Geriatrics: More Hospice

Today Justin and I started our day at the hospice center at JLWest, where we each saw a new admit (Justin saw the woman he did a consult note on yesterday). My patient was a 71-year-old man recovering from both a stroke and a parietal craniotomy (he had glioblastoma), and to me, he didn't look like he should be in a hospice center. He was eating well, could carry on a conversation perfectly, and had plans to eventually be able to get up and walk again. We tried to help him stand when Dr. M came to see him, but his left leg was way too weak to support his weight. Hopefully he'll be able to go home soon. Today was the first time I ever heard of "respite" hospice, where a patient goes to a community hospice center for a few days if the primary caregiver is overwhelmed and needs time for him/her self. There was a 96 year old Chinese patient that Dr. M went to see, and when he learned that Justin and I could both speak Chinese, he lamented not letting us talk to her. One patient I did see was near death; he had Cheyne-Stokes breathing and would sometimes go up to twenty seconds without breathing. The nurses have thought he was going to die every day since Sunday, so with him, it'll probably be a matter of time.

We got out one hour early, so I went to school to check email and ran into Dina. She was meeting Ben and Susan (with baby Anara) at Joe T Garcia's for lunch and invited me to come along. Not about to pass up a chance to meet Anara, I went =). Ben was still working at Harris, so it was just Dina, Susan, and me. Anara is 2.5 months old now and very adorable; she definitely looks more like Ben. It was cute hearing Susan describe Anara's growth progress and how one of their dogs, Minnie, has treated Anara like her baby and has become like a third caretaker to her. I wasn't able to stay until Ben got there, but it was nice catching up. Dina and I found out that we have our interviews in Austin on the same day, so we may share a hotel room the night before.

In the afternoon it was back to Harris where Justin and I ended up sharing a new hospice patient, a lady who came to the hospital with abd pain that was found to be ischemic bowel (yikes), and she hasn't awakened since her surgery. She only has one kidney and her creatinine is starting to go up, but her children don't think dialysis is best for her since it's not what she would have wanted. So hospice is the way to go. Justin did the physical exam while I wrote the note; Justin observed my mannerisms and said I'd make a great ICU doctor. Uh oh. What part of Dr. L or Dr. O rubbed off on me last month? =P

Geriatrics: Hospice Week

This week Justin and I are finishing up our geriatrics rotation doing hospice and palliative care (Corey's in Philadelphia taking his PE so he only gets 2 days of hospice care when he gets back). At Harris, where we were supposed to fill out paperwork and get badges made, we ran into Dr. KC, our Green team 4th year resident from ObGyn. She's working at Harris now and, from the looks of things, couldn't be happier (she was all smiles as always). It was good seeing her again. After we got our badges made, I called Dr. M only to be told that we didn't have to meet him until noon lecture, giving us 2 hours of "freedom" before then. I've been trying to find a pair of Danskos in Cordovan (that reddish hue) in my size and found them at a Scrubs Etc in Hurst, so I was happy =) Noon lecture involved learning about falls and how to prevent then, and then Justin and I returned to Harris with Dr. M. We each got a consult to see; Justin saw a hospice consult, and I saw a pain management consult. This lady was complaining of right leg pain (diabetic neuropathy) that was so painful that she was crying as she spoke to me, and she made several comments about how if she can't walk again she'd be better of dead, and why can't someone just chop off her leg so it'd stop bothering her anymore. I checked her meds and found her on Xanax and almost the full dose of Cymbalta (which can also be used for peripheral neuropathy), and Dr. M ended up upping her dose to the maximum with Cymbalta. He also prescribed some capfaisin (?) cream for her feet so they wouldn't hurt as much. Justin's patient just looked like she was almost at death's door, but her husband is hoping she'll last until their 43rd anniversary in two weeks. *sigh* Doesn't seem likely but it'd be nice.

