7:00 a.m. Lights on.
Coffee, black and a banana. Paperwork. 27 patient visits, 3 emergencies, 35 phone calls. Lots of computer time. Some laughs and a few tears. Paperwork. Last family meeting. Coffee, black. In between: Thursday.
Was not completely successful in explaining to my frantic patient with the multi-page lab printout, how the problem was not that her tests were bad, but that the computer had used the wrong “normal” range to decide what to flag bright scary-red. The lab company is going to issue a new report.
I told 87-year-old Lil that she looked great and young. She told me I was lying. “I know that I am an old hag and look like hell. But, don’t worry, I’m a tough-battle-ax broad.”
Reorganized the therapy of a patient who got a second opinion and started chemo without the doctor contacting me. The new treatment not only overlapped with prior failed therapy, it threatened major complications because of her general medical condition. I do not understand why doctors do not pick up the phone, send an email or at least type a note. I dream always of a universal EMR.
Gave my usual new patient instructions, which include the words, “This is not a time to go it alone. I am here to help. This is a time to be whinny, so I want you to call with any problem.” “No problem doc, you are the man, you call the shots.” I asked if they would mind telling my wife.
Saw four new patients regarding therapy for cancer. Despite aggressive chemotherapy plans, I was able to counsel three of them regarding end-of-life choice. All agreed to complete an advanced directive, one of them a POLST and two decided they never want to be on a ventilator or have CPR. I feel better knowing that whatever happens, we have a plan.
Paula requested a script for a wig. I was surprised because she had made a big thing about just wearing a scarf or no head covering at all. She believed that chemo baldness was just part of the battle. She would “declare her disease.” “What changed, why did you decide to get a wig?” “Well,” she said, “It turns out my friends were more attached to my hair than me.”
Put a new patient in a tough spot. I am advising therapy which is different than her primary oncologist’s recommendation and we were not able to completely agree, even when I called him. The patient must make a treatment choice when there is no good data. I will support whatever decision she makes.
Ron is recovering from cancer, which spread to his hip, for which he had radiation. I had given him a prescription for physical therapy; however, he has not gone to PT. “Why?” I asked. His wife had a better solution. For 32 years, she has been trying to get him to go shopping. Now, to regain strength, she takes him to the market and makes him use the shopping cart as a therapy walker.
A husband and wife were in to discuss her case. The medical records they provided are stunning; indexed, flow diagrammed, converted to Excel, color-coded and mounted in spiral folders. I told them these were the best patient documents I had ever seen. The husband responded this was because the two of them were “CDO.” I was not familiar with the term. “Oh,” they explained, “that is when you take OCD one step further and put the letters in the correct order.”
I got two separate messages from patients regarding the same complaint. Both felt well and were without pain, shortness of breath, dizziness or diarrhea. However, they complained that their temperature was “too low.” 97.3 and 96.6. I tried to explain that unless something truly terrible is happening a “low temp” has more to do with how it is measured than reality. One required a rectal temperature to be reassured he was OK.
Marlene, who is 94, was in the office with her friend Maude, also a nonagenarian. I needed to write a prescription for Marlene. She asked that I call a specific pharmacy, even though it is across town from where she lives. ”Why?” Well, it turns out that particular pharmacy has same-day-delivery, which involves a particular delivery “boy.” This young man apparently has the admiration of the “girls,” such as Marlene and Maude, in their senior-restricted apartment building. They rushed home to await the arrival of the “medicine.”
Told a 54-year-old gentleman he had “cancer.” What made this odd is that he had already undergone complex surgery for the “mass” and the doctor had taken out a large “tumor.” The surgeon does not like to use that most evil of words.
An advanced breast cancer patient of mine came in looking much the worse for wear. For once, the cause was not I, nor her cancer. Rather she was recovering from a “vodka drunk.” The hangover lasted four days. “Was it worth it,” I inquired? “Absolutely.”
“What is your goal?” I asked Brian, trying to move forward a difficult conversation about cancer, chemo and life. “I have no goal. I want nothing. I want to know nothing. I just want to live today, and maybe tomorrow. One day, one step. Nothing more.”
Finally, there was Rich. A once a Marine, always a Marine type, he is an ex-machinist who at 78 is strong and tough like drawn-steel, short military-silver hair, bright-blue eyes, and leather-tanned skin. His complaint involved his surgical wound. “Doc, I am a bath guy. I am not a shower guy. I am a bath guy. The surgeon says I can’t take a bath until I’m completely healed. This is killing me.” “What is wrong with a shower for a week or two,” I asked. “You don’t understand. In the bath, I have my soaps, my scents and my bubbles. How can you have bubbles in the shower?” Rich had a point. The cancer care was interfering with his daily foamed soak. We agreed to invent a shower attachment that sprays cologne and bubbles. I did not have the guts to ask about rubber ducks.
7:00pm. Lights out.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.