Author: Doc

Retired (2019) pulmonary/critical care physician with 35 years of experience and perspective
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The Dispensation Consult

Despite the handful of my brethren who have the self opinion of knowing all and doing all most physicians ask for help in certain situations. In medical lingo this is known as a “consult” (although I readily admit that consults are not exclusive to medicine). Here is my perspective on the use and abuse of this part of medical practice.

“I need your help.” A not infrequent statement that I have made, or have heard, through the years. It derives from the need for the additional expertise that either a medical subspecialist or surgeon can provide. This expertise comes in the form of a medical or surgical “consult”. So why do physicians request consults? Because they need answers to one, or all, of the following “essential questions”: 1) what’s the problem?, 2) how does the problem get diagnosed?, and 3) how does the problem get fixed? In response to the consult request the consultant obtains/reviews historical information, examines the patient, reviews relevant laboratory and radiographic information and may speak to other healthcare personnel involved in the case. With the pertinent information in hand the consultant then provides answers to the “essential questions” outlined above in a written report. This serves as a guide to the requesting physician regarding all three questions leaving implementation to said physician in all aspects or, not infrequently, the consultant assists in their implementation.

Sometimes a consult takes the form of patient management only. An example would be a consult for management of the care of a critically ill patient. Essential questions #1 and #2 may already have been answered (or not) but the primary focus is now most often on “fixing” (#3). Management can range from the fairly straightforward to quite complex (often with other consultants involved) to the impossible (kind of like putting back together grandma’s most prized vase which now lies on the tile floor smashed into a million pieces–see examples in my previous blog Conversations)

Occasionally there are “curbside consults” where a physician may informally ask (“curbside” ) a specialist for some guidance regarding one of the essential questions (e.g. “I have a patient who is short of breath.” The curbside answer is couched as general advice such as, “Well, if you think it is a lung problem, you may think about getting a pulmonary function test”). Responses to a curbside consult are generally broad and, to a measured degree, non-specific. Curbside consults are not written up and physicians (at least at one time) knew they were not to be abused.

Consultants don’t show up at the bedside by magic nor do they wander the halls until they hear of a situation where help is needed (Code Blues excepted). Consultants have to be asked. In the first 25 years or so of my practice the typical scenario was: Dr. X requests a consult from a medical subspecialist or surgeon. The request is written as an order in the chart and the chart is placed on the hospital secretary’s desk. If the request is not felt to be urgent nothing might be said to the secretary. If urgent, the physician would (sometimes) mention something to make the secretary aware. In either case once the secretary was aware of the consult the specific subspecialist’s office (or answering service if after hours) would be notified. Not infrequently (and irritatingly) the order would read , “Consult [subspecialty]” but no reason for the consult was provided. And it was not uncommon that awareness of the consult became known only after the subspecialist was no longer at the hospital. It takes no imagination to see that responses to consults could be delayed as the subspecialist attempts to determine the urgency of the consult. In the early days of practice I would come in for any consult– even after hours, regardless, as I assumed that was how it was done. My more seasoned partners, upon learning about my “due (and exhausting) diligence”, advised me to speak with a nurse caring for the patient, get some information, then decide about the immediacy of answering consults especially if after-hours. Dutifully armed with this advice I began to apply it and it worked well– most of the time. I recall one evening when I was notified of a “consult pulmonary” order with no reason given. Calling the hospital I was able to speak to a charge nurse who also didn’t know why there was a consult. Perusing the patient’s chart she provided some historical information and then said, “Oh, here, her oxygen level today was 45 [not good!].” I completed the consult that night on a paranoid schizophrenic woman who smoked “like a chimney” and had no intentions of quitting and did not want to wear her prescribed supplemental oxygen. [The consult had been requested by a frustrated resident who, in a fit of pique, wrote for the consult and then…went home]. I wrote up a brief consult report, made some suggestions, and, at the bottom of the consult sheet wrote (in my own fit of pique), “I AM NOT HER MOTHER!” Fortunately consult requests have since evolved and, especially with the advent of cell phones, physician to physician contact gradually became easier. In fact in my last 11 years of practice physician-to-physician contact for hospital consults was mandatory.

Office consults sometimes had their own challenges. More often than not the consultant knew the reason for the consult, but not always. Imagine, if you will, a patient sitting in the office, not knowing why they are there, and no reason for the consult was provided. Both patient and consultant are in the dark as to the issue. Questioning may begin with, “Why are your here (or what is bothering you)?”, the patient mentions something and so questions pertaining to that complaint come to the forefront. Toward the end of the appointment time, however, the patient’s Xray’s are reviewed only to note a lung mass (which, in this example, was the reason for the consult in the first place). Take home message–if your physician wants you to see a consultant, know why.

And, not to be forgotten, what about the “dispensation consult” with which I teased you in the title? While some of the consult examples above abuse time or illustrate some inconveniences, dispensation consults, in my opinion, abuse time and money, driving up the cost of healthcare. Most often a dispensation consult will be requested for a hospitalized patient. So, what are they? For some physicians they provide reassurance for simple straightforward problem diagnosis or treatments already instituted by them or, for others, provide “cover.” I encountered my first dispensation consult shortly after I started my pulmonary practice. The consult request dealt with a young woman with a small collection of fluid sitting between her lung and chest wall (a pleural effusion). As a dutiful consultant I reviewed the case including all pertinent data, interviewed and examined the patient, and wrote up the consult. Leaving the hospital I ran into the consulting physician and spoke to him about the consult, reassuring him that he had addressed the three essential questions, and opined that the patient’s issue would resolve. “Oh, I knew it would,” he said, “but I wanted some cover with any lawyer if it didn’t.” Welcome to the medical world of CYA. Remember, other than curbside consults, consultants don’t work for free. Unfortunately I’ve noted over the last 15 years of my practice, especially, a gradual (at least perceived) increase in the use/abuse of the dispensation consult with a resultant waste of consultants’ time and somebody’s money.

Lastly, while the cost added to the overall healthcare bill that could be attributed to dispensation consults specifically would be difficult to determine (easier to separate the wheat from the chaff), the utilization of medical consultations on inpatient hospitalizations has been looked at (1). Analyzing data collected in 2014 the authors illustrate costs and consultation patterns and raise the question as to whether hospitals are in a position to optimize consultation care. If so, I have yet to see it.

(1) OriginalInvestigation | HealthPolicy
Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults Kira L. Ryskina, MD, MS; Yihao Yuan, MS; Rachel M. Werner, MD, PhD. JAMA Network Open. 2019;2(4):e191634. doi:10.1001/jamanetworkopen.2019.1634

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, HOSPITALIZED SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, Covid 19 and HIV, Rationing in the Age of Covid…and other thoughts, Ode to a Ventilator During Covid, The Covid Vaccine Conundrum, The Almost FMG, The “Art” of the Explanation, can be found with “search” or, for some, just scroll down the page.

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The “Art” of the Explanation

I begin this perspective with an observation by Sir William Osler, a pre-eminent physician and teacher of his day, “The practice of medicine is an art, not a trade; a calling, not a business…Often the best part of your work will have nothing to do with potions and powders…” What, you may ask, is that “best part”? Why, the “art” of the explanation. Allow me to share my perspective.

After medical school comes the post-doctoral training known as Residency. This time can range from as little as one year (rarely done in this day and age) to 10 years or more depending on the chosen track. Newly minted residents universally show up on July 1 of every year begin their post-doc training. ‘Tis a heady experience for most despite the demands, stresses and hours and I was there in the thick of it. Differential diagnoses, therapeutic options, physiologic explanations came rolling (most of the time) off my tongue. I conversed well with my peers and my attendings in our second language, that of medicine. And then I met Miss Mable.

Miss Mable was a sweet, genteel elderly lady from the South, having relocated a few years beforehand to the North. She was hospitalized with pneumonia and, after a few days, was on the mend. I was the intern in charge of her care with oversight by a third year resident, Dr. C. One day while was checking back after formal rounds to see how she was doing she asked, “Oh, Dr. Lombard, I was so sick and now I am getting better! What happened to me?” Standing there and smiling I responded, “Why, Miss Mabel, you had a pneumonia and we gave you antibiotics. That is why you are getting better.” “Why, thank you,” was her reply. As I stood by her bedside the following day she once again asked, “Dr. Lombard, could you again tell me what happened to me?” After a momentary pause I responded, “Miss Mabel, you had an infection in your lungs and we gave you some medicine to make you better.” “Why, thank you, Dr. Lombard,” and she closed her eyes and went to sleep. The next day as I entered the ward (this was 1980) where she was I observed Dr. C. sitting next to Miss Mabel’s bed and holding her hand. They did not see me. I heard Miss Mabel say, “Oh, Dr. C. that Dr. Lombard is so nice but I’ve asked him twice about what happened to me and he told me but I just don’t understand. Could you tell me what happened to me?” “Of course,” came Dr. C’s reply, “you had some bad stuff hurting your lungs and we made you better with some good stuff that took away the bad.” Miss Mabel’s face lit up and she responded, “Oh, thank you, Dr. C., I jes’ now understand!!!” And she did. And I had my first real life lessons in empathy and the art of the explanation.

I tell you that story not to demean Miss Mabel in any way but to show how ignorant I was of the different levels of understanding that people may have about medical situations. The learning process for me, and I suspect also for others, begins by assessing, sometimes more quickly than one would like, the level of medical sophistication and education a patient or family may have. I did not realize that Miss Mabel’s medical sophistication centered no further than around “sick” and “better” and that she had had no formal schooling of which to speak. Her humanity was now peeking out from what I had been centered on, her disease. Time for some soul searching and to review, unbeknownst to Dr. C, the three things he taught me that day: 1) explanations at eye level (I stood; he sat) are important, 2) hand holding can be comforting, and 3) explanations can be very simply put.