Geriatrics: Last day of GAP clinic

For our last day of GAP clinic, we saw that there were three annual exams scheduled for today. Annuals take longer b/c you have to do a MMSE, a geriatrics depression scale, and various other questionaires about nutrition and other important things in life. None of us have had much experience with annual exams since Meng usually does them (though Justin and I did one on our first day of GAP clinic), but Justin and I, being future internists, had a pretty good idea of what to do. Corey, future radiologist, was still trying to find things on EMR, and he seemed determined not to see a patient requiring an annual for that reason. I took one of the physicals and met a very nice woman in her 80s along with her son. She seemed very alert with very little cognitive decline; she only had trouble naming animals and got the hands of a clock confused during the clock test. I probably spent an hour with her, and but it was well worth it, and afterwards her son thanked me and told me I would make a great internist someday =) When I left the room I found that Justin and Corey were gone; because there were so many no-shows, Dr. JK sent my "partners-in-crime" to Westover Hills to start seeing patients (we had 11 for the afternoon). That was fine with me; I just saw one other patient who needed and ER F/U for abdominal pain that Dr. JK and I think is attributed to anxiety more than anything else (but we're giving her Ensure with fiber and Benefiber to keep her bowels healthy, anyway).

I left the PCC at 12:30 and drove to Chick Fil-A for lunch. I left just as Corey came toward the restaurant; he said there were only three patients left to see. Back at Westover Hills, I meant to see two patients (I was taking too long pre-writing notes so Corey offered to see another pt to speed things along), but one of them was away at work and the other was perfectly fine (just needed labs). We went to some interesting rooms today; one lady had a room full of antique vases and other things from her grandmother and great-grandmother's time. We also saw my bipolar patient who'd taken St. John's wort; she was still having some abd pain so to be safe, we removed the bottle of St John's wort. With all the notes that needed signing and orders that needed writing (I spent about 5-10 minutes just trying to find a chart with patients' weights in it), even when starting rounds at 2:30, we didn't get out until after 5:00 pm. Imagine if the guys hadn't prerounded on the patients starting at 10:00...I'd hate to think how long we'd be there.

Geriatrics: Small is not harmless

This morning my classmates and I were supposed to present the papers we'd written about our experiences with grief, but Dr. RM never showed up at the appointed time (apparently he forgot). I was a little disappointed b/c I'd looked forward to hearing what others had to say, but instead we passed the time by chatting about our various rotation experiences (Eric and David had lots to share about their surgery experiences). Dr. JK gave Justin and me our patient cards for the afternoon (Corey was randomly chosen to spend his afternoon with another attending at the PCC) with the understanding that we'd see be ready to present at 2:00 pm. So we saw two patients in the morning, then two patients after lunch, and managed to start rounding a bit early.

One of my Alzheimers patients was all nice and sweet when I saw her (she kept humming Christmas carols), but later, for no reason at all, she came up to me with a somewhat menacing stare (even though she was smaller and thinner than me, I still felt scared) and asked me what I said. "I didn't say anything," I said, and a nearby nurse got the patient's attention and made her sit down. Dr. JK later told Justin and me that my patient used to fly into rages when she didn't get her way and has beaten both her grown son (gave him bruises all along his arm) and her incapacitated husband (who had a stroke and couldn't defend himself), and while she's calmed down considerably, her behavior can still be unpredictable. Another of my patients was a former firefighter captain, and he has a habit of spitting as he walks. It made me watch my step to make sure I didn't step on spit. We also met a lady who's been at JLWest for 13 years; there was a meeting held to discuss her care, but her son has been to so many of these meetings (52 to be exact) that he knew the drill and the meeting resolved in 5 minutes. Dr. JK also dug up some EKGs for Justin and me to read; I think we've gotten better at it =P

