Wearing The Patient Gown – Part 2

iStock_000016531274_SmallAs patients, we really just want answers. When my hunger pangs vanished (see previous post), I sat in the hospital waiting for follow-up cardiac testing. My mind became liberated to think of the possibilities of what my doctor would find or what would happen to me during the course of my evaluation. This is probably the hardest time to be a physician wearing the patient gown.

Ignorance is bliss, so they say. And they would be correct. As an emergency physician, I’m trained not just to recognize what my patient likely has, I’m also to be an expert concerning the worst possible diagnosis, and the worst possible complication. So, that’s how my brain is wired when encountering the health care profession as a patient. In most of these situations, armed with neurons that assess for every possible bad outcome, then, yes, ignorance would be bliss. However, it’s impossible to unlearn those many years of formal training and the experience that has contributed to the salt-and-pepper gray hairs on the side of my head.

As a patient, I was moved through normal hospital flow. I waited in the ED for more testing to be done. I was given updates about my tests. I was moved to PCU for monitoring overnight. I knew that a heart cath had my name on it the next morning. I was able to hold strong as family members came by. Then, I had time to sit and contemplate. What will my cardiologist find? Will there be a huge complication during the procedure? Surely not, they do these all the time.

At some point that evening, I got to speak to my 11 year-old son by phone. Keeping him in the dark may have sounded like, “well, they’re checking out my heart.” While I downplayed the situation, I did explain that the doctor was going to go in with a catheter to make certain my heart was ok, that my blood flow was good. He seemed to mostly buy my nonchalant description, until his voice cracked, and my voice, maybe, and then only ever so briefly, may have betrayed my confident exterior. Very, very briefly, of course.

The next morning, my cardiologist explains the risks of the procedure. I do this regularly with my patients to obtain informed consent. As a part his full disclosure, I am informed that my risk of dying during the procedure is less that 1 in 2,000 – 3000. That’s great, I think. Unless I’m the unfortunate 1. But, obviously I’ll take my chances and agree to proceed.

As I mentioned above, patients want answers. Doctors are not always equipped to provide those answers, despite the best of efforts. At the end of my evaluation, I was informed that my cardiac cath was normal. Normal? But, I had chest pain! While running! But, my EKG was abnormal! But, my heart enzymes kept rising! Nope. My arteries were normal. That’s wonderful news, but what landed me a night in this inn?

Maybe it was spasm of a small artery. Maybe it was a tiny tiny clot or plaque in a tiny tiny artery that we can never see by cath. Take an aspirin daily, and keep running.

While I’m not at all disappointed in the results, I can understand how a non-physician could be somewhat put off by such a huge ordeal resulting in no definitive answers. Me? I’m glad my arteries are clean. Knowing the piping is wide open, I was able to shave 24 seconds per mile off my personal record during a 4-mile run the following week.

So, when your doctor can’t find an answer, it may be because there isn’t one to be found. We aren’t gods, despite what our egos sometimes tell us. We can’t know every little thing that happened. What we can do is to try to make sense out of the information that is in front of us, and provide the most plausible explanation and treat accordingly.

These days, I run, I haven’t missed one dose of aspirin, and I try to get my patients food as quickly as is reasonable. Personally, I found food a double-edged sword. Once my hunger was gone, I lost enough distraction that I had to sit with my own doctor thoughts and consider the life-altering findings that were waiting for me the next day, or contemplate the endless complications that could leave me comatose or dead. Perhaps I would have been better off fasting.

Wearing The Patient Gown

I wish I could eat. My doctor told me I can’t. Not until all my tests are back. I understand. I do that to patients all the time. Still doesn’t make my stomach feel any better. That should be the least of my worries, but it’s not. I’m still hungry.

So, I sit in my little room in the ER, trying to keep my chest leads on so the annoying monitor doesn’t beep. Let me tell you, I prefer to be on the other side of this experience, not half naked covered by a not adequately buttoned gown. Shot caller. That’s the place I prefer to be in this patient-doctor arena.

Yet, I’m not the shot caller. Today, I’m the patient who was out for a 6-mile run and developed chest pain about 2 miles into that. Not bad pain, maybe 3/10, left sided, kind of an ache. Not a big deal. I’d stop and walk a little and it would go away. Hmm… Probably nothing. Start running again, at an 8:40/mile pace, after a third to a half mile, the same pain. It feels like when I’m running in the cold and my chest is a little tight. The only problem with that is it’s a perfect 75 degrees.

I’m an emergency physician. I’m trained to not overreact. But, I’m also trained to not ignore. I run through all the typical questions I would ask patients, only I’m not a good patient. I’m still running. Does the pain radiate to my arm or my neck? No. Is it getting worse? No. Am I short of breath? No, not any more than I should be on a run. Am I sweaty? Duh.