There have been innumerable articles in the medical literature on how to approach a patient regarding provision of medical information and explanation of medical situations. I’ve read my fair share but all the reading needs to be tempered by experience. This was driven home to me in one of the last years of practice. The system for which I worked “strongly urged” all employed physicians to participate in an afternoon of mentoring to assist us in dealing with patients as it pertained to their degree of medical sophistication and level of education. Obviously, speaking to a Miss Mable should be entirely different from speaking to a CEO. Participatory “interviews” where one MD is the physician and another MD is the patient were part of the session. We would then switch roles. The “patient” could play as dumb or smart as they wished. The goal was to craft the provision of medical information or answers/explanations commensurate with the level of understanding of the “patient.” The interview was overseen by one of the mentoring physicians. Initially I was paired with an older physician, such as myself, and we had a grand time. We would parry each other’s comments and questions ranging from sophisticated to dumb and really got caught up in the moment. In time older physicians were paired with younger ones. The mentoring physician quietly took it all in and never offered a comment as, I presume, he didn’t have anything to refine (or was too dumbstruck that we older physicians had survived for as long as we did). As the overall session wrapped up the participants were asked for feedback. Not surprisingly most all of the physicians who had been in practice the longest felt the session was of little value while those just starting out were more appreciative especially when interacting with an older physician. As someone once said, “Wisdom is knowledge tempered by experience.”

While didactics can provide the knowledge, experience comes from different sources. These range from seeing the results of direct application (“administration of morphine relieves pain”) to observational (“so that is how it can be done”[which is a polite way of saying, “Monkey see, monkey do”]). Physicians begin to plumb these sources while in medical school. In residency they have enough experience to utilize the direct application but what of the observational? Physicians at any level may observe a particular way to close a wound, put in a central line, etc. As importantly those same physicians may observe a way a patient or family was approached in particular situations and gauge their response. In either case the physician’s observation can lead to a current or future modification in their approach leading to an improvement, no change, or rejection of what they have observed. So begins the “art.” Some in time can paint a situational masterpiece while others, unfortunately, never learn more than to hold the crayon.

Allow me to provide two examples commonly observed over my years of practice to make my point.. The first has to do with the “death rattle.” Often unresponsive patients at the end of life will have an accumulation of secretions/mucus at the back of their throats. Families can become quite distressed especially if nothing is said by healthcare personnel in way of explanation. However, a simple comment such as, “Secretions not uncommonly build up in the back of the throat; we can give some medicine to reduce the amount of secretions, and [most importantly] your loved one is not drowning.” Relief for most is almost instantaneous. The second example has to do with “agonal respirations”, those deep sighing breaths taken by a patient as they near death. These are often interpreted by families as their loved one is suffering or dying in pain (hence the term “agonal”). Their concern can be easily addressed by explaining, “As the body slows down, carbon dioxide, which is the “waste gas” of the body, begins to build up. This leads to some deep sighing breaths as the carbon dioxide levels increase. In turn these increased levels essentially have the effect of Mother Nature giving your loved one a BIG shot of morphine allowing them to slip painlessly and quietly into a coma and pass on.” Again, the relief can be quite obvious. So basic, so simple, but, unfortunately, I’ve heard some rather callous explanations given in these types of situations.

As a parting thought, far be it from me to imply that the “art” of an explanation should be relegated only to medicine. Regardless of where you are in life consider that any explanation you are providing, while not necessarily ending up as a masterpiece, should result in more than holding the crayon.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, Covid 19 and HIV, Rationing in the Age of Covid,,,and other thoughts, Ode to a Ventilator During Covid, The Covid Vaccine Conundrum, The Almost FMG, can be found with “search” or, for some, just scroll down the page.

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The Almost FMG

FMG–foreign medical graduate. This translates to any physician practicing medicine here in the United States who had received their basic, and sometimes advanced, medical education outside of the medical education system in the U.S. There are a significant number of FMGs practicing throughout the country with a percentage of those being U.S. citizens who studied medicine abroad as they, for a variety of reasons, were not accepted to study medicine within the confines of their native country. From mid 1975 though the first half of 1978 I was one of those. Through the years I have been periodically asked about this; here is my perspective on those years.

While medicine ran in our family (father, grandfather, and cousin were physicians, grandmother a nurse) and my parents were silently hoping I would continue the tradition, I hadn’t firmly decided that was what I wanted to do until…I almost flunked out of college. Not a great start. I worked hard to recover but a combination of a less than optimal GPA and some rather tepid interviews for med school entrance did me in. So for the next two years I tried a variety of strategies (grad school; work in medical field) with two more reapplications failing again in each instance. Time to move on until a phone call from one of my uncles eventually culminated in my acceptance to medical school at the Autonomous University of Guadalajara (UAG = Universidad Autonomo de Guadalajara)) in Guadalajara, Mexico, a mere 2500 miles from where I lived.

The UAG at that time (1975) was a large medical school with a total enrollment of approximately 5,000 students, 50% Mexican and 50% from the U.S. The Mexican students were overall younger as they enrolled after high school ( which was a year longer than here in the States). The U.S. students were invariably older, late 20’s, 30’s, and a few in their 40’s and were a mix of singles and marrieds with some of them bringing their families. The vast majority were either from New York or California but there were representatives from almost every state. Most, if not all of us, had an underlying sense of inferiority to our counterparts who were matriculating in U.S. medical schools. That sense, based on our non-acceptance to a U.S. medical school, was that we weren’t good enough or smart enough or too old (in 1975 the vast majority of medical students studying in the U.S. were in their early to mid 20’s). There also was concern on our part that our medical education would be substandard when compared to the medical education provided in the U.S.

Our first challenge was the language as all courses were taught in Spanish. It was a requirement that, if one did not have at least some fluency in the language, a semester of Spanish was mandatory prior to starting med school proper. UAG offered this instruction known as “Intensivo.” In conjunction with learning Spanish we also had basic courses in Mexican law, history, and geography (the phrase “Los Lagos de Mexico”[the lakes of Mexico] still resonates). It was also during this semester that we were trying to integrate into the Mexican community and to share common, as well as unique, experiences and perspectives with new found friends from across the United States.

So how do you accommodate 5,000 medical students in a 4 year medical school program without classes becoming overwhelmingly large? First, by having two entering classes, one starting in January and the other in September. Second, by then dividing each semester into “blocks” of study. In light of the former a student identified themself by semester (1st, 2nd, 3rd, etc) and not year in school. With this scheme there could be two “first (second, third)” semesters in a given year, one in the Fall and the other in the Spring. . In first semester anatomy, embryology, and histology were taught concomitantly. Anatomy was especially challenging (as in the U.S.). Spanish terms for the body parts had to be mastered as well as descriptions of organ function, the skeleton, vascular and nerve placement, direction, and function. Starting with the second semester there would be a block of classes all with related major subjects but each subject would be taught solely in a “block” of 6 weeks. For example, second semester included 6 weeks of physiology, 6 weeks of biochemistry, and 4 weeks of “minor” subjects (e.g. medical statistics). So while I may be in the physiology block one of my friends could be in the biochemistry block, and so on. This kept the classes small and, for me, I found it much easier to study one subject at a time, understand and master it, and integrate it into the next subject.

The first 3 semesters at UAG were on one campus and students then moved to a larger campus starting with the fourth. Pathology dominated the fourth semester but there were other blocks of courses to round things out including an intense course specifically on physical examination. Who did we examine? Why our classmates, of course, although there was an understanding that certain parts of the female or male anatomy were off limits. Rectals were also a no-no. Semester five saw us moving into clinicals. These were blocks of instruction on a specific discipline, e.g. cardiology, pulmonary, and so on. In addition to the didactic side of the discipline we had the physical exam aspects to learn by examining “patients”. This is where it got interesting. With the size of the school it would have been impossible to troop students through the campus hospital. Instead we had separate clinical exam sessions where we were required to supply a “patient” for examination. Regardless of whether one was in the pulmonary, GI, dermatology, etc. block, supplying patients for examination was a requirement. Fortunately an enterprising Mexican had solved the problem some time ago by creating a cottage industry whereby he would procure a “patient” for a fee. The “patient” would also receive a small fee and life was grand–as long as the “patient” showed up (most did). Not surprisingly many patients did have findings (rashes, wheezes, heart murmurs) that corresponded to the discipline being studied. (As an aside, in my years at a teaching hospital it was quite common for a teaching physician to ask if there were patients with interesting physical findings that medical students could examine–maybe I should have started my own “cottage industry.”)