Geriatrics: The Flat Tire

This morning Corey, Justin, and I went to the Arlington Heights Health and Rehab center to see some more longterm care patients. From the start, we could tell that AHHR was nothing like Lakewood, Westover Hills, or any of the other assisted living facilities we have seen. The interior had a more hospital-like setting, and the halls smelled of urine and medications (the reason for this was that AHHR was for Medicaid patients who can't afford other luxuries that the other places offered). And of the 4-5 patients assigned to us, all of them had either dementia, a psych disorder, or both. One lady with bipolar and dementia was convinced that she had pneumonia and even went to Sherry to inform her that she had a doctor's appointment later that day (and her roommate looked at me and gestured that the woman was "cuckoo"). Another guy with schizophrenia went down the hall mumbling to himself, and when I called his name, he turned to talk to me but had extremely pressured speech and some mild lip smacking tardive dyskinesia. My last patient had multiple sores on his body b/c he'd been paraplegic (paralyzed below the nipple) for almost thirty years after a C5-C7 injury. Sometime later, when we were all in the conference room discussing patients, a nurse poked their head into the room and asked, "Does anyone here drive a Honda Accord?" I said I did, and after describing my car perfectly, she said that it had a flat tire. Whaaaaaaat?! I went outside to check, and sure enough, my car's left rear tire was completely flat. I had no problems driving to AHHR this morning so I had no idea what went wrong, but even still, I was grateful that my tire didn't burst while I was driving. After talking it over with Corey and Justin, we decided to leave my car at AHHR until after our afternoon shift at Westover Hills.

The three of us did lunch at Chick Fil'A (Corey's favorite fast food restaurant; he joked that the chicken had crack) before going to Westover Hills. We had time to kill before Barb (the NP) arrived, so Corey and I played a round of checkers (and I got soundly defeated). When Barb arrived, she assigned us two patients each and gave us a little information about each one (which none of our attendings have ever done, so this was nice), warning us if any patients were particularly cranky. One of my patients was rumored to be quite argumentative, so I made a note to be on my best behavior. She was a 95 year old lady who used to be an opera singer in FW, so her room was filled with pictures from her glory days in the 1950's. She was nice enough and told me she developed RUQ pain after taking St Johns wort, but fortunately she knew to stop taking it by herself. Barb said that there are many residents here that she'd love to take home and care for as a surrogate grandmother, and others where she can understand why their family doesn't visit b/c they're so cranky. Pretty interesting overall.

I called Triple A after work and they send someone to my car within 10-15 minutes. Justin drove me back to my car, and the repairman showed me that not only was there a nail deeply embedded in my flat tire, there was also a thin slash across part of it (on top of that, the tread was wearing thin so I would have had to change the tire anyway). A part of me wonders if someone purposely cut my tire. At any rate, the spare tire was put in place and I was cautioned not to drive more than 50 mph. Luckily for me, Lancaster St goes all the way to Arlington so I was able to return home without ever driving on the highway. I'll get the car fixed at a later date.

Geriatrics: More Long-term care

Today Corey, Justin, and I went back to Lakewood Village. As we sat surrounded by charts and jotted down medications and problem lists, a woman nearby kept humming and singing non-stop (though I couldn't recognize a particular tune). Then another woman set off the alarm by opening one of the doors leading outside. I had to wonder how much order there was in the dining room (where we were charting) or if we med students were the only non-residents there. One of the patients I saw was 99 years old and practically completely deaf; I either had to scream in his ear or write on a sheet of paper. I asked Sherry (the NP) if he could benefit from hearing aids, and she told me that most families won't do it b/c it costs about $3000, which is almost as much as it costs to stay at Lakewood for a month. Fortunately we were able to finish before noon, but the three of us were late to the geriatrics board review at noon (led by Dr. JH). At least there was free food =)

On a random note, looks like I was right to make December my vacation month. It's not easy scheduling interviews during a rotation.

Geriatrics: Another Day

This morning Corey, Justin, and I found ourselves back at Lakewood, but this time we were working in the long-term nursing unit where patients undergo physical therapy and more after they are discharged from hospitals. Today we followed Sherry, a nurse practitioner who gave us a stack of 10 charts and told us to see the patients while she does some new admits. I saw three patients: a lady recovering from spinal surgery, an Alzheimer patient who's very deaf (he couldn't understand most of what I said), and a lady who's learning how to use a walker after being independent previously. Sherry saw our patients independently; we all met at 11:30 to discuss our findings with her and see if they match up with her findings. We were allowed to go at noon and I called Dr. JH to see if she needed us to come to school to pick up her charts. She said since we were at Lakewood and already closer to Arlington than school, we should just have a nice long lunch. Sounded fine with me. Corey wanted to know where the closest Chick Fil'A was in Arlington so I was able to tell him that one.

