Kelwel's the state of medicine Blog

ICU choices

kelwelrt — Sun, 15 Jan 2012 00:35:27 +0000

So, I just put the finishing touches on my Advance Directives presentation. This has been a work in progress for many years, and I think I finally have the right approach. Have you ever gone into a restaurant in a foreign country? And not been at all familiar with the cuisine? For many people, that is what the US medical system is like. We see cool stuff on TV, and everyone’s problem is resolved in 30 minutes. Meanwhile, back in real life, problems take weeks to solve. And, like trying to plug a leaking dike with your fingers, other issues start springing up when someone is chronically and /or critically ill. Advance Directives allow individuals to make choices about their healthcare. Now, imagine you were on your way to Italy, but got re-routed to Siberia. You make it to a restaurant, and they hand you a menu in Russian. It is a huge menu, with many choices. But you have no idea what any of it is. Or what would go with what. Without someone to help you, who speaks both languages, you may end up with Borscht with chocolate sauce on top and spaghetti with sugar and mushrooms for dessert. There are as many choices in healthcare, and if you want the best and most practical care, you’d better learn the language. Relying on your doctor gives you the care that he (or she) would want, plus or minus the legal slant with the understanding that he or she is trained to do everything to a patient to try and get him better. In other words, an MD is trained to save lives, not end them. And even if he wouldn’t want to go to the lengths that you might, he has a legal reasoning to do so. So, you can get talked onto doing a lot of things that may not be harmful, but likely will prolong death more so than prolonging your life. On the other side of this is the patient (or family) who wants everything done, over and over, until the healthcare team keels over from exhaustion from performing CPR over and over on someone. Once upon a time, people were allowed to die of natural causes. Technology has overtaken nature, and man has allowed himself to believe he can outsmart life and it’s subsequent natural course. Next up: The Menu.

Transplant Medicine

kelwelrt — Thu, 01 Sep 2011 04:17:14 +0000

I was reading about non-judgmental acceptance the other day. You know, how it’s never good to be judgmental. People and Things are what they are, and from a spiritual perspective, they have either chosen their path to clean up their karma, or may have chosen (by selfishness) to create more karma, to have to balance later. I am no expert on this, but what I do know is that after 30 years in the hospital, while I try not to judge, I do have an opinion. If I keep it to an expert medical opinion, is that judging? I have taken care of many transplant patients over the years. Heart, lung, heart and lung, pre-op and post-op. Outpatient and in. Young and old. There are some things (maybe most things) in medicine that are between God and the patient. We, the caregivers, merely do the best we can with what we know. A transplant allows a second chance at life. But many people forget, it is at the expense of another life. Which in and of itself raises a lot of questions. So, I can only stand back, not judge, but state my opinion. I get asked questions like, “If it were you, what would you do? Do you think it would be worth it?” Defining worth is a hefty task. I would love to hear from any transplant recipients.

3 in one day can take its toll on us healthcare workers

kelwelrt — Sat, 19 Feb 2011 19:51:43 +0000

The first one we took off the ventilator was my age. She had been at another facility on the liver transplant list. Slowly, all her other organs failed, and her family requested she come to us for care. A liver transplant at this point would have been futile; too many other systems were shut down. This is the hardest part to explain to the family. Ventilator for lungs, dialysis for the kidneys, blood pressure meds for the heart, and pain meds to keep quiet. All this and the patient looks perfectly comfy, with the monitor showing good numbers. We took her off the meds and the ventilator, and she was gone to Heaven within minutes. That, I think is what shocks the families most; how much we are able to support life, and, when we stop, how close to the edge the patient really was.

The second one was not much older than me. Woke up in the middle of the night with a headache, took a couple aspirin, and went back to bed. Woke up again at 3 AM, woke up her husband, who noticed she was having a stroke. By the time she got to the ER, it was too late for medical intervention, and CT scan showed a massive infarct at the brainstem. She would never recover any functions. The family agreed to let her go, and again, within minutes, she was gone.

The third one angers me. A teenager, tired of being bullied at school, hung himself. He left a note to describe why he chose to leave us. HIs brain and lungs had bled out, but his family agreed to donate his heart, liver, and kidneys. The organ procurement people are really very nice, but I don’t like it when I see them at work. As we all walked down to the operating room with him, it is most difficult to reconcile that this child will give life to 4 other people at least. It starts odd discussions in my head about the whole world of transplantation. Blog on that to follow.