Then there was Guardia (pronounced gwardia). This was a 2-4 week block of time each semester whereby we med students were “farmed out” to the community to provide, as least on paper, medical services. It was a crapshoot where one ended up and sometimes there was no community service to provide. I was fortunate for two semesters, ending up doing school physicals outside the city for grade school children ranging in age from 6 to 10 years of age. The interaction was fun and we got to practice our Spanish and the kids picked up some words of English. The “well checks” centered mostly on heart and lungs or something else if the student was concerned (rash, lumps, etc). We were also tasked with health screening, usually questions about parasites or certain illnesses, e.g. diabetes. My basic parasite question (tailored to my Spanish and a kid’s understanding) was, “Ha visto animalitos in la caca?” (Have you seen little animals in your s___?). I never got a “si” that I can recall. On one occasion a classmate, D., overheard my health screening questions, asked me about them and was quite upset that he had been remiss in doing his due diligence. Armed with the questions after we reviewed them, off he went to his station firing questions right and left at the students he was examining. Peals of laughter soon after began to drift from where he was stationed. Flustered, he walked over to me trying to figure out what was so funny about his questions. We started by reviewing the parasite question which, it turns out, had devolved to, “Ha visto arbolitos in su casa?” which translates to, “Have you seen little trees in your house?” D., understandingly, then decided to forgo the parasite question and focus on others. As we were leaving for the day I asked him how things had gone with the other screening questions and he sheepishly admitted he had stopped asking. He realized it would be a futile endeavor as he recalled asking “Do you have diabetes?” to which the child replied, “Yes.” D. said his heart sank as this was the first time he had asked the question thinking about the number of children he had seen previously but never raised the question. How many others with diabetes had he missed? He said he was at the point of despondency thinking he had utterly failed in his duty until he noted a not well suppressed smile on the face of the kid who had responded “Si.” So D. asked the question again, the kid responded affirmatively, which prompted D. to ask, “Donde?” (where?). The kid was now grinning ear to ear and pointed to his elbow, “Aqui” (here). D. never asked another health screening question.

Although Guardia was a requirement for each semester an alternative was to join a freestanding health clinic and volunteer time on a weekly basis. I was able to do this eventually but not before one final Guardia. No school physicals this time but rather a remote freestanding clinic in a small town in the country. Dirt streets, adobe houses, huts, no street lighting, toddlers running around naked. All that was missing was the Magnificent Seven. Our small group was supervised by a “pasante” (Mexican med school graduate doing her [in this case] social service obligation). We treated the kind of problems you would now see in an Urgent Care here in the U.S. The clinic was invariably crowded and the pasante was invariably pulled in many directions in trying to supervise us and dealing with her own set of patients. One time this lead to one of my classmates (realize, we, at this time, had been in med school for 1/1/2 years) delivering a baby as the pasante yelled instructions to him while she dealt with another emergency. What a learning experience for us all! During one of the quieter times at the clinic I asked our pasante why the townspeople all seemed happy and content in light of their circumstances and lifestyles. “Because they don’t know any better,” she said, then added, “and they will be content for the most part until someone comes along and tells them things could be better, makes promises, stirs them up, and then doesn’t deliver.”

After my third Guardia I was able to join a local freestanding clinic which relieved me of future Guardia obligations. It was another equivalent of an Urgent Care and we did our best with students of different experiences and knowledge mentoring each other as there was no pasante. There were several medical textbooks (the Merck Manual was a Godsend) well thumbed through. We did our best and were not hesitant in directing some patients to the hospital to address problems we felt were out of our league.

Not only were the courses taught in Spanish but the exams were also. While difficult (especially anatomy) they were multiple choice or short answer. Essays would have been a disaster. After each block a student received a grade (no pass/fail) and moved on to the next block. If one failed a course then one stayed for “segundos” (seconds). These were repeat exams given one week after the end of the semester. Fortunately I escaped segundos.

I finished 5 semesters at Guadalajara, took part I of the medical boards (same ones Stateside students took), did well, interviewed to return to the U.S. to finish as a new federal law mandated expansion of medical student seats with schools scrambling to fill, and made the cut to return to finish my medical education in the U.S. (Penn State Hershey). (As another aside, Hershey accepted a total of 5 U.S. “almost” FMGs, one each from different foreign medical schools. Since we were unknowns we were “sequestered” for several months with additional didactics until the school realized that we were as knowledgeable (or not) as their current crop of Hershey medical students. The rest, as they say, is history).

So what were some of the life lessons I learned while studying abroad? First, for the first 2 years of medical school in Mexico I came to appreciate that the instructions and disciplines were very similar to what was being taught stateside and I felt well grounded in the basics of medical science. To bolster this confidence I was fortunate to have had a younger brother in medical school in the States and we would often compare notes. Same topics, same books, similar labs. And, as stated previously, once I returned to the States to finish medical school I found myself with a foundation of knowledge similar to my fellow stateside classmates. Second, as there were no dormitories, we students rented houses or apartments that were scattered throughout the city or surrounding country. This contributed to we Americans having to integrate into the community. Yes, we could cluster in our American “barrios”, speak English, follow American customs but at least a degree of integration into the Mexican society was prudent. Third, issues with international finance came to the forefront. Tuition had to be paid in dollars. Many of my classmates would bring their tuition money with them to deposit in the local bank where those dollars were converted into pesos (8 pesos = $1) then, when tuition was due, withdraw the money in dollars and pay. Catastrophically in either 1975 or 1976 the peso was devalued and suddenly classmates were short of tuition money. Hard lesson learned. Fourth, while we did our best to integrate we faced discrimination routinely. Virtually every Mexican thought every American was rich. I was once stopped by a policeman because I was “speeding” (I drove a used Ford Pinto). When I asked how he knew I was speeding he replied, “I counted how fast your wheels were spinning.” Bribe paid. (In all “fairness” bribes were a common way of life). Class registration was in person and the “cajas” (cashiers) were only open for a few hours a day. We Americans would start lining up in the early hours of the morning (4-5 am) as, when the Mexican students would start showing up, they would routinely cut in line (they typically would send a Mexican student as an early morning “place holder” in line who would then allow 10-20 students to join him when they arrived much later). Protests were muted, if at all, as one feared getting kicked out of school. On one occasion I recall being verbally berated by a Mexican as I stood in line at a local taco stand. You quickly realized that you were never a “winner” in a fender bender with a Mexican and prudence dictated just to drive on if the car was drivable. Fifth, overall the Mexicans were kind, friendly, tolerant, and helpful to us from north of the border. Government officials were another issue. Sixth, time spent in the Guardias, especially my last, as well as the freestanding clinic, traveling the 600 miles from the U.S. border over 2 lane roads winding through desert and mountainous terrains and through small towns, as well as my wanderings through the city itself, gave me a different perspective on life in the States and how blessed we were. Lastly, there were a number of smart, dedicated people who were not fortunate enough to transfer back to the States, graduated, went through a winnowing process (“Fifth Pathway”) upon returning to the States, and went on to become great physicians.

One final thought–while I am grateful to have received my M.D. (thank you Hershey) here in the U.S., my overall experiences and education in Mexico as an “almost” FMG were, in some ways, superior in many ways to any education I could have received in the United States.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, Covid 19 and HIV, Rationing in the Age of Covid,,,and other thoughts, Ode to a Ventilator During Covid, The Covid Vaccine Conundrum, can be found with “search” or, for some, just scroll down the page.

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The Covid Vaccine Conundrum

The mantra has reached crescendo proportions, “Get vaccinated, get vaccinated, get vaccinated!!!!”, and, for many, advice that should be followed. But is it good for all? Now, before being accused as being an “anti-vaxxer,” I’m not. At the same time, however, should it really be a “one size fits all” recommendation? So here is my perspective.

To my simplistic thinking here in the U.S. there are two segments of population as they pertain to the vaccine:

  1. Those vaccinated. I fall into this group as do my many family members and friends. From the CDC data from July 2021, approximately 69% of the adult population has been vaccinated, most fully, while others have received at least one shot (Pfizer or Moderna). Other sites (e.g. USA Facts, which accumulates data from 70 government sources) report the vaccination rate of the entire U.S. population as being lower. In the case of USA Facts the published rates are 57% of the population having had at least one dose of the vaccine while 50% of the population are fully vaccinated (data as of July 25, 2021). So next time you hear about an “x” vaccination rate ask yourself whether the rate refers to adults only or if it refers to the entire population. If the latter, then anticipate lower rates as children <12 years of age, comprising ~47 million individuals, are being included. I am confident the reader is aware that there is a raging debate regarding the advisability of vaccinating this group to begin with as there is good data showing that both the likelihood of infection is very low in this group as well as the likelihood of transmission to adults is also low.
  2. Those not vaccinated which, in light of the above figures, means 31% of the adult population or 43-50% to the entire population. I’ve had questions about the breakdown of this unvaccinated group because I suspect that, if the group is taken as a whole rather than component parts, it keeps the unvaccinated numbers high which are then alarmingly reported on whatever news outlet(s) you choose to get your information.

So what could make up the component parts of the unvaccinated group? For me this would include: a) kids <12 years of age if the vaccination rate is referring to the entire population, b) those with a true medical contraindication to the vaccine, c) those with moral objections to the vaccine (e.g. since there were cells used from aborted fetuses in developing the vaccine [esp. J&J] a number of Catholics refuse to get the vaccine), d) those who don’t believe any vaccine is worthwhile or safe, e) those who don’t trust the system and never will, f) those with misconceptions (e.g. microchips, risk of DNA alteration) or concerns (e.g. adverse affect on fertility) and, finally, g) those who have had Covid and either have questions about, or refuse to get, the vaccine. It is in this last group that I feel faces the vaccine conundrum. More about this momentarily.