Pecan Park, the assisted living facility in Arlington, was very much like its sister complex in Fort Worth and had a homey feel to it. We had seven patients total, of which Dr. JH saw two and we split the other five amongst ourselves. My first patient was a very nice man (used to be a professor at UTA) who had early Alzheimers; his biggest problem is word recall, as he knows he has an illness that makes him forget but can't remember the word 'Alzheimer' until I brought it up. He had a dog named Mr. Happy that barked and growled menacingly when I knocked on the door, but when the door opened out ran a Lhasa Aspo/dachshund mix, hardly threatening at all =P My second patient was a pleasant 97-year-old woman (who can still walk without any assistance) who kept saying she was fine. Going through her file, though, I read that three years ago, her son scheduled her for a geriatric exam b/c he was concerned about her memory loss. During that exam, she was uncooperative and kept lashing out at her son for doing this to her, saying she hated him and threatening to cut him from her will. How is it that I get the patients who are normally mean but are nice when I examine them? Justin had one patient who was very talkative, and when I looked at the pictures of her grandchildren I thought I recognized a guy who was in orchestra with me during high school. At any rate, today was our last day with Dr. JH. I've enjoyed working with her, and she seemed to like us, too.

Geriatrics: Well-Behaved patients

I wore my "interview shoes" to work today in order to break them in, and Anita teased me about not wearing my usual Danskos. This morning we had lectures at JLWest about behavioral changes in the elderly and the cost of living in nursing homes and assisted living centers. Not surprisingly, prices started at about $150-$200 per day, give or take another hundred or more for incontinence care, medication dispensing, trips to the YMCA, etc. Bottom line: the cost of health care for the elderly is very expensive, and will probably require a lifetime of saving in order to live comfortably.

Grand Rounds covered yellow fever and was actually pretty interesting. The afternoon found me back at the JW Clinic, where Justin, Corey, and I were each given 4 patients to see. My first patient was well known for refusing her meds and fighting with staff (and med students), so I was determined to be at my nicest when I saw her. As it turns out, she was very pleasant towards me and had no objections to having me examine her. A "Happy Birthday" balloon hung from her wheelchair, but since she has dementia she said, "I haven't had a birthday in a while." Then she saw her balloon and remembered. My second patient was severely impaired and though she smiled at me, I couldn't understand her speech when she did speak. My third patient was a Parkinsons patient who's been having awful hallucinations ever since his Seroquel got discontinued; he told me his legs had been shot off and he needed prostheses (yet both legs were intact). I had to see my fourth patient in under 2 minutes (it was dangerously close to 3:00 pm, our meeting time), but fortunately she just sat still and let me examine her. As I later found out, she was one of those patients who was notorious for spitting at med students, yet she was well behaved for me. Dr. K later said that the stars must have been smiling at me for two normally troublesome patients to be so nice this afternoon. =)

Rounds proceeded as usual, with one of Justin's patients being flirtatious towards all things male and even called Corey to her side to say that she was waiting for a handsome man to carry her home (we all got a good laugh out of that one). My Parkinsons patient has a son who's a radiologist in FW, so when he was told that Corey wanted to be a radiologist he seemed pleased. Unfortunately the radiologists in FW don't allow med students to shadow them, which is odd and Dr. K suggested that Corey tell our associate dean Dr. D about it. Another patient proudly showed off his past as a Marine with pictures around the room, though it took him a while to explain the USMC on his polo shirt (US Marine Corps). On the Azalea wing, we met Miracle the cat again, and on the opposite wing we saw two cages, each with a rabbit in them. Two resident rabbits, how cute! One of them was black (Blackie) and rather defensive, and the other (Thumper) looked like he had a bum leg. The two of them are caged most of the time until the evening, when they are put in a pen so they can play together. Dr. K likes to quiz us all on EKGs, which we're not all very proficient at, but Corey gets the worst of it since Justin and I are future internists and Corey won't have to read any EKGs after his intern year. We all agreed that we'll have to find Dubin's EKG book and read it before next week.

