have given this book to many of my patients’ caregivers even while they waited  in the waiting room of our burn unit. Ms. Borrie’s book will be available in the USA on April 5, 2016. This is a great book for anyone anticipating practicing medicine as it gives much insight into the rich relationships that anyone with dementia is capable of maintaining.  The Long Hello: Memories, My Mother and Me

Additionally, Daniel Potts MD, has written extensively on his relationship with his father who suffered from AD. Dr. Potts is a neurologist, gifted poet/writer, speaker and educator/scientist who has been an award-winning advocate for caregivers of patients with AD. His blog Maria Shriver-Igniting Architects of Change contains many stories and much wisdom learned from watching his father, Lester Potts, produce countless amazing watercolor paintings while suffering profoundly from Alzheimer Disease. Dr. Potts has been a shining example of what all physicians, especially this one,  should aspire to in terms of seeing the dignity in the most vulnerable of patients.

As you go through this month and this day, seeing purple around your neighborhoods and communities, be sure to give a donation, lend a hand and most of all, if you are a practitioner, look at your patients with AD in terms of where they are and not what they have lost. We have seen the success of the “Ice Bucket Challenge” in terms of increased awareness and funding for Amyotrophic Lateral Sclerosis (ALS) but as health care professionals, we are far more likely to encounter patients with Alzheimer Disease than ALS. A 2011 article “Nature Review Neurology -Reitz C” estimated the global burden of Alzheimer Disease to upwards of  24 million and double every 20 years to 2040. This is a tremendous number of patients who will have a significant number of caregivers.  Let’s support caregivers, research and most importantly the patients who suffer from Alzheimer Disease with our passion to be good physicians and our dollars.

21 September, 2015 Posted by | medical school | 3 Comments

My Patients Do Not Die Alone…

Introduction
One of the duties of a physician is to attend to those, who are near death, who are dying and who will die in your care. From the time of the first patient that I pronounced as a newly minted MD to the present, I consider my presence at the end of my patients’ life one of my sacred duties as a modern practitioner of medicine.
My first experience with death as a physician
The second-year resident had paged me to let me know that a patient was coming out the TCV (Thoracic, Cardiac and Vascular Surgery Intensive Care Unit) into my care as the resident covering the Thoracic floor. She said that she would write transfer and floor orders but as this patient was dying, all I would have do is to pronounce and fill out the “Death Pack”. She said that she didn’t think he would last very long and would be no “trouble” for me.
As soon as the floor notified me that the patient had arrived, I ran down the stairs to see what I could do for this patient. He was a 38-year-old man who had a massive dissecting thoracic aortic aneurysm that was inoperable. He was not conscious but I could see that his breathing was shallow and slowing.
“Does he have any family that need to be notified?” I asked the nurses. They said that they were sure that he had no relatives. I looked at his chart and found no family contacts. I headed back up to my call room to fetch my surgery journals. Since my father’s death (before I started medical school), I will not allow anyone to die alone. I would be present in this moment with this patient.
I settled into a blue chair next to his bedside and moved close. I looked at his peaceful yet young face with curly blonde hair and a very neatly trimmed mustache. “I am not going to leave you,” I said. “It’s OK to leave because you must but I am here if you need anything,” I said to him as the nurse looked at me quizzically. I said a prayer of thanks for being able to be with this very young man in the final hours of his life. I didn’t know him, other than what was on his chart but I knew him as a human being.
I decided in the moments that I sat with this patient that sitting with my patients in death, being present with my patients in death, is something that I would do for those under my care. I would be thankful for the privilege of being present as a soul that might connect with another soul beginning a journey.
Death and being a physician
We can read many articles and texts on how to handle the death process from the standpoint of being a physician. In some manner, every physician finds a strategy to deal with the death of a patient that is under their care. Some attempt to look at death as an opponent that must be conquered while others look at death as a part of life.
As a physician who is a life-long Christian and a person of faith, death is neither an enemy nor part of life. Death is a transition into eternal life for my patient, my belief since childhood. The physical body is left behind but the soul soars and continues eternally. As a physician, my vocation challenges me to make sure that the physical body, in terms of health, is optimized but death of the physical body happens no matter what we, as physicians do.
In the Christian doctrine
“Jesus said to her, “Your brother will rise again.” Martha said to him, “I know that he will rise again in the resurrection on the last day.” Jesus said to her, “I am the resurrection and the life. Whoever believes in me, though he die, yet shall he live, and everyone who lives and believes in me shall never die. Do you believe this?” – John 11:23-26
Many of your patients (and their families) will be Christians and will have heard the above Biblical passage many times. Still, in most cases, the death of a loved one will be very difficult evoking anger, sadness and a host of other emotions. Additionally, other faiths have explanations of death and its place in the life experience.
No matter the faith (or non-faith) of my patient, I try to assure them that I will make my patient as comfortable as possible. If family are present, I encourage them to speak with their loved one even if there is no answer. I encourage family members to touch, embrace and hold their loved one. If no family, I can do this easily.
Many of my fellow surgeons
Many of my fellow surgeons are very uncomfortable with spiritual aspects of patient care and the spiritually of their patients. From my Introduction to the Practice of Medicine in medical school to my present practice, I was never uncomfortable with sharing the spirituality of my patients or their families. For me, this sharing has been an honor. My practice partners tend to dismiss spiritual matters in favor of surgical matters but for me, spirituality and surgery are intimately connected.
I have often shared my belief that patients who are spiritually connected and comfortable have better outcomes in all aspects of their care. As I have aged in my practice, I have become more, rather than less spiritual. As a medical student, I was encouraged to ask patients about spiritual beliefs and discuss them if necessary. One of my fellow surgeons said that he would rather have “brain surgery” than discuss “religion” with a patient. I simply asked, “Why not?”
“Why are you infinitely comfortable with your hands in a patient’s abdomen but you are uncomfortable with discussing spirituality?” As I have gained more life experiences, I tend to see that when I may not be able to treat illness with a scalpel, I can give care spiritually and that’s all right with me surgeon or not which is why I can be found sitting at the bedside of a patient who is dying.

4 September, 2015 Posted by | practice of medicine | | 4 Comments