Why get a vaccine? To build up immunity to an infectious process that could have significant consequences if infection occurs. So in the case of Covid, as with other viruses, immunity to the virus can develop because one becomes infected, recovers, and generates antibodies via a robust immune response to subsequent infection (natural immunity) or though vaccination. Natural immunity to Covid encompasses an individual’s immune response is to all components of the virus (capsid [think of it as the “shell” of the virus] as well as the spike [those projections sticking out of the capsid shown in multiple illustrations]). With vaccination alone the immune response is generated to the spike only which, as the data show, can still provide a very high level of protection. Antibodies to these components (anti-N, referring to the capsid; anti-S referring to the spike) can be measured and tracked (seroprevalence). “N” antibodies alone only develop through natural immunity while “S” antibodies are linked to the vaccines and natural immunity.

There is widespread agreement that individuals who become infected with Covid can be symptomatic or asymptomatic. In light of this there has been a persistent question as to what percent of the population, whether from symptomatic or asymptomatic infections, has recovered, and now has immunity to the virus? One attempt to generate data to answer this question has been through the Nationwide Commercial Laboratory Seroprevalence Survey. As of mid-May 2021, positive “N” seroprevalence rates (implying natural immunity) in the 50 States has ranged from 2.7% (HI) to 36.7% (OH) overall, with 25 states having rates <19%, 20 states 20-29%, and 5 states with rates >30%. The data, however, has been tempered by less than robust testing in some of the states. It was also not clear to me how the data breaks down between symptomatic/recovered and asymptomatic/recovered individuals. Overall, however, I think it is safe to say that there is a significant part of the population (depending on the State where they live) who has developed a natural immunity to the virus.

Now onto the conundrum. The conundrum faces those who have developed natural immunity (knowingly or unknowingly) to the Covid virus. Simply stated, it revolves around the question as to whether or not unvaccinated, but previously infected, individuals should get the vaccine. Those urging this subpopulation of individuals with natural immunity to Covid to get vaccinated do so for a variety of reasons some of which are: a) the duration of natural immunity is unknown, 2) potential side effects from getting the vaccine are uncommon (“rare” per CDC), and 3) it reduces the risk of reinfection. There are a few observations I would like to make.

Regarding duration of immunity–there are a growing number of studies showing that whether after Covid infection or vaccination the immune response is robust in most people. Ongoing studies also show that individuals with natural immunity still have immunity 12 months after infection while individuals who have been fully vaccinated have immunity at least to six months (discrepancy due to the fact that the virus has been around longer than the vaccines). It is unclear to me why those with natural immunity are being encouraged (and soon likely to be mandated) to get vaccinated. A few, of many, links: https://www.nih.gov/news-events/nih-research-matters/lasting-immunity-found-after-recovery-covid-19; https://www.nature.com/articles/s41590-02109233; https://clarion.causeaction.com/2021/07/28/johns-hopkins-physician-the-power-of-natural-covid-immunity/

Potential side effects–I agree statistically rare but tell that to the young adult, for example, who has developed myocarditis as a result of vaccination. Since it is understood in the scientific community that those in younger age groups (<40) often contract Covid but are asymptomatic, how clear is it that the vaccine is being given to someone in this age group with natural immunity especially when there has been concern expressed about the risk (regardless of age) of causing serious side effects? (Noorchashm, Hooman. “A Letter of Warning To FDA And Pfizer: On The Immunological Danger Of COVID-19 Vaccination In The Naturally Infected.”)

Reinfection–so reinfection in an individual who has received the vaccine is unfortunate but acceptable but not for one who has natural immunity?

I leave you with this final question and thought . Leaving aside the naysayers/doubters who will never be convinced, should unvaccinated individuals of any age group, but especially younger age groups, be given the opportunity to have Covid antibody titers checked periodically? If positive and high what is the advisability then of following (“natural history” in the science world) vs. forcing a needle into their arm at the risk of being considered a pariah otherwise? The science could be better. And, lest we forget, the vaccines are allowed to be administered under “emergency use authorization (EUA)” only (implying that the FDA isn’t totally comfortable with the safety and/or efficacy data). So, to me, those adults who have never been infected or are vaccine naive should strongly consider getting vaccinated especially if they have risk factors. Those who have developed natural immunity should have a choice.

Below are three links for additional review:

https://www.msn.com/en-us/news/politics/vaccines-benefit-those-who-have-had-covid-19-contrary-to-viral-posts/ar-BB1fZrwb

https://www.news-medical.net/news/20210608/No-point-vaccinating-those-whoe28099ve-had-COVID-19-Findings-of-Cleveland-Clinic-study.aspx

If You Had Covid, Do You Need the Vaccine?

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, can be found with “search” or, for some, just scroll down the page.

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Ode to a Ventilator During Covid

Quiet with a silent screen,

Oblivious to the unfolding scene,

Now powering to life with a flip of a switch,

To breathe for a patient you know not which.

“You will be the savior of us all,”

Cry the people from city hall,

“Thousands, no, millions, needed,” is the call from on high,

Though no one is sure exactly why.

Powered up with buttons pushed and dials turned

by a respiratory therapist from knowledge earned,

The curves appear, the patterns flow,

Sanskrit to those not in the know.

Another patient with the Covid curse,

With respiratory failure getting worse,

“Need oxygen, need air,” say those who care,

explaining to the patient they need to prepare.

Drugs are given, sedation is met,

The tube is placed and all is set,

The life saving machine is now put in place,

And attached to the tube extending from patient’s face.

Air flows in, the chest expands,

The therapist awaits any physician commands,

The size of the breath, the rate of flow,

And other things needed to know.

Oxygenation has improved, the patient at rest,

But no one thinks the time is best,

To feel relieved and claim success,

While the virus continues creating a mess.

So, to you, oh mighty machine!

With benefits galore but harms unseen,

You begin your mischief in the dead of night,

When workers are few and schedules tight.

Airsac overstretch with resultant inflammation,

Not evident with the usual information.

A collapse of a lung from a rent in a sac,

An emergency to take anyone aback.

Compromising muscles that help you breathe,

Another problem hard to conceive,

But all you do is what has been commanded,

All you’ve done is what has been demanded.

Through all your support you have sensed no slight,

As the patient struggles and continues to fight.

Eventually the day comes when you are withdrawn,

As the patient arises to begin a new dawn.

Savior of many, executor of a few,

What we know is nothing new,

Oh mighty machine, you support, not cure,

All you do is help the patient endure.

Now once again quiet with a silent screen,

Oblivious to the unfolding scene,

Now powering to life with a flip of a switch,

To breathe for another patient you know not which…

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, HOSPITALIZED SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, Conversation, can be found with “search” or, for some, just scroll down the page.

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Rationing in the Age of Covid…and other thoughts

I was still in practice in 2009 and played my critical care physician role in treating patients as part of the H1N1 swine flu pandemic. I do not recall issues as much as they pertain to personal protection equipment (I believe supplies were sufficient) but, as a tertiary care center, our institution was inundated with transfer requests for critically ill patients requiring use of a very sophisticated type of ventilator called an oscillator. Our supply was limited as were the respiratory therapists who could run them and so many transfers were denied once all our oscillators were in use. Regarding the oscillators the biggest hurdle I can remember was knowing how many were available at any one time and, fortunately, once the problem was realized, it was quickly solved. I never recall having a conversation with, or hearing discussions about, anyone in my group of 16 critical care physicians regarding rationing the use of an oscillator. The approach was one of “first come, first serve” when an oscillator became available; otherwise patients remained supported by a “standard” ventilator (patients rarely, if ever, went directly to oscillator support) or not accepted in transfer. Fortunately the pandemic subsided and all was (relatively) quiet until the Covid-19 pandemic began its assault on the world.

For a brief time, although it seemed like an eternity to patients and those in the healthcare system, Covid-19 had the potential to overwhelm the system with escalating rates of infection, available healthcare personnel, lack of PPE, and an ever increasing concern regarding the dearth of ventilators and how to ration those that were available. It is to this last point upon which I wish to give my perspective.

Rationing has always been part of healthcare whether we like it or not. For example, drugs or testing (try spending countless time on the phone with insurance companies, Medicare or Medicaid or with “peer to peer” to get something approved for a patient) are often regulated [rationed] by criteria set forth by the “powers that be.” But let me emphasize, there are criteria, no matter how well formulated or stupid, that are utilized. This brings me round to the early discussions regarding potential ventilator rationing if a hospital does not have the the capacity to meet the demand. Once that tsunami of Covid-19 infections hit, physicians and hospital systems worldwide came to the stark realization that there wasn’t enough–not enough PPE, staff, effective treatments, ICU beds, ventilators and…time. Time to think, to take a breath, to make a thoughtful decision knowing its profound consequences on life or death. At that time physicians did their best, decisions made, with the post-mortems of those decisions to follow. Currently the tact being taken is the formation of hospital committees in which rationing criteria are discussed, agreed upon, periodically modified and made available to physicians to help them in their decisions regarding situations where ICU care or ventilator rationing needs to occur. So, what would some of the criteria be?

Age was one of the first criterion to be considered. Why? Based on early data (see graph below) from China it appeared to be a no-brainer; older folks had higher mortalities thus leading to consideration of picking a certain age above which rationing would be considered and/or implemented. Several weeks ago I read a well written thoughtful article by a 70 year old author from the Hastings Center who, in his discussion regarding a particular age cutoff, opined that 70 years would be acceptable. His rationale? Data showed that deaths began to especially spike at age 70, that the older generation had to give the younger ones every opportunity, and he felt that he had lived a good life and would have been willing to forgo ventilator or ICU care if it meant potentially saving someone younger. However, controversy by that time had already arisen about using age as the sole criterion for rationing.

