ACP Internist Blog


Friday, January 18, 2019

Yes, yes, y'all

A life was saved. Yours. And I was there and involved and there to bear witness to it all.

Yes, I was.

No, it wasn't in that sexy or thrilling way. You know, like the kind where someone tears into the room and dives upon your chest for compressions in a single bound. It was nothing like the ones they recreate for melodramatic television dramas with people running beside fast-rolling gurneys steadying wayward IV poles and charging up defibrillator paddles at the same time.

Nope.

But still. A life was saved. Yours. And I know it was because I was there and have been doing this for a while now.

Sometimes we miss it. Those moments like this one. The ones where just one tiny shift in the path does something game-changing. A teeny, tiny nudge toward a seemingly insignificant fork in the road that moves the patient inches away from a giant cliff. Or maybe not a cliff because those are big and obviously treacherous. This was different. More like a slow, downhill trainwreck.

Yes, that.

See, a student listened to you and then shared your story on rounds. Described what you said in detail and all that had been done. And the way he honored your truth helped me to make sense of your perspective but simultaneously recognize that some aspects of our direction didn't make sense at all. And so, I asked one question. Which led to another question. That became a discussion with the whole team.

“Why is this?” I asked. “This doesn't make sense to me. Does it make sense to y’all?” This is what I asked my team. And yes, I said “y’all” because I think easy and calm learning and working climates help us think easier and take better care of patients like you. Or not even just like you. Like any patient who comes before us. I do.

So that student wrinkled his nose and thought about it. And so did my resident and my interns, too. And, though I could not see myself, I am certain that I did the same. Because it didn't make sense. The path we were on and that you'd been on for months and months did not.

Nope.

We came up with a plan. To bring in a consultant to look at some aspects of your case. The parts that weren't readily explainable by the standard pathophysiology of your working diagnosis. And that--that call? It was a game-changer. It was.

And, I think, it saved your life.

No, not in the fireworks and confetti way. Not like that old TV show “ER” or even the newer ones like “Grey's Anatomy.” More like with the subtlety of shaking a tiny shard of glass out of a shoe that could ultimately lead to something bad or even adding a drop of much-needed oil to a bike chain and popping it back into place before the entire thing is irreparably destroyed.

Yeah. Like that.

And I thought about it the whole way home. I thought of you and the story you told and the student who listened and the socioeconomic challenges that you face. I reflected on the barriers all around your care that day and how God let this tiny ray of light slip in. And how all of it working together saved your life. I thought about that for my whole drive. Then the next day, I talked to my student about it and cried right in front of him.

I sure did.

“We don't always get it right,” I said in our team room later, “but on some days, we do.” And I wanted them to not miss what our team had done. They didn't.

A life was saved this week. Yours. And I was there and involved and there to bear witness to it all. A life just as worth saving as my own. Or any person involved in your care. I am so proud of the care our team gave to you and the privilege we had to be involved. Damn, I am. And no, we don't always get it right. But this time we did.

Yes, yes y’all.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.
Monday, January 14, 2019

Eye protection and seasonal influenza

At the last HICPAC meeting, Drs. Bryan Christensen and Ryan Fagan led an excellent discussion of the following question: should eye protection be included in droplet precautions for seasonal influenza and other respiratory viruses?

Eye protection is one aspect of Standard Precautions, of course, to be used whenever there is a risk for splashes or sprays of blood and body fluids (BBF), or during aerosol-generating procedures. However, there is no recommendation for routine use of eye protection as part of Droplet Precautions—it's an “unresolved issue”.

Nonetheless, whenever CDC has had to issue interim guidance for new respiratory viral threats (SARS, MERS, novel influenza A viruses, etc.), they've included the routine use of eye protection. But seasonal influenza kills far more people annually than any of the novel threats, and there's little reason to believe that seasonal flu strains can't use the eye as a portal of entry (in addition to rarely causing direct ocular disease). The same applies to various other respiratory viruses (adeno, RSV, rhinovirus, hMPV, etc.).

As is so often the case, we don't have much published data to help answer this question: some work done in the 80's suggested that eye protection was important for RSV transmission prevention, and Dr. Werner Bischoff demonstrated in an experimental system (air chamber into which live attenuated influenza vaccine virus was aerosolized) that the eyes could serve a portal of entry for influenza. So definitely wear goggles if Werner invites you to enter an airtight test chamber.

Anyway, thanks to Bryan and Ryan for their review (I will link to it when the transcript is out), and to HICPAC members for the lively discussion that followed … so what do you think? Does your center use eye protection routinely for droplet precautions for seasonal flu?

