I had to go into the hospital and round this weekend. I also had to go in and round two weekends ago (we treat holiday weekends separate from the regular rotation so it just fell that way) and was feeling particularly sorry for myself. Fortunately it has been a light weekend so far (wait…there is a saying in clinical medicine… “they can always hurt you more” … with doctors being a very superstitious lot and me still having 12 hours to go, I retract that last statement). It has been an OK weekend. I did have several observations worth commenting on occur in the course of the weekend:
1) Personal connections are powerful – I have a long-term patient, Mr A., who has multiple problems and was admitted on Thursday to the ICU. He was transferred to our service on Saturday and I rounded on him. The residents told me that he was not doing well, being a bit confused. When I walked into his room and when I walk up to his bed and inquired about his health he looked up, smiled, and said “Doc, I’m doing well. How are YOU?” I responded that I was doing well also and he then asked “And the wife? Your two children? LSU gonna win that baseball game?” Confusion resolved. To be honest, I have tried working with this patient for a long time to get the diabetes, hypertension, and other chronic problems under control. In my mind I have not given Mr A his money’s worth. It may be that as a result of our personal connection, he has done better than he would have done without me.
2) Wound care trumps antibiotic choice, every time – Ms B was admitted with a badly infected laceration following a fall. She had been in the hospital for several days and there was a flurry of antibiotic changes prior to the weekend. My philosophy is typically when covering for the weekend to follow the plan of the weekday team. In this case, it was clear that the weekday team was hoping that changing antibiotics would make up for a lack of attention to the wound. The weekend resident worked to optimize healing of the wound and it looked much better after 24 hours. The lesson there is while we have a lot of antibiotics in our armamentarium, often we need to find an old fashion barber surgeon.
3) Dementia is a terminal illness – We are all going to die. I hope to die at the age of 85 immediately after finishing the Boston Marathon (not only making for a great story but leaving my children with a messy transportation problem to deal with). It is my experience that very few of us will be so lucky. Most of us will drift away with multiple chronic illnesses, hopefully receiving less and less marginally useful care as we get closer and closer to death. We now have the ability to replace kidney function, provide artificial nutrition, and provide respiratory support. We do not have brain replacement therapy. Let’s acknowledge the finality of dementia and forbid the replacement of feeding tubes rather than repeatedly trying to make families say “Yes, I want my loved one to die” when the patient keeps pulling it out. Clearly, death is not a choice.
4) Patient care at its best is fun – Medicine at its best is a collegial activity. Multiple smart people get together and problem solve on behalf of a patient who has a complaint or condition that is either bothersome to them or that we’ve decided will become bothersome soon. In an article from the New England Journal of Medicine about money and the changing culture of medicine, the authors identified that “money” put barriers in the way of collegial patient care. As they say “Once money enters the conversation, selfishness comes along with it.” The fun thing about rounding on the weekends is that my thoughts and those of my colleagues are often not on the bottom line. We talk informally about patients, share ideas, and all in all try to “do the right thing” for the patient. I will say that being rainy outside helps to keep us focused on the patient and not on the beach, too.