Death rate in China March 2020

Fortunately, not soon after mortality data by age was published, wiser heads prevailed by asking, “What, other than age, affects mortality associated with Covid-19?” The answer, comorbidities, those chronic conditions or diseases that may be found in any age group resulting in less than optimal health. Listed in the below table are the comorbidities reported early in the pandemic. The developing rule of thumb–the more comorbidities one has, especially, but not exclusively, coupled with increasing age, the more likely of dying from the virus. Later on, morbid obesity and other comorbidities (see bottom of NYC table further on in blog) were added. The coupling of age with comorbidities has lead to subsequent formulation of healthcare guidelines in different settings regarding those situations where physicians and others were faced with the prospect of denying ICU care or ventilator utilization.

Significant (P <0.5) comorbidities complicating Covid-19 infection

Now, with using age coupled with comorbidity, a better perspective of how this combination can provide an evolving overview of the stratification of patient groups as it pertains to dying from the virus. A snapshot of this can be seen in the following chart:

provided by New York City Health as of April 14:

AGENumber of DeathsShare of deathsWith underlying conditionsWithout underlying conditionsUnknown if with underlying cond. Share of deaths
of unknown + w/o cond.
0 – 17 years old 30.04%3000%
18 – 44 years old 3094.5%24425401.0%
45 – 64 years old 1,58123.1%1,343591793.5%
65 – 74 years old 1,68324.6%1,272263856.0%
75+ years old3,26347.7%2,2892794714.2%
TOTAL6,839100%5,1511371,55124.68%
[1] Underlying illnesses include Diabetes, Lung Disease, Cancer, Immunodeficiency, Heart Disease, Hypertension, Asthma, Kidney Disease, and GI/Liver Disease. [source]

As I studied the above information what struck me was the number of patients without a comorbidity in the: a) 18-44yr age range who made up 8% of the cohort deaths but only represented 0.4% of total deaths, b) 45-64yr age range who made up 3.7% of the cohort deaths but represented 0.9% of total deaths, c) 65-74yr age range who made up 1.5% of the cohort deaths but represented 0.4% of total deaths and d) 75+ yr olds who made up 0.8% of the cohort deaths but represented 0.4% of total deaths. The obvious conclusion is that few of us get into our older years without experiencing some kind of comorbidity. The second obvious conclusion is that increasing age plus comorbidities increased the likelihood of death from the virus. The less obvious conclusion, however, is that if one gets into their older years without any comorbidities, then the risk of dying from the coronavirus is the same as those without comorbidities who are younger or much younger. This, then, circles back to the argument using age as the sole criterion for rationing; it should not.

Let’s now put the information above to the test. Here are several scenarios I’ve envisioned, but have not specifically read or heard about. You are the critical care or ER physician on duty and are faced with the following two patients, both with Covid, both with respiratory failure, both need ventilator support, BUT…there is only one ventilator. Decide between one or the other or…neither: I) an 18 year old male otherwise healthy or an 84 year old man with COPD and hypertension, II) a 42 year old morbidly obese man with hypertension and diabetes or a 75 year old woman otherwise healthy, III) a 38 year old woman with advanced cancer or a 73 year old woman with diabetes and hypertension, IV) a 68 year old man with COPD and hypertension or a 72 year old woman with diabetes and chronic heart failure, V) a 38 year old man otherwise healthy or a 76 year old man with hypertension, diabetes, and asthma who happens to also be a noted public figure, VI) a 72 year old woman with chronic heart failure, diabetes, and hypertension or a 72 year old man with chronic heart failure, diabetes, and hypertension.

Did you choose wisely or not at all? The one not chosen may not have thought your choice wise at all. Understand that the guidelines put in place by hospitals all anticipate physicians having time to discuss them with a patient and/or family in those critical decision-making situations. If the clinical status of an already hospitalized Covid patient deteriorates to the point of needing more critical care, then there is a relative “luxury” of time to review guidelines with all involved and make decisions no matter how positive or negative they may be. I suspect that if the 70 year old Hasting Center author was hospitalized with Covid there would be a welcome discussion of the guidelines and most likely a decision not choose ventilator support based on his previous opinion. What if there was no time for discussion, for example, two critically ill Covid patients arriving in an ER at the same time? What if the patient and/or family don’t agree with the guidelines and want “everything done”? While not with Covid, I have encountered the latter in previous clinical situations and leads to an incredible amount of stress for all involved.

There are a few final thoughts on a slightly different, but related topic, having to do with elective surgeries or procedures. I can understand the closing of these in light of the real concerns about the virus overwhelming our health care system. There was a need to divert supplies (e.g., PPE, ventilators), nurses, and at least some physicians (e.g. anesthesiologists) until we could have a better idea of how things were going to play out. Screening protocols and testing needed to be put in place. However, in my opinion, the return to elective surgeries or procedures has been too slow. Any surgeries or procedures done at least at a free standing surgery center could have resumed several weeks ago. Unfortunately the next few months will give us a better picture of the likely non-Covid mini-epidemic of missed cancers, delayed non-cancer diagnoses, and delayed corrective therapies leading to prolonged suffering.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions, Tales from the ER, can be found with “search” or, for some, just scroll down the page.

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Covid-19 and HIV

A few weeks ago one of my brothers texted me–“Can you liken this to anything in your career [as a pulmonary critical care physician]? I guess HIV-AIDS…” My immediate response was “no” in light of the different viruses but as time went on, and with further reflection, I came to the realization that my career had been bookended by two viral pandemics both of which were approached in very different ways. Here is my perspective.

The Acquired Immune Deficiency Syndrome, most commonly referred to as AIDS, reared its ugly head in the early 1980’s. As a third year resident (1983) I remember reading a detailed article about it in the “Annals of Internal Medicine.” Unusual diseases (pneumonia, parasitic infections, uncommon cancers) were cropping up in a segment of the population defined as “the 4 H’s”–homosexuals, hemophiliacs, heroin addicts, Haitians, with the largest group at that time being homosexuals. While the diseases were recognized as manifestations of what appeared to be an altered immune system, no specific underlying cause of this alteration was known at that time although a viral etiology was suspected. Also, it was not totally clear how easily or by what means the underlying cause for AIDS could be spread. Blood and semen appeared to be logical conduits for transmission in light of some of the affected populations but what about saliva? or a sneeze? or a cough? or sweat? What was your risk for developing AIDS if an AIDS patient scratched you or if you just accidentally stuck yourself with the needle you just pulled out of the arm of one of these patients? If you were infected with whatever was the presumed causative agent, but not manifesting and AIDS symptoms, what was the risk of passing the agent on, for example, by swimming or playing sports (especially contact sports)?. All unchartered territory.

As a pulmonary fellow I held the distinction (I think) of being the first physician at our institution to bronchoscope a presumed (subsequently confirmed) AIDS patient. He was a homosexual, freshly arrived from the baths of San Francisco, who, when respiratory symptoms began and after being informed by a physician there he likely was developing an AIDS illness, decided to come back home to Pennsylvania not by plane but by car. While he phrased it more crudely than what I write here he explained that by traveling this way it gave him the best opportunity to spread as much love as he could across the nation. In light of a constellation of symptoms and an abnormal chest x-ray, the infectious disease docs wanted tissue confirmation of a pneumonia. Hence the bronchoscopy. I asked my Chief what precautionary measures we (he, and others, would be in the room with me) should take. He didn’t know. With a little literature digging I found an article suggesting what might be appropriate to wear while bronchoscoping an AIDS patient. As I was the primary bronchocopist extra protection was recommended. My attire on the day of the bronch included a lead apron first (we needed fluoroscopic {x-ray} guidance when doing the lung biopsies), head covering, double gowns and gloves, mask, and goggles. I could barely move. One of the RT’s snapped a picture (Polaroid) wearing my finest and for years the picture hung in the RT break room as “AIDS patrol.” Little did I know that I, as well as everyone else, had just been introduced to what in later years would be called “personal protection equipment” (PPE)–minus the lead apron.

One of the tenets in Infectious Disease mitigation in time of widespread infection is quarantine. This was a hotly debated topic at that time but eventually was not pursued out of concern that a quarantine would drive infected people “underground”and away from healthcare. So, what were the treatment options at that time? Very limited; mainly symptomatic relief with an occasional respite from a particular type of pneumonia affecting AIDS patients with use of a sulfa based antibiotic. In essence, an AIDS diagnosis was a death sentence.

Government and the healthcare system, slow at mobilization at first (read, “And the Band Played On”), eventually began to ramp up. The human immunodeficiency virus (HIV) was ultimately found to be the underlying cause of the immune system dysfunction. Over time it became apparent that one could have the virus (HIV+) and be totally asymptomatic. Only when a person developed manifestations of disease related to immune deficiency was the term “AIDS” applied. So asymptomatic HIV+ patients could spread the virus (e.g. blood, semen, vaginal or rectal fluids, needles) and never manifest an AIDS scenario. One of the saddest cases I knew about was of a young mother who developed AIDS after she was infected by her HIV+ husband who “played both sides of the street” and never let her know. Since one did not know who was HIV+ a universal premise in hospitals was established–assume everyone was infected. Thus the advent of “universal precautions.” This lead to the routine use of gloves when dealing with patients and establishment and ongoing refinement of disposal policies for needles and other “sharps”, soiled bandages and blood products. Protocols for dealing with a healthcare worker injured by needles or other sharps were developed and refined.

