love

Saying Thank You to Patients

The year was 1990. I was in Detroit, Michigan working as a resident physician in Internal Medicine. Detroit was dilapidated, its old structures were crumbling, boarded up unkempt houses in neighborhoods once humming with life were now empty, desolated, overgrown with weeds. Brick walls of the old houses, once rock-solid were now fragile and cracked, in some of which parasitic plant lives had found foothold telling the story of once mighty Motor City. A drive through such neighborhoods evoked an unknown anxiety and fear that was only interrupted by sight of an occasional industrial park, equally gloomy, in disrepair, hauntingly desolate, behemoth brick buildings with broken glass windows and ragged pitched roofs still oozing melted snow, as if only kept alive in this state of coma by some unknown force just to remind people of the old industrial glory of Detroit. Coming from Bangladesh, an overpopulated country of 2000 people per square miles, it was terribly lonely for me not to see any people on the streets and neighborhoods deserted whereas in my home country it was hard to see an inch of empty spot devoid of humans. I was struggling in my conscious and subconscious to reconcile and digest the contrast. Loneliness that I found impossible in Bangladesh, now in Detroit was over abundant and almost overwhelming. Demand of residency training, both physical and mental vigor that is called for from a young trainee doctor, kept me busy and had distracted me somewhat, perhaps even protected me from the malady of loneliness. Working in a large urban medical school training program I needed to rotate through many different hospitals. Allen Park Veterans Administration Hospital and Medical Center was one such a place. Allen Park, twenty minute South and West of Detroit was a small working class community of Downriver area. Houses were small but neat, yards were tiny yet tidy. The imposing structure other than nearby shopping mall was the VA Hospital. As I drove the very first day of internship towards this hospital, the first sight of the sprawling red-brick building stuck right next to the freeway, with its multi-floored structure and hundreds of small panes of glass windows on all sides seemed like I was being watched by a giant alien with hundreds of eyes looking out over the plains. The sight was overpowering. As I approached the building close, the billowing cloud of smoke from the smoking veterans on both sides of the entrance outside greeted me with an aura of Burmese Opium Den. But time is a great healer; distance is the halcyon; work is the opium; my old familiar sights and sounds from the home country of Bangladesh faded gradually, and soon realities and demands of current surroundings took the center stage. Curious part of my brain sprang back into action again, perhaps I subconsciously realized it to be a healthy distraction from the monotonous grueling work of patient care at the VA Hospital. Often in call nights, I would look through the cracks and crannies of the old hospital building noticing the fine color difference of the two buildings put together, the subtle difference of the pinkish bricks, the variation of the poured concrete, the rusted iron rods sticking out as if I was driven by an impulse to find an old skeleton hidden somewhere. There are times at night I would circumnavigate the old buildings as if I were the Columbus on a mission to discover America. The reason behind as to why the Federal government put this huge hospital in such a place outside the city limits of Detroit was simply another Henry Ford story. In the dark days of Great Depression of the 1930s, the Ford family had donated 38 acres of land to the federal government in Allen Park, MI, as an inducement to set up this VA hospital. The construction work began in 1937. At the end of Second World War as the rank of Midwestern veterans swelled, the hospital was expanded in phases to accommodate the increasing demand. The architects in charge of these renovations never wanted to hide this fact perhaps, because any observant set of eyeballs could easily still tell each additions of the hospital separately. This VA Hospital was gem of a place to learn for any aspiring medical student. Veterans and the teaching faculties were always easy going compared with elite private hospitals and sophisticated patients therein. Veterans on the other hand, did not have any special demand upon the trainees. VA Patients were always compliant and unabashed at the request of physical examination and as of yet, neither there was the looming threat of malpractice law suits, nor there was any pressure from the administration to discharge anyone early to save the hospital money. In fact the pressure was opposite: to keep patients in the hospital for any reason as long as one can, medical to social. It was not unusual to keep someone for days even weeks in the inpatient hospital service because the veteran had no taxicab fare or bus ride to go home. Apparently each individual VA Hospitals used to get budgeted money allocation according to the census of the hospital. The more patients each hospital had in its rolls the more money were to be allocated. I remember one day, the chief of the hospital came in our morning round and told us to “keep as many patients in hospital as you can so our census goes up since the budget allocation time is coming up”! Inside the mammoth building it was gloomy dark with old fixtures. The walls were old and bare, as if the building was missing the touch of a woman and truly it was devoid of women at that time. In my whole time of service over several years, I only got to see two or three female veterans in this hospital. The whole hospital building was made for only men by men. The rare female veterans who were to be admitted were

Saying Thank You to Patients Read More »

Am I Wrong or Am I Right?