So, after 7-8 episodes of chest pain with running that goes away with walking, I run (yes, I did) on over to the firehouse, where I ask the fire fighters to do an EKG for me. They did, and it’s not normal. Uh oh. Honestly I’m too young for this. I’m 42, I run 20-25 miles per week. Blood pressure, and cholesterol good. I don’t smoke. I don’t snort cocaine. I don’t really have time for this. I’m supposed to be at work in 3 hours. Doctors don’t get sick. We don’t NEED doctors. We ARE doctors.

Until we’re not. So, I wait hungrily. Maybe I’m not so hungry. Maybe the hunger is a diversion that I’m anxious that something could be wrong. It’s easier to focus on a few pangs from my stomach than to concentrate on the fact that my ticker is in disarray. Sometimes it’s good to be a physician. Other times, ignorance is bliss. Right now I’m somewhere in between.

If you’ve ever wondered what happens when doctors get sick, let me tell you. We try to be good patients. We have an intelligent dialogue with our health care providers to develop the most reasonable plan. We try not to complain. We ask good questions, but we defer to the experts taking care of us. It’s impossible to give yourself good care.

And, like all the other patients, we wait. We wait for tests and consultants. We wait for good news or bad. While our stomachs churn just like all the non-doctor patients around us.

Sometimes A Cold Is Just A Cold

young female having a coldWe’re all human. When we get sick, we want symptom relief. We all want a pill to make us feel better. Pills are easy and they’re everywhere. It’s time that we don’t have. We don’t have time to feel so bad. The problem is, humans suffer illnesses. Some smarter than me have said that illnesses and pain are symptoms of being alive.

In general, we can break the cause of these illnesses into bacteria and viruses. Bacteria may get better with antibiotics (keep reading), but viruses don’t. Most common sicknesses are what we call self-limited, meaning they’re going to get better whether or not you see your doctor. When you’re sick with a cold (caused by a virus), even a really bad cold, you plead with the doctor to give you an antibiotic. You may even find some old antibiotics lying around. You pray to the god of whatever –cillin drug you ingest, and you do get better. Eventually. Yet again, you suffer the delusion that the Z-pack made you better.

The problem with that? You were going to get better in the same amount of time anyway. Yes, I know you got better with the antibiotic, but your body was already fighting the virus. Your immune system was making you better.

Even some bacterial illnesses have shown they don’t necessarily need antibiotics. Studies show most ear infections get better without antibiotics. So, really we should start off just treating the pain from the ear infection. Sore throats? Most of them get better on their own. Steroids can help the pain of a sore throat. Bronchitis is another common ailment. So, you’re coughing up thick green stuff and running a low-grade fever. Antibiotic? Not helpful, unless you have a chronic lung disease, or it’s actually truly pneumonia that you’re dealing with.

What’s the harm in getting more of the same antibiotic that helped you last time? Well, the harm is multitude.  First, dispensing antibiotics to anyone with a sniffle means that those antibiotics are circulating in your body for all the bacteria to figure out ways to be resistant to it next go round. It’s like we’re letting the enemy know the game plan for how we’re going to combat them in the future. They are taking notes. That’s why each year hospitals have to release reports about what percentage of the bacteria are still sensitive to the drugs.

Most people don’t really care a lot about antibiotic resistance, especially in the short term when they feel terrible. But, there is still the potential for things we all care about: diarrhea, allergic reactions, rashes, and pregnancy. Diarrhea? Sometimes only a minor inconvenience, other times it can be so severe it leads to hospitalization. Pregnancy? Yes, some antibiotics can make oral contraceptives less effective.

So, herein lies the rub: as your physician, I want to do the right thing for you, but in today’s climate, I need to do that in a way that you don’t evaluate me poorly because of it. It’s easier for doctors to do the wrong thing. It’s easier to prescribe antibiotics that aren’t needed because we think that’s what our patients want, and we’re usually right about that. It’s also less time-consuming to write a prescription than to explain all the reasons why antibiotics won’t be helpful. So, some doctors prescribe. Personally, I like to educate my patients on why I think the therapy they’re seeking may be harmful.

How can we differentiate what needs antibiotics ourselves? Well, obviously that’s challenging to summarize in a blog. I went through a lot of training, and I still sometimes have legitimate trouble sorting it out. In general, I explain to patients that bacteria tend to cause fever and fairly local symptoms: fever and sore throat, fever and cough, fever and earache. When your symptoms cover multiple systems, such as fever, achiness, congestion, cough, and sore throat, that usually suggests to me it’s a virus, and antibiotics are off the table.

If you feel bad, it’s usually reasonable to give it a couple of days to see how you’re doing. If you find you’re rapidly getting worse, go see a doctor. If you’re symptoms have taken you beyond inconvenience and you’re legitimately worried, go see a doctor.

So, how can we save some time and money? My advice is the next time you have a cold, even if you really feel bad and are tired of having a cold, think twice before going to the doctor. If you do have some symptoms that are worth getting checked out, or maybe you need some symptom relief, at least be open to the idea that antibiotics may be exactly what you don’t need. Understand that a good physician still has your best interest at heart.