Universal precautions eventually became standard everywhere and remain in place today. Screening of blood donors took on a new aspect with a pre-donation questionaire given to all. One of the questions, controversial at the time, inquired if the donor believed they were in one of the risk groups (the 4 H’s) or engaged in activities which might place them at risk for an HIV infection. If the answer was “yes” the policy was to let that person leave with no further questions asked. In sports protocols were established to deal with a bloodied player. For example, basketball games would be stopped briefly so that a player displaying a bloody (no matter how minor) injury could leave the court to be treated (note the gloved trainer). The use of PPE (gloves, gowns, face shields, masks, head/foot gear) also became standard and was tailored to the type of patient being cared for, with gloves always the minimum requirement.

A breakthrough in testing for HIV occurred in 1985 with development of ELISA assays. Now that there was a way to “track” the virus, drugs related to treating the underlying HIV infection could begin to be developed. Testing improved over time as did drugs for the treatment for HIV+ patients with the goal to suppress/destroy the virus in an effort to maintain a healthy immune system thereby preventing the development of AIDS. Anti-virals appeared in the late 1980’s and were continued to be refined over the ensuing 10-15 years. Different drugs in different combinations (“cocktails”) came to the forefront with greater and greater success at treating the infection. For a growing number of people the specter of the inevitability of AIDS was no more as, if the virus could be suppressed, the immune system would remain intact.

Now to present day and the coronavirus, aka “Covid-19”. Did the approach to HIV give us a “leg up” in dealing with this current pandemic? Undoubtedly these are different viruses with different manifestations of infection and contagion. However, I think there are several observations which can be made.

1) Testing–AIDS was the visible result of an HIV infection but it would take time before HIV was recognized as its cause since genomic testing was in its infancy. In light of the explosion in genomic testing since then the coronavirus genome was mapped within the first month or so of the first patient becoming symptomatic.

2) Contagion–Early in the AIDS epidemic, before HIV was discovered, there was a large degree of uncertainty regarding the ease of contagion. In time it became apparent that asymptomatic HIV+ patients could not spread the disease just by being, for example, on a cruise ship or plane or where there are/were large social gatherings. Now as we are more and more a global society the coronavirus spreads much more easily, especially since early warnings were not forthcoming (China) or played down (WHO) or response times were slow (many governments), thereby giving it a “head start.” The coronavirus contagion shares this similarity to the influenza virus of 1918 in contrast to HIV.

3) Personal protection equipment (PPE) and Universal Precautions–as noted above had its beginnings with the AIDS epidemic. As I look at pictures of those currently decked out in their PPE, I often think about that “AIDS patrol” picture taken long ago.

4) Treatment–“social distancing” is the phrase of the day and the strategy appears to be working. But don’t fool yourself, this is about as close to a quarantine as one can get short of utilizing the true draconian measures that have been periodically used in times past. However, social distancing, i.e. avoidance, isn’t treatment in the true sense of the word. That’s where drugs and possibly plasma infusions come to the forefront. Recall that drugs to treat HIV took years to develop and numerous trials before released to the public. Currently there are several drugs, both antibiotics as well as anti-virals, being investigated. The debates rage–compassionate use? seat of the pants? trials?–as the debates did then for HIV. Currently there are more options being looked at than ever were in the early days of HIV.

5) Prevention–there are no vaccines for HIV but there is hope and expectation that sometime within the next 12-18 months there will be a vaccine for the coronavirus. The rapidity with which efforts are being made to this end are breathtaking. What has yet to be answered is whether the vaccine will offer “once and done” protection or will it be like the influenza vaccine where yearly “boosters” are required. And what about the anti-vacciners? (As an aside, I recently spoke with an older woman who says she NEVER gets a flu shot but would consider getting a coronavirus “shot”).

6) Unknowns–we’ve had 40 years to “work out the kinks” regarding HIV and the knowledge base is solid. Not so with the coronavirus. How long can a patient infected with the virus remain contagious? Outside of the 14 day “window” will there be asymptomatic people who could be carriers for extended periods of time? With recovery from infection is there immunity and is it transient, lifelong or something in between? Will the coronavirus take its place along side influenza as a seasonal recurring infection? Will the virus play along with the rules of “herd immunity”? What is the true infection rate as many people infected with coronavirus will remain asymptomatic?

Lastly, but as importantly, is the economic effect. HIV never affected the economy to any large degree, let alone shut it down. Covid-19 obviously has and to potentially devastating effects. While not able to contrast HIV/Covid-19 in this light, I wondered about the 1918-1919 influenza pandemic–were there economic parallels? If you are curious I refer you to a very interesting paper (written for the layman), “Economic Effects of the 1918 Influenza: Implications for a Modern Day Pandemic,” by Thomas A. Garret, written in 2007. The link is: www.stlouisfed.org/…research-reports/pandemic_flu_report.pdf (or Google or Bing it). To me it was an eye-opener as to how that pandemic was eerily similar in many, but not all aspects, of what we are seeing today regarding urban vs rural mortality, density population mortality, white vs non-white mortality, age mortality, and effects on local, as well as the national, economy. And, once the pandemic abated, this paper points out that overall economic recovery was rapid for most. Hopefully this will be the same this time.

If you wish to leave a comment, click on the particular blog title on the sidebar at www.docmentation.com. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, Decisions can be found with “search” or, for some, just scroll down the page.

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Conversation

Talk is cheap, or so they say, but not when decisions regarding life or death are concerned. Those decisions are played out in a variety of settings but especially in the intensive care unit (ICU) of any hospital. In this blog I’ll not consider the economic cost which, while significant, pales in comparison to the psychological cost of these discussions, both to families and physicians, that can accompany weighty decisions affecting critically ill patients. There are, however, a variety of reasons influencing how physicians subconsciously or consciously broach, or not, these serious discussions with a patient and/or family.

Allow me to begin by framing the topic accordingly. I recently gave a talk about medical issues to a small group of individuals. As part of the discussion I recalled three cases in which I was involved as examples of what challenges can be faced by both physician and family. These cases included an intubated patient with the potential for recovery but the family wanted her removed from the ventilator, a 92 year old man with multiple medical problems, all of which were gradually getting worse, necessitating transfer to the ICU as he and family wanted “everything done”, and a 28 year old woman with “treatment failure” melanoma metastatic to lung to the point that tumor burden was leading to increasing respiratory distress. The first case (detailed in a previous blog, Decisions) played out over a few days but the last two over a few hours as I had just met the patient and family. In all three cases I gave an overview of the issues as I knew them with the patient and/or family, listed possible options for going forward, and then made my recommendations. Time, relative to the immediacy of the situation, was given to the family to discuss among themselves and, eventually, with me. Decisions were made for what was thought to be in the best interests of the patient; in the first case the patient was not extubated early and eventually recovered, the 92 year old man did not mean by “everything done” to include mechanical ventilation or cardiopulmonary resuscitation, and the 28 year old was made comfortable and allowed to die in peace as further aggressive intervention would not have altered her outcome. Toward the end of our group discussion one of the participants, a priest, commented that he had been involved in any number of cases of critically ill patients where the physicians spent so little time talking to patient and/or family, contrasting my taking the time for discussion with other physicians who didn’t. He asked for my perspective as to why such a variation in physicians’ willingness to engage in such discussions.

The first thing to keep in mind is that physicians have varying degrees of comfort with these types of discussions. As medical students and residents we received no formal education on how to discuss issues such as these with patients. While there has been an ever increasing body of literature through the years about “how to” and, perhaps, a course here or there for an attending physician, most of us developed our style of approach and substance of discussion by watching others, usually one or several attending physicians or fellow residents. As you can imagine our styles became eclectic, picking what we perceived to be the best approaches and adapting them to our way of dealing with certain situations. For many of us it was on the job training and would, if we were fortunate, have a more seasoned physician with us who, under their watchful eye, would allow us to broach the subject while willing to intervene to assure the discussion did not get out of hand or off on a tangent. These mentors would often give mini-critiques afterward to help our communication style. Unfortunately, though, I think there were/are some trainees who never worked on their style either because of an inability (psychological?) to do so or their mentors were lacking in their own way (e.g. an attending physician who rarely, if ever, would discuss end of life matters). And, as one can imagine, without effective mentoring, the challenge of dealing with these kinds of discussions could become even more daunting and stressful.

Moving on, I suspect the pressure of time, real or imagined, plays the largest role in this variable engagement . When I was a resident I was a proponent of an “open” ICU policy regarding a constant family presence at the bedside in contradistinction to a “closed” time with limited visiting hours where nurses and/or physicians could complete tasks or rounds without have to interact with family at that moment. I had difficulty understanding why so many physicians were against an open policy until I spoke with a well respected surgeon who, after a back and forth regarding the merits or non-merits of such a policy, simply said, “Wait until you go into practice.” Several years later, now as a private practicer, I finally came to understand what he meant. As a resident I was in one place all day and had the luxury of speaking with family virtually at any time and, generally speaking, there were no time constraints as to the length of the discussion. Now, as a physician in private practice who, on a daily basis, had to split duties between hospital and office, felt the time pressure of getting rounds done and to the office on time vs. speaking with a family (or several) which could (and often did) delay the completion of rounds or lead to being late to the office. In time you learned to adjust as best you could–short meetings, placating irritated office patients because you were late, or returning to the hospital at the end of the day to either finish rounds and/or talk to families. Over the course of two of my practices (Pa. and Indiana) I also felt the time burden that “travel” (hospital{s} to office and vice versa) puts on a physician. There were also periodic challenges of trying to coordinate meeting times as families would not necessarily be available to meet when I was at the hospital. For those thinking, “Why just not pick up the phone?” remember, cell phones haven’t been around forever and time is lost when trying to find a phone number or calls aren’t answered or, when answered, the wrong party is responding. Voicemail is not an option for a variety of reasons. In my third practice (NC) I did shift work, scheduled in one particular area (ICU or ward) for a week at a time, and did not have to travel. What a luxury! In addition, when in the ICU, the residents would do a portion of the work thereby freeing up additional time for the attending to have one or several discussions with family every day (our ICU had an “open” policy). It also helped when families were available only certain times of the day.