The stuff of bad TV drama, part II

kelwelrt — Fri, 28 Jan 2011 01:08:58 +0000

Now for Mom number 2: An older mom, this is her second baby. Her first child was IVF. Maybe. She went through IVF and got pregnant, but not from her husband. Why did she get IVF treatment if she was not the problem? Who knows. The child, now 5, is in a custody battle because the husband, who raised him, wants to keep him (take him away from the mom) because this 2nd baby is from the same man who is the father of the 5 year old. This man, (father of both) lives in another State, while mom lives with her mother. You can’t make this stuff up. What will happen to the boy? The Mom? Stay tuned, I may be able to weave this all together into a new daytime drama titled, “Social Worker”! Maybe I should better pitch it to Lifetime or Hallmark channel and present it as a lesson to today’s careless “DTF” youth. We really, really need to pray for these families and especially for these kids, who will grow up with parents absent. Although it is often these very kids who turn to God as their rock. Let’s pray they do.

The stuff of bad TV drama, part I

kelwelrt — Fri, 28 Jan 2011 01:00:35 +0000

WARNING: This is not a script for a bad soap opera! This is REAL LIFE.
In rounds today, we have 2 patients that took the most time to discuss: The baby that belongs to a 15 year old Mom. Problem: Dad is 19. From the baby’s perspective, the grandparents are pressing charges against the Dad and are forbidding dad to see the baby. He is possibly going to do some jail time for the jailbait crime. Meanwhile, as he is the legal father, he has rights to see the baby. The judge issued a ‘peaceful contact’ order. Not sure what all that means, maybe just lay low and don’t cause any trouble here at the hospital or at home. Grandma has applied for legal guardianship of the baby. The Father’s parents won’t come around thanks to the mom’s parents. The Father and the girl want to try and work out a relationship and raise this baby together. Now, !reality check time! The baby will be insured through the Grandma when she gets guardianship, because right now only the MOM is insured. Will grandma allow the father any contact after she is fully responsible for this child? Stay tuned for the next episode of…. Pray For These People.

Let me just say it out loud : You are too F-A-T!

kelwelrt — Wed, 26 Jan 2011 22:11:48 +0000

Allow me to introduce you to: The Lift Team

The patient, Mr. B., must have weighed 300 pounds by my guess. He was too big to register on the bed scale. Anyway, it was time for the patient to turn. Most patients, unless we have them snowed or they are comatose, turn themselves. It’s how we stretch, avoid pressure sores, keep our lungs clear, and stay comfortable. ICU patients have a hard time, so the nurse will usually help. Sometimes it takes 2 people to turn, to ensure we don’t lose a tube, an IV, or something else that might be important. But more and more, we need additional people to help us turn- simply because the patients are so BIG nowadays. Now, I KNOW I am shrinking, and the new 20-something nurses and therapists these days look like stick insects to me, but…. SIX people to turn one patient? I am reminded of the patient that came into the ER , and we had to help the paramedics get him from the gurney to the ER bed. “Why don’t we just get a regular bed now”? I asked. That woudl avoid having to transfer him again if we admitted him. Plus, I wasn’t sure he was going to fit on our gurney. Rules say we have to have the side rails UP when patients are in bed. That was not going to be possible. We flopped him onto a regular bed, where upon he asked for help using the urinal. “How do you go at home?” asked the nurse. “My mom helps me”, he replied. 32 years old and still not potty trained because he was too FAT. So sad what people choose………..

She wants none of this! And I am on her side!

kelwelrt — Thu, 30 Dec 2010 04:07:45 +0000

The day I started at the new hospital, in July, I met Mrs. D. She has bronchiectasis and an incurable lung infection. She is on a ventilator, trached, and has very little lung capacity. She is awake and alert and with it, and has had enough of hospitals for the time being. She has asked her family repeatedly to make her a DNR so that, if, while peacefully sleeping, angels come to escort her Home, we will not call a code blue and start CPR, pump her full of chemicals to keep her heart going, and continue to try and ventilate someone who essentially has no lungs. Her family, however, is not ready. They are insistent that we do everything. Again, she is of sound mind. Where is the paperwork? The Advance Directive and the DPOA? Give it to her NOW!!!! Rumor had it that the Doctors were on the fence. They want to respect her wishes, but also want to appease the husband and the kids. Each person has a right to have their own healthcare wishes respected. Fast forward to now, this poor woman has had enough. She wants to go home. Her family has agreed to care for her at home on a home ventilator. But then, I get a call from the social worker, something about a policy on ventilators for the acute care facilty she is going to. What?? Perhaps the family decided it was too much. Perhaps the patient decided otherwise. I really hope this patient goes home. I believe God lives in all places, but I had a really hard time seeing him in any sub-acute facilites. There is a difference between being alive and living. I think every doctor on the planet should have to write an essay on that subject.

