Sleeping dogs

"Not that you think I might have an alcohol problem...!"

Yes, when I hear these words they usually tell me that the patient has one.

"Not that I don't want to work, but...!"

Yes, that's when I take a mental note that this patient doesn't like his job or work in general.

Absent Ghost

One of my patients is like a ghost. I just know him by phone. He calls me every third or fifth week, to talk about some other doctor's exams and his/her recommendations and he asks me, whether I think them to be justified. 

Then I tell him, that to know I should first get the report from that doctor. So my patient agrees, "Yes, that's a brilliant idea, yes, I'll get the papers for you!", and promises to come and see me soon - but then he never shows up. 

I usually tell him by phone then, that the proposed therapies seem to be okay, and what options there are if he should remain doubtful. He thanks me and announces to show up soon, only to call me again for some other problem a few weeks later. It's very funny.

Is it still serious medicine that I'm doing this way? Up to now I felt no pressing urgency to call him in, the problems all could be handled safely that way, but of course the day may come where I'll need to see him. 

It's just that I realized how this pattern is repeating itself now for 7 months or more and how I start to smile when one of my ladies announces another call by Mr ... Ghost.

Potential side effects - justify your interventions!

I remember a patient in the clinic with a very rare genetic disorder, that affected his collagen fibers, that was known to cause aneurysms of the big vessels already after a harmless trauma.

There are different types, but an aneurysm is basically a pathologic widening of a vessel, usually of an artery, as if in one place a tube suddenly blew up like a balloon. Of course this is bad for the current in this vessel, the aneurysm leads to turbulences that themselves oftenly increase the size of the aneurysm. It's a vicious circle that can remain somehow stable for a long time, even for one's whole life, but that can as well suddenly lead to an uncontrollable growth and rupture of the lesion with major, eventually lethal bleeding.

This patient I remember was hospitalized for some obscure belly pain. He knew about other persons in his family with the genetic disorder, but he didn't know that he had it himself and he didn't mention it, when he was admitted. He was in his thirties or forties, had children, and didn't remember to have ever suffered from serious medical problems.

Maybe he had been asked routinely by the admitting resident, whether there were some noteworthy family events, and he did not remember, or maybe he was not even asked, because to this question patients sometimes tend to give lengthy reports about family events and names of involved doctors and preferrably professors that often are of little useful information, so it is a question that tends to be neglected, when there is not enough time (which is almost always the case) for the initial exam. Though in some cases the informations from the family history can be absolutely essential!

Diagnosis and treatment were difficult, the patient obviously suffered from a serious problem but reasons were not easily identified. At one point he was operated. Then, during his stay, there were more and more problems and finally and sadly he died. By then it was known that he probably suffered from his family's disease and precautionary measures were set in place, he was treated like a raw egg, but too late, important time, days, had been lost. It has to be said that he probably died from the consequences of the aneurysm that caused already his initial problems and had led to his admittance. And yet!

As tragical as this case was, what fascinates me until today is the following: when, after his death, his body was examined by a team of pathologists, they found multiple aneurysms in different parts of his body. They were all over!

Basically it could be reconstructed that every invasive procedure to his vessels had left an aneurysm at the spot where the intervention had been performed. And most shocking: not only simple intravenous punctions, as usually done to obtain a blood sample, had left him with an additional aneurysm, but even at the site of his upperarm where his blood pressure had been taken (before his disease had been known), there were aneurysms as well.

Imagine: even taking your blood pressure can once have (serious) side effects. To me, this is a very noteworthy illustration of the fact that no useful intervention in medicine is without potentially harmful side effects! Every intervention has to be justified!

Do you remember me?

Recently I met a patient in one of the elevators of the hospital. I recognized him immediately though last time that I had seen him he had been in a much worse general state and far from only leaving his bed. I said 'hello Mr ...' and expressed my joy to see him so well. He looked at me with surprise, first said thank you but then found it unbelievable that I could remember his name. We had only met twice on a sunday afternoon two weeks ago, how could I remember who he was?!

This is something many patients don’t realize. There are patients a doctor on call may see only a few short moments on a weekend or at night. But outside of their room he spends hours discussing and reevaluating the situation with nurses, supervisors, specialists, in front of an x-ray or lab parameters or articles in books and specialised magazines. That’s how he gets to memorize these patients. That’s why he knows them by name weeks later.

No Answer

A typical situation in the medical emergency room: the phone rings, I lift the receiver and say my name and function and then: silence. No answer. Nothing.

I repeat „hello, you can speak now“ but noone talks, only static crackles. But I also hear that the line is open. And sometimes I can hear somebody breathe.

And then I know from experience that this is usually someone who is trying to commit suicide. Maybe he’s just taken an overdose of sleeping pills. Maybe there’s a loaded gun next to him and I’m the last person he calls.

Usually I just ask bluntly: „Hello, how are you? Did you swallow any tablets? Do you need help? What’s your address?“

That’s usually when I hear the first sound. Often it is not clear talking but a muffled sigh or some crying, sobbing. Only later come the words. As soon as I get an address, I’ll send an ambulance to the place.

Once a lady told me that she had taken an overdose of tranquillizers to end her life and in that moment in the background you could hear a door open and her family come home.

She hang up.

Do one, see one...

On my surgical rotation, after two months in the outpatient clinic, I just had my first day in the emergency room. When I arrived, my colleague told me, that there'd be a lady waiting for an appendectomy.

Me: "who's going to do it?"
She: "You."
Me: "Who...?"
She: "You! It's your's."
I was laughing my head off. The last one I had seen was when I was in anesthesiology, about 4 years ago, and now I should do one myself. First I wanted to see one, so we arranged that my colleague did it.

Okay, now I know what it is about, I'm eagerly waiting for the next one...

Is my doc his money worth?

The main problem in western healthcare today is that it is getting too expensive.

There are several factors accountable for this. But the key reason, that prevents an effective cost control, is that healthcare is an extremely intransparent market. It is very hard to know for patients, whether their doctor is a good one or a bad one. Even for doctors themselves, it is many times almost impossible to find out how good or bad their colleagues are.

If there was a way to measure the quality of physicians' work, one that would allow to really compare one doctor with another, that would be THE breakthrough to give market forces a realistic chance -- which would lower costs in healthcare substantially.