Nothing pains me as much or nothing burdens me as much except when I am faced with the decision of putting a FEEDING TUBE device in a human being. One might question: as a gastroenterologist I am trained to do this, I have done lots of them and also it is not that the procedure is particularly more dangerous than any others that I do. Yes, technically speaking it is easy for me, I have not found it more dangerous than many other things that I do in my day to day practice. Yet, at a human level I find it to be extremely difficult. People who need feeding tube often have lost control over their lives either by stroke, Alzheimer’s, cancer, accidents or other major life-changing events. Lot of them cannot even communicate, living in a state of either in coma or in persistent vegetative state. People who are lucky in such circumstances, relatively speaking, have family members available, in others it might be an administrative decision and even at times a court order. It reminds me of the very basic helplessness and vulnerability that we have as humans. Perhaps my own subconscious does not like that reminder in such a vivid way. Then again, how do I know I am making the right decision to put the tube in or even in declining in doing so? I know the consequences of not feeding: slow agonizing death, slow dehydration, malnutrition, slow shut down of the vital organs one by one. I also know if I put the feeding tube in, true we have a way of administering medicine and food, but still it may do nothing with relation to the original condition that led to such a situation. Some might say, such a human would still not live the full potential of life. Yet, who am I to make a decision about what quality of life another human should have? In times like this I feel the full burden of human limitations, imperfections and lack of prescience.  But I know that paralysis is not the answer either. I have to make a decision as a physician based on my past and present knowledge and to the best of my judgment, or, using the language of law, “using reasonable medical judgment”. Again, not all cases are so difficult. In some cases, perhaps a family or a friend would tell me a little story about such a person that sheds light to her choices of life, what she wanted, what he or she liked and disliked in the past. Sometimes, patient will leave a letter or a will clearly delineating what she would want. Easiest one will be the one who has a loving family member and who can relate to the disabled personal at a very emotional level. At times I will have supportive kin or caregiver. At times I just have to make the decision summoning all my inner strengths. At times even in the midst of such tragic cases, there are happy endings, not all are gloom and doom. So let me finish my current story with such a fairy tale but true story: just last week, such a human patient was brought to my office from nursing home accompanied by his brother. In my office, the human patient was in wheel chair, not making any eye contact, he had words but not purposeful and neither making any sense to a human with limited perception like me, a doctor. The nursing home staff and brother told me that he has been living in nursing home after the major heart attack he had about a decade ago and went to cardiogenic shock. Although he was revived, due to lack of oxygen, his brain suffered irreversible damage and he was not able to freely move or take care of his daily needs anymore. Since that time he has been living in nursing home and doing reasonably well. He seemed to get across his brother very well and each week, the brothers will go out and eat and watch a movie together. Sometimes after the matinee show, the two brothers will go for a wheel chair stroll on the nearby shores of Gulf of Mexico and Galveston Bay. At the end his brother will drop him off. For last three months, he developed difficulty of swallowing food. He seemed to be hungry but just not being able to eat. Nursing home and brother wanted to give him some times thinking it could be a temporary situation, but his condition went downhill without any reversal leading to more weakness and severe weight loss. I could do no meaningful communication with the patient himself and on my physical examination he had all the telltale signs of recent weight loss, dehydration and malnutrition. I found no contra-indication of placing the feeding tube.  Technically and medically speaking, he was an appropriate candidate for Percutaneous Gastrostomy Tube or stomach feeding tube placement. At this time only issue to reconcile with the ethical and human issues associated with the medical procedure. In another word to put myself in the shoes of the patient and sort out if the patient would have really wanted it or not or is it in the best interest of the patient. I wanted to gain more insight into the patient, his past and present. I started speaking with the brother, the only line of communication I had with the patient. He reminisced from the childhood memories of their growing up together in the expansive geography of West Texas. The two brothers grew up in a farm, with nearest neighbor eighteen miles away. They spent times in fishing, hunting and also getting into mischief. In such a desolate land, the two brothers were best friends. When his brother, our patient, had the heart attack and subsequently became disabled, the other brother brought him back from West Texas to South Texas, a distance of 10 hours of driving and settled him in nearby

Am I Wrong or Am I Right? Read More »