Community outreach with an edge

kelwelrt — Sun, 14 Mar 2010 21:07:18 +0000

Today I was asked to teach a one-hour class on smoking and children. We have a community outreach program at the hospital, so companies, churches, any groups call and request information and a speaker on any topic they are interested in. Anything to do with lung disease, asthma, etc., and I get the call. So I had to clarify the content: smoking and pregnancy? Smoking around kids? Keeping kids from starting smoking? I had spoken to this group before. They are recovering moms. Each is recovering from something different, I know not what. Slowly, from the questions they ask, I can learn what their struggle is . It is hard to keep them focused. I keep the handouts up front with me until the end, otherwise they will read them during the lecture and not pay one bit of attention. But it is 45 minutes into the talk, and the girl sitting up front has discovered the handouts and brochures and is passing them out already. I have to keep it simple, get out an important health message on what smoking really does to the body without offending anyone and without getting too medically technical. I try to keep it on about an 8th grade health class level. So today, before talking about what smoking does, I start with what oxygen does. And how the heart and lungs are intertwined. So you have to take good care of both. And how the blood needs to stay clean so the heart and lungs can do their job. Fast forward to the slide about fetal development. What mom eats/drinks/smokes passes through the placenta to the baby, and baby eats and drinks and smokes whatever mom does. I get lots of questions about the placenta. Where is it? What does it do again? These are all women who have borne children. All races and colors, ages from 19 to what looks like 40. I explain carefully that it is attached to the uterine wall, pulling nutrients from mom’s blood supply into the baby, and taking away the baby’s waste to be eliminated by mom. They ask me to explain it again. I take it down another level. I don’t think any of these women ever realized that waht they ingested was actually going to their baby. I explain fetal alcohool syndrome. I talk about cocaine moms that go into labor at 26 weeks every time. I talk about how hard it is for preemeis to make it when their lung’s blood vessels and air sacs are simply too far apart to support life. It’s hard to educate without guilt sometimes. It becomes the art of making a factual point without passing implied judgement. I want them to ask me as many times as it takes until they get it, so that maybe they will tell a friend- a friend that is putting her baby at risk by making poor choices. If I can cause one less baby to be borm prematurely, one less to be born with a raging headache, one less to be born addicted to harmful chemicals, then the time reviewing and reiterating and going over the pictures one more time was worth it.

Can I teach just one class at Medical School? Just one?

kelwelrt — Sun, 14 Mar 2010 21:03:17 +0000

I cracked up at a recent youtube post that is circulating: “Call Respiratory Therapy STAT!”. The doctor keeps asking the nurse if the respiratory therapist will go out with him. Then the nurse will ask him a question, such as, “Did you order some impossible thing on a patient? Then, she will not go out with you.” So I have a few of my own to add. Yesterday some doc ordered an oxywalk on a bed-bound patient. It says clearly in the H and P: BEDBOUND. Later is says she does ADL’s with assistance. I’m going to guess this mean they give her bedbaths. Anyway, this poor 88 year-old lady is in restraints because she is combative. Now, when I am 88 and bedbound, sleeping peacefully, and you come bother me and ask me if I’d like to go for a walk, I’ll probably take a swing at you, too. That aside, I still feel the need to re-iterate one point: PATIENTS WHO ARE BEDRIDDEN =CAN’T WALK! So, they will not be performing an oxywalk for you, me, the PT, the nurse, or anyone else. And if you don’t like that, and order it again the next day, the crash you just heard was your respect-o-meter hitting the floor.

Update on Mom, Medicare, and Extended care facilities

kelwelrt — Wed, 20 Jan 2010 03:57:52 +0000

Well, she made it through. Mom doesn’t remember much about the fall, and remembers nothing about her stint in ICU. They gave her 7 days in the step down unit to start Physical Therapy. Much of which she declined. Now she is in a care facility, where they are supposed to do PT 5 days a week. Only she got a bit of a slow start. Her 2nd night there, someone misread the sleeping pill orders and gave her 6 pills all at once. A day and a half later, she woke up. As her usual self. I am beginning to think a freight train could run over my mother, and she would just sort of reinflate and walk away like they do in the cartoons. So she is walking now, with a platform walker. They are talking about sending her home in about 2 weeks. In the middle of all this, though, she had to go back to the hospital for a blood transfusion. Which turned into 5 days of looking for the cause of bleeding. The doctor threatened her with putting a tube up her nose to get the prep solution in if she didn’t drink it all. If youve ever been scoped, you know I am talking about a gallon of gatorade with laxative in it. My mother apparently told him where he could go. The nurses had to spell it out for him: SHE IS R-E-F-U-S-I-N-G. He discharged her back to the care facility the next day.