werner@aecom.UUCP (Craig Werner) (11/02/86)
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The New Physician, Oct. 1985, p.18-19
(orig. published 1972)
Do Doctors Know the Real Enemy?
His name was Eli Kahn. He was 78 years old. He was admitted to the
hospital because of abdominal pain and vomiting. X-rays taken on admission
suggested a small bowel obstruction. Having reviewed his case, I walked
over to the division to work Kahn up.
He was a thin frail old man with a weathered face and marvelously
bright eyes. When I entered the room, his attention was fixed on Kovanich
in the next bed, an old man recently operated on for colonic cancer.
Kovanich had not done well, and now he lay entwined in a tangle of drains
and tubes, breathing laboriously.
I introduced myself. Kahn wrenched his gaze from his neighbor and
looked up at me. "I'm dying," he said.
"Don't be silly."
"What's silly about dying?"
"Nothing. But it's not allowed. You are in a hosopital, a university
hospital, equipped with all the latest technology. Here you must get
well."
"My time has come."
"Time is measured differently here."
"What do you understand about time? Wait until you are 78 years old
and tired and alone and have pain in your belly."
There was no arguing with him.
Physical examination revealed an erratic heart beat, a few crackles
in the lungs, a tender, distended abdomen, an enlarged prostate, and
arthritic changes in the joints.
"You see," said Kahn, "the engine is broken down; it is time for the
engineer to abandon it."
We discussed the case with out attending and elected to decompress
the bowel for a few days before attempting surgery. When I went into
Kahn's room to pass a Miller-Abbott tube, I found him again staring at the
patient in the next bed. Kovanich was comatose.
"We have to pass a tube down into your stomach, Mr. Kahn."
"Like that?" He gestured toward the tube protruding from Kovanich's
nose.
"Something like that."
"Listen, doctor, I don't want to die with tubes sticking out all over
me. I don't want that my children should remember their father that way.
All my life I tried to be a mensch, you understand? All my life I tried to
live so I could hold my head up, to have dignity, even though I didn't
speak good English.
"Now, I'm dying. Okay. I'm not complaining. I'm old and tired and
have seen enough of life, believe me. But still I want to be a man, not a
vegetable that someone comes and waters every day -- not like him." He
looked over at Kovanich. "Not like him."
"The tube will only be down for a few days, Mr. Kahn. Then we'll take
to surgery and fix you up."
"What, are you going to make me 25 years old again with your
surgery?"
"No, we can't accomplish that."
"So what are you trying to do?"
"We're trying to make you feel well again."
He seemed suddenly tired of the conversation. "You don't understand,"
he said more to himself than to me. "You don't understand."
That evening, I stopped by to start an I.V.
"Another tube?" Kahn asked.
"You've become dehydrated. We have to get some fluids into you."
He nodded, but said nothing. He watched silently as I started the
I.V. and secured the line with tape. Every so often he glanced across at
Kovanich. Still he said nothing.
Early the next morning, I heard the hospital page issuing the code for
a cardiac arrest. I raced up to the division to find nurses dashing in and
out of Kahn's room. Inside, I saw Kovanich lying naked on his bed in a
pool of excretions with the house officers laboring over him -- pounding on
his chest, squeezing air into his lungs, injecting one medication after
another, trying to thread a pacemaker down his jugular vein. The whole
thing lasted an hour. Kovanich would not come back, and finally all labors
ceased.
The nurses began clearing the resuscitation equipment out of the room,
while we filed out to begin the round of postmortem debates.
"Doctor, wait a minute." Kahn was signalling me. I went over to his
bed.
"What is it, Mr. Kahn?"
"His eyes were frantic. "Don't ever do that to me. I want you should
promise you'll never do that to me."
"Mr. Kahn, I know that this has been very upsetting..."
"Promise!" He was leaning forward in bed and his eyes were boring
through me. There was an interminable silence.
"All right, Mr. Kahn, I promise."
Satisfied, he leaned back against the pillow and closed his eyes. I
was dismissed. I wandered out into the hall, where my colleagues were
discussing Kovanich's defection.
"It looked like a pulmonary embolism. I knew we should have
anticoagulated him."
"Did you get permission for an autopsy?"
"Don't lose his last EKG; we'll need it for the conference."
I walked away. I had other things to think about.
On the fourth hospital day, Kahn went into congestive failure. I
found him cyanotic and wheezing on morning rounds. Swiftly the housestaff
swung into the practiced and coordinated action of acute care: morphine,
oxygen, IPPB, tourniquets, digitalis, diuretics. But despite our skilled
efforts, Kahn responded poorly. "He's exhausting himself trying to breath,
and he's still hypoxic." our attending said. "I think he ought to be
intubated; it will give him a rest and will help us oxygenate and get at
his secretions.