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, January 10, 2019

Lewy body dementia and a farewell to my father

When I finished my training I was taught that the vast majority of dementia was Alzheimer's disease, with occasional cases of multi-infarct dementia as well as odd syndromes such as Kreutzfeld-Jacob disease and genetic, traumatic, toxic and tumor related syndromes. Parkinson's disease, we were taught, caused a tremor and freezing up of a person's movements and only very rarely was associated with any kind of memory loss.

These teachings helped us modern doctors leave behind terms such as “senility” or “hardening of the arteries” to explain cognitive loss. We still had no useful tools to change the course of dementia, but we were more scientific in our description of it.

In the last several years, however, neurologists have determined that there is a very common dementia that is associated with Parkinson's disease. Lewy body disease or Lewy body dementia was a condition that I had been taught was not only uncommon but only accurately diagnosed at autopsy or with a brain biopsy. It appears, now, that it is quite common, comprising up to 30% of cases of dementia. It is more common in men than in women, like Parkinson's disease but not like Alzheimer's disease, and is more common in people who have higher educational attainment. It is characterized by collections of protein known as Lewy bodies that are found throughout the cerebral cortex, rather than just in the movement centers of the midbrain, as in Parkinson's disease.

There are some medical tests that will help to diagnose Lewy body disease, but they are not commonly performed. It is most commonly diagnosed by the identifying two of four common clinical features. These are:
1. Fluctuating cognition with varying levels of consciousness and alertness. They will fall deeply asleep and be unarousable or be very slow and confused, lasting hours sometimes, then improve to a more normal baseline, laughing and participating in conversations. Family will sometimes think they have had a stroke or a seizure.
2. Visual hallucinations. These may be quite detailed.
3. REM sleep disorder. Patients will often talk in their sleep or do complex movements, often getting up and walking or performing complex behaviors. This can be disturbing and even dangerous to a bed partner.
4. Motor features of Parkinson's, including pill rolling tremor, slow movements and rigidity. These features almost always follow the development of memory loss.

Patients have other clinical features such as depression, anxiety, apathy and loss of executive function (unable to clean a closet, sort and pay bills or put together a photo album.) They often have autonomic dysfunction, with fainting spells due to drop in blood pressure or inability to tolerate changes in temperature. They become unstable in their walking or standing and fall frequently. They have urinary incontinence. They have delusions that are detailed and hard to shake.

My father had this and I didn't recognize it until about 3 months before his death. He was a very smart man, having graduated in physics from Caltech and then worked with early computers and was an important part of the space program. He worked on developing electric cars and wind power and studied the feasibility of oil shale and tar sands (not feasible and not efficient, he concluded.) He brought a supercomputer to the island of Maui and helped jump start their technology industry. He was funny and engaging and had a knack for encouraging others by being a springboard for their ideas. He was the most compelling conversationalist I have ever known and played a mean game of Scrabble.

When he lost his wife to cancer 12 years ago he began to notice some disturbing memory failures. He put those down to the stresses of home hospice and the depression that followed her death. He was capable with his laptop computer and enjoyed the early handheld computing devices, but when he got his first smartphone, the technology became more difficult for him to learn. He could use email, but forgot how it worked and never learned to access it with his iPhone. He took on the position of board president with an academic organization and wasn't able to keep up with what he needed to do. He resigned and felt terrible about that. He tried to take blood pressure medication but would pass out unexpectedly so stopped it. He kept all of his mail and couldn't figure out how to file it, feeling ashamed about the state of his desk. He flailed and talked in his sleep so much that his wife had to go to bed elsewhere. He would wake up at 4 in the morning, inconsolably sure that he needed to catch a plane or teach a class.

He fell frequently and when he walked or stood, would lean to one side, unaware that he was doing it. It was nerve wracking to walk with him because he refused to take an arm and never learned to use a walker or cane. He slept more, often while sitting up, and had periods of unresponsiveness that were alarming. His falls were not minor and he gashed his face and ripped the skin on his arms, broke his hand and hit his head hard enough to spend an agitated night in the hospital. His writing became small, shaky and cramped.

It was clear he had dementia and that it wasn't a normal kind. He saw a neurologist who thought he might have Parkinson's disease and a wonderful gerontologist who diagnosed Alzheimer's disease. His wife, who had been attending a dementia support group, had heard about how common Lewy body dementia was and suggested it might be that. I read the most recent literature and decided she was right. Not only did he have it, so had many of my patients over the years who I had thought had Alzheimer's disease.

The fluctuations. The falls. The detailed hallucinations and delusions. The executive dysfunction. It isn't subtle how different it is from Alzheimer's disease. These are the people who come into the emergency department frequently when they are clearly worse than normal but improve overnight and return home, even though we think that's a bad idea. They do fine until they fluctuate again and then are back. These are the difficult to handle patients with the mean delusions who drive their families or spouses nuts but are unmanageable in nursing homes. If Alzheimer's disease were vanilla ice cream, Lewy body dementia would be rocky road, with real rocks.