While the time element is likely the most common reason for non-existent, limited, or truncated family discussions, there are others. We physicians are, in general, an optimistic lot, certain that with our skills and knowledge our patients will get better. Although, with that said, our optimism is not infrequently tempered by reality. There are some physicians, however, who retain an eternal optimism to the point where reality is denied. Nothing is more demoralizing than receiving in transfer to the ICU a critically ill patient who, already dealing with underlying chronic progressive medical illnesses, has experienced a new complication or illness requiring immediate intervention, while the attending physician of record lays out a glowing scenario to the family of, “They’re (ICU personnel) top notch and will get your loved one better in no time at all.” To all other health care providers involved, however, it is evident that the patient’s likelihood of survival is extremely poor. Now the challenge is to begin the difficult task of getting to know the overly optimistic and hopeful family, gradually and delicately introduce them the likelihood that there loved one is not going to get better, and not paint the attending physician of record as Pollyannish. This approach can take days and, obviously, discussion time of which the ICU physician may not have an abundance depending on circumstances or other obligations.

Another consideration regarding the extent of discussions with family or patient has to do with “the path of least resistance.” I have observed and talked to any number of critical care physicians who will spend more time trying to talk a patient or family out of a specific care plan rather than acquiescing to a care plan already proposed by other physicians. For example, the path of least resistance for the above referenced 92 year old man and the 28 year old woman would have been to proceed with decisions already made (aggressive resuscitation, mechanical ventilator) rather than to take that extra time to explain why those decisions would have little to no benefit to either patient.

As you might imagine it is easier to discuss difficult issues and arrive at certain decisions when the physician knows the patient and, at least tangentially, the family, and the longer the relationship the easier (relatively speaking) decisions can be made. Why is this? Trust. Trust that the physician has the patient’s best interests at heart and recommendations are made are done with these in mind. In my first two practices I would follow a patient for days, sometimes weeks and, rarely, months. I knew their history and learned the nuances of their care. I’d meet with family, even if briefly, and they came to know me and I, them. In my last practice generating trust became more challenging as my time on a particular service was limited to no more that 7 days. Getting “up to speed” with many issues regarding a particular patient usually took 1-2 days and sometimes almost the entire week. While family discussions were held daily it became easier to have those discussions and more time allotted as the trajectory of the patient’s progress (or lack thereof) became a little easier to discern. The most stressful times are when attempts at succeeding in generating that trust occur over a very brief period of time (e.g. the 92 y/o man and 28 y/o woman mentioned above).

Lastly, there are a few of us out there who just don’t like to discuss the situation especially when the outcome is highly likely to be poor. Why? Perhaps it is because of, in a way, admitting failure. Some physicians feel their responsibility is to assess the patient, write the orders and daily note but leave informing the patient’s family to someone else, either nurses and/or other physicians involved in the patient’s care. I remember in my first practice on an especially busy on call weekend getting a “stat” consult on a patient who, hospitalized several days earlier already critically ill, had now suffered respiratory failure and was just placed on a ventilator. After reviewing the chart, examining the patient, and speaking to the bedside nurses, I knew things weren’t going to end well for the patient in light of his ever worsening multiple organ failure. Being pressed for time, as I had two other hospitals to go to and many other patients to see, I’d planned to forego a family discussion that day. However, as I was leaving, one of the ICU nurses pulled me aside and said, “The family is waiting to speak with you.” Tag, I’m it. I stopped by an ICU meeting room full of people and, as it turned out, all related to the critically ill patient that I had just seen. Putting aside the recommended protocol for opening up discussions such as this, I introduced myself, paused, and then bluntly stated, “He is going to die.” Dead silence. Someone then rose, looked at me while making a sweeping gesture with his hand toward those assembled, and said, “Thank you. You are the first one who had the balls to tell us what we already knew.”

So there you have it. Why don’t some docs take the time to discuss important life and death issues? Time pressure assuredly but also factors related to unrealistic optimism, trust, just not wanting to talk and, finally, not wanting to acknowledge failure that a patient under their care was not going to get better. There may be more–what do you think?

If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, Responsibility, can be found with “search” or, for some, just scroll down the page.

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Tales from the ER

Been there, done that. The “heat of battle,” the trauma, the diagnostic challenges. The world of the emergency room (ER for the uninitiated few)– stories that you have seen on TV, sometimes fanciful, always dramatic, sometimes humorous, or easily found in any number of online bookstores. However, let me remind you that not all is drama and there is the mundane, which never, or hardly ever, rises to the level of a TV script or the chapters in a book but does provide additional “slices of life.” What follows are a few accounts from the 1970’s and early 1980’s, “tales from the ER” that reflect “slices of life” during those times each with their own non-medical lesson.

In the early 1970’s I worked as an orderly in our small (<80 bed) community hospital nestled in a blue collar town of 13,000. I would always work the late shift (11-7). One of my responsibilities was to be the first to greet and assess any patient that showed up at the ER door as no one was stationed in the ER all the time. Since the ER door was locked at night a patient would ring a buzzer that sounded at the nurses’ station which itself was some distance from the ER. This was my summons to duty. The ER was a two bay affair with the waiting room directly facing the bays. One would walk by the bays, through the waiting room, into a hallway and, turning left, could quickly visualize the locked glassed paned double doors. I would pop the door open, usher the patient and any others in, find out what the problem was, and begin the registration and subsequent assessment (obviously all quickly bypassed if this was a true emergency).

One night after the buzzer summoned, I made my trek, arriving at the glass paned ER doors and looked out. What met my eye was a late middle aged man standing between two buxom women “dressed to the nines.” His arms were draped around their shoulders and I could see that he sagged a little bit between them. I let them in, noting he walked slowly and gingerly, continuing to rely on the support of these two women. In response to my question about what was going on he replied, “I threw my back out again; I need my shot.”

This was my first introduction to “Jimmy” the town pimp and at least two of his girls. Jimmy was a periodic visitor to the ER and his complaint and request was always the same–“bad back; need shot.” Apparently Jimmy was well known to the ER docs and after several previous assessments it was determined that there was nothing ever really wrong with Jimmy’s back other than mild muscle sprains. However, Jimmy always insisted that he needed a “shot” to get better and, I am told, would raise quite a ruckus if he didn’t get one. The ER doctor on call that night knew Jimmy quite well. After a brief Q & A, and limited exam (again confirming a mild sprain, if that), the doc went to a locked medicine cabinet, pulled out a vial and loaded the contents into a 5cc syringe. “OK, Jimmy,” he said, “assume the position.” Jimmy dropped his pants, turned away from the doctor, leaned over one of the ER beds, and said, “Ready.” The ER doctor then shot 5cc of normal saline into the man’s buttock. Jimmy let out a howl (I have it on good authority that injected saline hurts). straightened up, pulled up his pants, turned to the doctor and said, “Thanks Doc, I feel better already.” After Jimmy and his girls left, the ER doc turned to me saying, “Yup, it was a placebo. Technically we’re not to give placebos but I’ve been on the receiving end when Jimmy doesn’t get his shot; it also keeps him happy for several months and away from the ER. It also means it is less likely he’ll ER shop until he gets what he wants.”

On another occasion I was watching one of the older and well seasoned ER docs sew up the calf of a young man who had neatly sliced it open earlier that night after putting his leg through a glass door. The doc had a rhythm going with the suturing and the wound was closing nicely. Suddenly the entry way glass doors rattled and both of us heard shouts. I circled out through the waiting room and into the hallway. Several men were pulling on the ER doors and behind them I could see a pickup truck backing up close to the doors. Opening the doors I heard, “It’s Charlie. He collapsed while we were drinking and fishing down at the river.” The truck’s tailgate hammered down and there lay Charlie, all 300 pounds of him. We slid him on a gurney and rolled him into the waiting room. The doc put his hand up, indicating we should stop there, laid down his instruments, stripped off his gloves, and walked over to Charlie. Feeling for a pulse in the neck, he raised one of Charlie’s eyelids, waited a moment, then looked up at us and said, “Yup, he’s dead.” He went back to suturing. Charlie’s friends looked at each other, then at me, and one said, “Damn!” And that was it. The friends left and Charlie went to the morgue. Reality without the histrionics.

I got my M.D. in 1980 and began my training at an inner city hospital that same year. After the first year of training residents were allowed to moonlight in the ER. You learned a lot there and not all of it medicine.

One evening I saw a man who had hurt his back while at work. After the history and exam I concluded he had a mild muscle strain. He went on his was with a few days off and prescriptions for a muscle relaxant and a mild analgesic. Several days later I was called into the ER director’s office about this particular case. The director noted that I had not ordered any x-rays and I explained that I felt none were needed. While he agreed with my diagnosis and treatment he pointed out that this was a workman’s compensation case and x-rays should always be done. Why? Because if the patient ever hurts his back again, whether at his current job or another, and an x-ray was done showing some abnormality, the patient could claim his injury dated back to the time I had seen him and there would have been no radiographic proof to negate his claim. Lesson learned.

