11 October 2008

Does it matter? - The Ocker Doc

Some patients are a little hard to take. I had one like that. A big tall man with a wife and two small children and ... lung cancer. So why was he hard to take?

He had had a life threatening illness a long time before, having suffered an intracranial hemorrhage from a berry aneurysm of the cerebral artery. Yes, I know, stop with the big words and tell us what it means!

One of the blood vessels running into the brain has a weak spot. Weak spots in vessels under pressure form a bleb - like the bike tyres. Because the area is weak, it swells and then can burst or leak. When that bleeding happens the blood will track into the brain and cause a stroke, or it will flow into the space around the brain. This 'space' is a layer filled with fluid called cerebrospinal fluid (I know big words again, it's not my fault! Really, that's what it's called! We will call it CSF!) that provides a cushion for the brain. So the blood can flow into the CSF area and coat the brain.

When this happens, the brain gets really irritated! The patient gets sudden severe headache and can pass out, become brain damaged, a 'vegetable' (horrible name but more horrible condition) or even die.

So that's what happened to him, but he recovered with some changes in the way his brain worked. Where you and I might think a thought and keep it to ourselves, he did not. He was 'dis-inhibited'. It's a little hard to take because it's so confronting? Questions like "are you married?", "got any kids?", "where did you spend your holidays?", "who gave you the tie?", "where did you go to school?". No questions were taboo. No questions were malicious. No answer was unacceptable!

But after the initial gasp, I just packed away the discomfort and settled in to enjoy the ride!

He had a real bad disease and he came back pretty often for more treatment, so I was subject to a lot of questions. To make matters worse he had developed brain secondaries and was on a steroid tablet. Happy pills! So you can imagine the combination of the dis-inhibited being uninhibited! I took my medical students to see him - they get that 'kangaroo in the headlights' look when they are out of their comfort zone, and I thought he would rattle them (that allows me to then make some points to further their education). I thought they needed to meet some one like him.

During the teaching session I got a call and wandered off for two minutes before returning. On return I heard him address the blond petite medical student as "Barbie Girl". They were all laughing. Before leaving he wanted to know if he was going to see me next week and I told him I would be at a course. Before long he had all the details! Seattle, needles, prostates and finally the big question - "what are you going to get me?"

I hesitated momentarily and as that happened, I saw what lay ahead of him and how we had become more than usually involved. "I'll bring you something back" I said, wondering just what would be the right thing.

In Seattle, I visited the Space Needle and traveled to the top. Glorious! You have to do it one day! Of course like all good tourist destinations, you exit through the gift shop and there it was! A baseball cap from the Space Needle. This was it - he was going to lose his hair soon!

I arrived back at work on Monday and there outside the department he was. Not waiting, just good timing. He was heading in for his treatment. I called out "Hey, come here, I promised you something!" He stopped and looked startled as I thrust the cap into his hand. "See, the Space Needle! I told you I'd get you something!" More quiet than usual he said thanks. I ushered him towards the machine for treatment.

That was the last I saw of him.

Until last week .... the nurse collared me in passing to say, his wife called in to say that he died and to say thanks for looking after him .... oh and by the way, guess what he is wearing in his coffin?

2 April 2008


When a panel of doctors was asked to vote on adding a new wing to their hospital, the Allergists voted to scratch it and the Dermatologists advised not to make any rash moves.
The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the administration had a lot of nerve, and the Obstetricians felt they were all labouring under a misconception.
The Ophthalmologists considered the idea short sighted; the Pathologists yelled, 'Over my dead body', while the Paediatricians said, 'Oh, Grow up!'
The Psychiatrists thought the whole idea was madness, the Radiologists could see right through it, and the Surgeons decided to wash their hands of the whole thing.
The Internists thought it was a bitter pill to swallow, and the Plastic Surgeons said, 'This puts a whole new face on the matter.'
The Podiatrists thought it was a step forward, but the Urologists felt the scheme wouldn't hold water.
The Anaesthesiologists thought the whole idea was a gas and the Cardiologists didn't have the heart to say no.
In the end, the Proctologists left the decision up to some a_s_s hole in administration.

30 March 2008

The Price of Competence - The Ocker Doc

"The price one pays for pursuing any profession or calling is an intimate knowledge of its ugly side."
James Baldwin, US author (1924 - 1987)

Her name was something like Thea Tribes. She died last week.

Thea came to me over two years ago with a cervix cancer. Big thing - the cancer that is. She was a pretty petite girl with a young family. It was not surprising that the cancer was big when you consider the the preceding 12 months. Thea had seen her family doctor with vaginal bleeding. She was sent to see a obgyn. He said it was 'dysfunctional uterine bleeding' - a common enough hormone-related problem of the womb lining which results in episodic, non-period bleeding - and she needed a D&C (a scrap out of the womb lining). She was booked for theatre and got a start some 7 months later. But the obgyn got sick ... so no D&C. Thea saw the obgyn again and was re-booked. And she saw the obgyn a third time.

Finally 12 months after the first visit, Thea made it to the OR with the obgyn. As is normal, the patient is put to sleep and the obgyn begins with a pelvic examination. Now according to Thea, and she was believable ...... THIS WAS THE FIRST TIME A PELVIC EXAMINATION WAS UNDERTAKEN BY ANY OF HER DOCTORS.

Of course with that one simple examination, the penny dropped and the diagnosis was made. After a year left untouched, now it wasn't small. Other tests including MRI and PET scans showed the big cervix cancer as well as lymph nodes halfway up the tummy. Probably incurable. Almost certainly incurable.

Then it was my turn to try to turn this mess into something positive. But not surprisingly, I wasn't up to the task. She managed about 2 years of pretty reasonable quality of life while her little girl grew up, but the last 6 months have not been any walk in the park with increasingly difficult problems. Life had become no fun. She needed more medications - steroids for swelling, anticlotting agents for clots, platelet infusions for lack of platelets. And then the day before yesterday, it became too much.

She died with her family.

At our first consultation she asked me why these other doctors hadn't examined her and whether they were incompetent. I know the examination wasn't done, but I don't know if they are incompetent. I told her that she needed to concentrate on her treatment and her family then, and that she had my support if she wanted to do something later.

Competence is a strange concept. The media thinks that it means being perfect and never making a mistake. Obviously no doctor will be competent if that is the definition - certainly I wouldn't be competent.

The competent doctor tries to be better when they are shown to be deficient, and they try not to make a mistake again. Certainly if you have made such a grave mistake as not doing a standard examination in this case, what does the competent doctor do? Apologize? Say sorry? (the patient may have died anyway but her cure rate was reduced) Alter their practice?