My father was a sweet guy but this disease made him critical, unkind and selfish. But only sometimes. Only when we were so deliberately stupid that we didn't understand that his reputation would be ruined if he didn't get to the airport or to the lecture he was supposed to be giving. Only if we tried to help him walk when he could clearly do it better without our pushing him off balance. Only when he woke up scared and didn't understand what was going on. At other times he was kind and appreciative and full of sweetness, humor and wisdom that he could no longer put express with words.

It was possible for him to stay at home with his wife for a long time with the help of caregivers. Eventually, however, the combination of impulsiveness, weakness and sleep disturbance made even 24-hour caregiver support inadequate and he had to be moved to a memory care center. The facility was really wonderful, catering to the dotty, delirious and demented, many of them with what appeared to be Lewy body dementia. He perked up briefly after moving, but then began to sleep more, sitting up in his wheelchair. He still had up times, explaining the chemical properties of tungsten, listening to a talk I needed to practice and offering good questions. He became weaker, unable to hold a cup or a fork, barely able to lift a cookie. Eventually he didn't wake up at all and two days later died peacefully, in the care of hospice.

Since his diagnosis, I have been much more aware of those demented people who don't have Alzheimer's disease. It helps to know, so we don't compare them unfavorably. They aren't just difficult people with dementia, they are regular people with difficult dementia.

Robin Williams, the gifted actor and comedian, developed a set of disturbing symptoms in the last years of his life that were unexplained but progressive and horrible. He said goodnight to his wife one evening (she slept in a separate room because of his sleep behaviors), went to his bedroom and hung himself. An autopsy showed severe Lewy body dementia. She wrote a letter to the journal Neurology detailing their medical odyssey. It is heartbreaking to read.

We have no useful treatments for Lewy body dementia. Sometimes benzodiazepines help a bit with the sleep disorder, but my experience was that they did nothing. Anti-psychotic medication is not helpful and often can worsen the symptoms significantly. Parkinson's medication can help with the rigidity and tremor, but my experience was that, by the time that was prominent it was more helpful for my father not to have the ability to act out his impulsivity. A wheelchair was much safer. Cholinesterase inhibitors, used in Alzheimer's disease, are recommended but don't help much and can cause sleep problems, nausea and drooling.

I will miss my father. I will think about his voice, his conversation, his smile, his love of math and his scientific contributions. I will remember his smell, his wispy white hair and the way he loved to have his back scratched hard. I will not miss his last 6 months, though, and I resent those nasty Lewy bodies that infested his wonderful brain.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Friday, January 4, 2019

Stigma

I tell myself: Speak in tones that aren't patronizing and sorrowful or as if you're irrevocably broken. Then coach yourself away from the fear of not being able to help.

Like really help.

I think what gives me the most angst is the math of it all. The numerator of too much always, always, always divided by that denominator of not enough.

Remainder: Too much.

It looks like a lattice. This network of scarred remnants of self-mutilation covering your limbs. I heard this lady say on television once: “Why would someone take a knife and cut themselves on purpose? Why would someone do that?”

The girl she was talking to on like Dr. Phil or whatever it was countered sharply: “You sound stupid. It is never about the cutting.” Then she rolled her eyes hard in this way that made that point stick for me. Focusing simply on the concrete act is asinine. Because it is never just that.

“I think we can discharge you from the hospital,” I said. “How does that sound?”

You nod and shrug. “That's fine.” And that's it. Your eyes float over my head and somewhere else. Where I do not know.

“Are you still hearing voices?” I ask. You shake your head no. “Good,” I say. Though I feel everything but.

The medical part has resolved. The psychiatry team has given their recommendations for the mental health parts. Our team has kept you firmly on the balance beam through this hospitalization even after a few topples. Now is the time to prepare you for the dismount. But that's the problem, the dismount. This life that awaits you just won't let you stick the landing.

Nope.

The math is bad. Too much divided by not enough. Too much is left over every time.

You are sitting on the edge of the bed. Yawning and rummaging through the sheets for a cell phone or a wallet or some other personal item. Shoulders slumped and resigned to whatever is next. I stifle an inward sigh. Whatever is next? It's just too much. Still divided by not enough.

But too much what? Divided by not enough what? Too much awful divided by not enough better? Too much need divided by not enough resources?

Or am I a part of the problem? Too much learned helplessness divided by not enough optimism? Too much ignorance divided by not enough courage? Too much darkness divided by not enough light?

I tell myself: Speak in tones that aren't patronizing and sorrowful or as if you're irrevocably broken. Then coach yourself away from the fear of not being able to help. Like really help.

Then help. Like really help.

Or at least make up your mind to try.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.