Another evening I was forewarned by a nurse about a patient who had come in by ambulance. Fearing a true emergency I quickly moved to her ER bay. With either, “How can I help you?” (a standard ER ice breaker) or, “What’s wrong?” (another) I began my assessment. “Need my sugar checked,” she replied. She saw the puzzled look on my face and explained, “I’m diabetic and my doctor says I need to get my sugar checked regularly. I didn’t have anything else to do tonight so I thought I’d get it checked.” “But why the ambulance?” I asked. “I didn’t have anyway to get here so I called them. Medicaid will pay for it.” Her sugar was fine and taxpayers were out several hundred dollars.

On an afternoon shift I saw a late middle aged man with complaints of abdominal pain. It turns out he had had it for quite some time (weeks). After the history and exam I felt this was not an acute problem and could be seen in the GI clinic. After I explained this to him he replied, “Oh, I already have one.” I then asked if something about the pain had changed such that he felt it best to come to the ER now. “No,” he responded, “I just got tired of waiting.” To my next question, “When is your appointment?”, his response was, “This afternoon.”

Booth “B” was the dreaded (at least to medicine residents) Ob-Gyn room. Notified by nursing about a patient waiting there, my fellow resident, John, and I flipped a coin to see who would evaluate the patient and John lost. He told me later when he entered the room he encountered a beautiful young lady, 15-16 years old, sitting on the ER bed. He introduced himself, asked how he could be of help, and she responded, “I want you to tell me why I can’t get pregnant.” She went on to explain, “I’ve been trying and trying but I just can’t get pregnant.” Taken aback, John weakly said, “And what does your mother think?” The girl shot back, “She says I’m trying too hard.” As brilliant a physician as he was, John didn’t even attempt an answer. As he told me later, “Harrison’s (Principles of Internal Medicine) failed me.”

This last tale (1970’s) is actually one recounted by my father, a general practitioner. An elderly married couple, whom I’ll call Fred and Molly, were longstanding patients of his and Fred was in the last days of a terminal illness known to many. Molly left to do some shopping after checking with Fred who was lying on the living room couch to see if there was anything he needed. According to Molly, Fred indicated he was “fine.” When Molly returned a short time later she found Fred unresponsive on the couch, dead. Not knowing what to do Molly first called Doc’s (the town knew him as “Doc”) office but he wasn’t in. Her next call was for an ambulance reasoning that the crew would transport Fred to the morgue at the hospital and then decisions could be made as to the next steps. The ambulance crew arrived, confirmed that Fred was without pulse and…began resuscitation efforts despite Molly’s protests and statements that Fred’s death was an anticipated event. Loading Fred’s body into the Basic Life Support ambulance the crew decided Fred needed to be transported to the large city hospital which was 12 miles away, rather than the local hospital which was only several blocks away. Halfway there the BLS ambulance was met by an Advanced Life Support ambulance leading to Fred’s body being transferred to the second ambulance and from there transported to the city hospital where resuscitation efforts not surprisingly failed.

My father would never have known about the circumstances of Fred’s death until he received a call from a distraught Molly. She had received 3 bills, one from each ambulance service as well as the hospital. To her the charges were overwhelming and, since Molly and Fred had not been financially well off to begin with, she was at a loss as how to pay the balances due as Medicare only covered a portion of the charges. Phone calls were made and the ambulance services, as well as the hospital, agreed to accept the Medicare payments only, thus avoiding the human interest story that might have appeared in the local newspapers.

So from these tales the non-medicine lessons taught included 1) there may be an occasional need for placebo therapy, 2) ER shopping/inappropriate use will be never ending (made worse by not allowing seasoned nurses to triage some types of patients), 3) workman’s compensation cases drive up the cost of medical care, and 4) ambulance personnel, by statute, are required to begin resuscitation efforts unless given a physician’s order to stop.

If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, Housecall, The Four Reasons, Medicare and Medicaid, can be found with “search” or, for some, just scroll down the page.

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Decisions

Decisions–we make them everyday. Some minor (latte or expresso today?), some major (this car, or that?), some life changing (do I marry this person?), some life ending. It is the latter that I wish to comment upon but to the exclusion of physician assisted suicide and euthanasia. The life ending decisions that I shall address deal with withdrawal of non-comfort care (from here on referred to as “withdrawal of care or ‘withdrawal'”). Let me begin with an example.

In 1985 I was a freshly minted attending pulmonary/critical care physician working in a 5 man single specialty group. I was on our ICU rotation when the housestaff (residents) presented the case of a late middle aged woman who had been admitted overnight in respiratory failure requiring mechanical ventilation. While I do not remember the specifics of the case I do remember this was not a “quick fix” situation and the patient remained unresponsive for a number of days. What I do remember is meeting with the family on a daily basis and that after two days of no improvement (but no clinical deterioration) the family insisted that she be removed from “life support.” They argued that she had told them previously that she had never wanted to be on life support and they wanted to honor her wishes. There were no written “advanced directives”, only the (permitted) “substituted judgement” of next of kin. I found myself in a bind, acknowledging the family’s request but at the same time believing the patient had a reasonable chance of recovery. Over time the daily discussions became more contentious as I refused to withdraw ventilator support arguing that the patient was showing some signs of incremental recovery while the family continued in their insistence that their loved one’s wishes be honored. Fortunately for all, the patient finally became conscious and within 48 hours was able to be successfully removed from the ventilator. By the next day the patient was able to converse and, with family present, I explained to her what had happened and then asked, “If something like this happens again, do you want to be resuscitated and put back on the ventilator?” Her emphatic response was, “You’re damn right I do!”

I present this as not a “what a good boy you were” moment but as an example of what physicians, and families, can face on a daily basis across the nation (and for that matter, the world). Decisions regarding medical treatment, especially resuscitation efforts and/or end of life, can be daunting for many and, until the moment arrives, often ignored. For you see, when really thinking about it, one is contemplating one’s own mortality. Comments like the above patient’s could have been just offhand (her’s was) or the result of thoughtful discussions with her family and/or physician. Some patients just hope that the family and physicians can “figure it out” if the patient is unresponsive or they can go to extremes like having “Do Not Resuscitate” tattooed on their chest (case reports). Written instructions, termed “advanced directives,” can be very helpful in guiding physicians as to what resuscitative care is to be provided while also providing guidance or insight to the family as to how the patient wishes to be treated. One of the key recommendations regarding advanced directives, however, is to discuss them with those who may need to determine a response to physician recommendations when the patient is unable.

One should understand that advance directives are not written in stone but only provide guidance. While physicians are obligated to follow the basic instructions of an advanced directive as this is a legal document, patients can change their mind at any time. On more than one occasion as a critical care physician I had been called to the ER to admit a patient with known advanced directives (and not infrequently a terminal condition) to the ICU after arriving responsive in the ER, revoking their directives, then collapsing and triggering resuscitation efforts. Although most rarely, if ever, survive their hospitalization, it is not an absolute as some will live to leave the hospital once again often with re-established advance directives. With all this said, let me leave the topic of advanced directives with some rules: 1) advanced directives are a good idea, 2) discuss those directives with those who may have to make health care related decisions for you if you are unable and, 3) give your physician a copy (in this day and age the directives should then placed in an electronic medical record for quick reference).

I have previously written (see “The Four Reasons“) as to what I perceived as being the basis for decision making, usually by family members, as it pertains to certain treatment, or not, of their ill loved one. Along those lines is one of the most difficult and challenging decision a physician has to make–that of withdrawal of care. Picture a critically ill patient with multi-organ system failure with continued clinical deterioration despite aggressive therapy or an elderly patient with a massive brain bleed both of whom are supported by mechanical ventilation. In either case survival, let alone meaningful survival, is extremely poor. If the physician has been fortunate enough to have cared for the patient for several days and has established a rapport with the family (in some institutions where shift work is routine a physician who has dealt with neither the patient nor family can come on duty at a time when the withdrawal of care discussion needs to occur) the withdrawal of care discussion may be a little easier to have. While each physician has their own style when broaching the topic of withdrawal vs. continuing care, physicians vary in how they leave the final decision to family but it is usually in one of two basic ways. In either, after the current state of the patient is explained and, hopefully, the family has been assured that comfort measures will continue, then the options–a) “We can continue doing what we’re doing or we can decide to withdraw; you decide,” or b), “We can continue what we’re doing or we can decide to withdraw; my recommendation is _______ (continue or withdraw).” My bias is option “a” is cruel, burdensome, and is the physician shirking their ultimate responsibility to provide the best advice possible. On more than one occasion I have encountered family members who, when they had been presented with option “a”, refused to decide to withdraw as they feared they would then be burdened with the guilt of “killing” their loved one. With option “b” the family is given the option of agreeing (or disagreeing) with the physician’s recommendation. The physician is put in the position of being the “decider” with the family providing their input regarding the physician’s decision. As nuanced as this seems, I have found (because I’ve asked) “b” to be less burdensome to the family and many have been relieved not to directly make the final direct decision.

So there, some perspective on the difficult decision making that can confront us all. I shall, however, after writing the above and thinking about it some more, make a brief comment afterall regardiing decisions pertaining to physician assisted suicide and euthanasia. We physicians are constantly looking for the best ways to advise patients regarding medical treatment decisions. In the Hippocratic oath one can find the passage, “To none will I give a deadly drug, even if solicited, nor offer counsel to such an end…” and in the Judeo-Christian religions the commandment, “Thou shall not kill.” At least for this physician that was all the advice needed.

(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, On the Evolution of the Medical Record, can be found with “search.”