Tomorrow it's back to Lakewood

Geriatrics: The Last Founding Father

This morning GAP clinic proceeded as usual: slow. Dr. K passed out paper progress notes so that we could take notes first, then transfer those notes into the computer whenever we had spare time (which we did, whenever we weren't seeing patients or waiting for Dr. K to come out of an exam room so we could present to her), but it wasn't a total success. One of my patients had brought along his own problem list, and I found it easier to get on the HPI template on the computer and type down everything he told me. The last patient wasn't seen until about 12:40, but Justin and I finished earlier so we were able to grab some lunch at the conference room. Corey got some lunch after his patient was seen, and then we made the drive downtown to Trinity Terrace, an upscale retirement community that probably costs lots of $$$ to stay at. We had seven patients to see, among them 3 annual exams. One of those annual exams just happened to belong to Dr. E, the last surviving founder of our medical school, and we debated over who would see him. In the end, Corey got to see him while I took the extra patient.

All our patients were on the 2nd floor and required more nursing care than other residents who lived more independently on the higher floors. My patients were fairly straightforward. One was a 89-year-old lady who was hospitalized after a fall and is getting physical therapy here; she seemed to be doing very well and even hit on Corey when we came to the room (she said we were all good-looking young people, hehe). My second patient was a man with Parkinsons and a very prominent right hand tremor; he was once a prominent citizen of Tulsa, OK, though I'm not too clear what his occupation was that made him so important. My third patient was s/p ischemic bowel and had a colostomy bag; he was also weaned off his trach but failed his swallow study so he should only be on a thickened liquid diet. However, when I saw him he was munching on Doritos and saying he didn't need a liquid diet. Dr. JH laughed when I told her that.

While we presented our patients to Dr. JH, some of the staff brought out a Nintendo Wii for the residents to play Wii Sports. At first it was just the staff playing (to demonstrate?) and one family member said within earshot, "I thought it was for the residents to play." Eventually the residents did get to try their hand at baseball and golf. Still, the Wii is definitely something good to have to keep the residents swinging their arms and stuff =)

Of our patients, we were all most interested in meeting Dr. E, now 94 years old and having some forgetfulness (among other numerous health problems). He remembers that he used to be a primary care doctor, but can't remember practicing at the O (even though he has a tile from the OMCT on his desk). He asked Dr. JH if he could stop taking any of his medications b/c his monthly bill was high, but the only thing that they could do was make Mucinex prn. When Dr. JH recommended not stopping his gout medicine, he asked just how much a gout attack would hurt, saying that he could probably take it. "No, it really does hurt," said Dr. JH. It was a little sad seeing Dr. JH explain what each medication does to him; he knew all this once upon a time. And later Dr. JH said that it's because of his stubbornness regarding his medicines that he had to move to the 2nd floor (from independent living) b/c the nurses had to make sure he takes everything as directed. DNR was discussed as well, and fortunately his mind is still clear enough that he can make a decision for himself. That's always good.

Geriatrics: The Family Conference

This morning Corey, Justin, and I attended a family conference with Dr. K, Dr. Hall (the psychologist), a social worker, and the patient (an 82-year-old lady) and her nephew. Dr. K and Dr. Hall each presented their findings which showed that the patient's cognitive function was slowly declining, typical of early Alzheimer's. Now we were told that many patients become angry when they heard the "A" word, but this lady was very accepting of the diagnosis. "I knew something was wrong," she said, and the fact that she had the insight to tell that she was losing her memory was a positive sign that we had caught this early. So the family conference proceeded as perfectly as one can imagine. The patient has a supportive extended family, so I feel confident she'll be in good hands.

Because we finished at 10:45 a.m., there was time to call Dr. JH (one of the other geriatrics attendings) and ask her which patients she wanted us to see at our assigned assisted living center for the afternoon. She gave us six names and we headed for the center in hopes of completing rounds by 1:30 (our original meeting time). In that, we succeeded (my two patients were in their 90s and slightly demented but very friendly). Dr. JH listened as we presented our patients and then we went to round on them, but there we hit some roadblocks whenever we had talkative patients. One man kept us in his room for nearly 30 minutes talking about how he cured his own Crohns' disease by "flushing out the bacteria" with supplements. *sigh* We did get out before 5:00 though =)