When the anesthesiologist arrived to intubate him, Kahn was gasping. I
explained to him about the endotracheal tube. His breathing became more
labored as he struggled for words. "You promised ..." was all he could say.
"But this is different, Mr. Kahn. This tube is just for a short while
-- maybe just a day. It's to help you breathe."
He stared off in another direction. The anesthesiologist intubated
him without difficulty, and we hooked him up to the ventilator.
"I think he ought to be monitored also," our attending said.
So we brought in the cardiac monitor and pasted the leads onto Kahn's
chest while he looked on, not stirring, his face expressionless, his eyes
dull.
Kahn was asleep that night when I stopped in for an evening check.
The room was still save for the beep-beep of the monitor, the rythmic
whoosh of the ventilator and the hum of the nasogastric suction apparatus.
And Kahn looked suddenly so old and frail, lost among tubes and wires and
enormous imposing machines. I could not help but thinking of the
physiology labs in medical school where we used to put dogs to sleep and
hook them up to all kinds of intricate recording devices. I checked the
settings on the ventilator and slipped out of the room. There were a lot of
other patients to see.
Some late that night, Kahn woke up, reached over and switched off his
ventilator. The nurses didn't find him for several hours. They called me
to pronounce him dead. The room was silent when I entered. The ventilator
issued no rush of air, the monitor tracked a straight line, the suction
machine was shut off. Kahn lay absolutely still.
I mechanically reached for the pulseless wrist, the flashed my light
into the widened, unmoving pupils, and nodded to the nurses to begin their
ritual over the body.
On the bedside table, I found a note, scrawled in Kahn's uneven hand,
"Death is not the enemy, doctor. Inhumanity is."
Nancy L. Caroline, MD
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A Piece of My Mind
JAMA, Feb. 7, 1986, 255:650
When Jennie Took to Bed
When Jennie "took to bed" years ago, Uncle Bill and Aunt Jennie were
living comfortably in their South Dakota homestead farm home.
Bill and Jennie were brother and sister. Bill was a farmer and
gentleman. Neither were married. Their parents had emigrated from an area
near Prague in eastern Europe to Dakota territory, where, through sheer
will power and common sence, sickness and injuries were accepted and treated
with patience and prayer.
Jennie accepted with no obvious reservations the responsibility of
raising the orphaned children of her sister, who died while being operated
on for what was apparently a ruptured appendix. One of the girls she
raised was my mother.
Jennie was a beautiful woman of quiet dignity. All who knew her
instinctively accepted her as a person of authority. She had the ability to
analyze problems and make correct decisions in a straightforward way. I
suppose she could be referred to as an aristocrat in the best sense of the
word. Her home was remembered as a place where tea was served in porcelain
cups with dainty cookies. It seemed a haven to all who visited.
At the age of 82, a silent carcinoma of the colon gradually took her
strength. Jennie needed more and more help. One day Uncle Bill came to
talk with my mother. Bill's comment was, "Jennie took to bed."
The family doctor advised Jennie to go to the Mayo clinic but she
said, "No, my family will look after me," and they did. Neighbors and
loved ones came to visit. They brought food and words of comfort.
The doctor left medications for rest and pain.
When it became obvious that the end was near, Jennie consented to
become a patient in our small country hospital. A few weeks later, she
died peacefully in her sleep.
The total cost of her terminal care was a few hundred dollars.
Recently we treated a 72-year-old lady of like temperment with a
similar problem. She was bedridden with multiple tubes and surgical scars.
Chemotherapy had taken her hair and even the slightest movement caused her
to cringe and often scream with pain. Her total medical bills were about
$50,000, and she had nothing to look forward to other than pain and
institutional care. The lady was a person of dignity whom I had known and
admired for many years.
I had arranged for consultation with and transfer to the care of
specialists whom I respect. I did not see her again until she came to our
hospital for continued chemotherapy and tube feeding. Because of the
mutual respect and friendship that I knew existed between us, I very, very
carefully asked her why she had consented to the continued, obviously
losing battle. She answered, "The doctors at the university said there was
a chance."
She died a few weeks later.
Roscoe E. Dean, MD
Washington Springs, SD
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A Piece of My Mind
JAMA 255:1341, Mar. 14, 1986
The Plan
"Hello, Carl?"
"Yes, Andy, what can I do for you?"
"Carl, do you have a few minutes? I;d like to discuss something with
you."
"Sure, Andy. What's on your mind?"
"Carl, you and I have known each other a long time. We've worked
together on hundreds of patients over the years. You've really been the
ideal consultant. You're there day and night. You're sharp. The families
love you. I'm sure you'll inderstand how difficult this is for me."
"What's the matter?"
"I won't be referring patients to you anymore."
"Andy, what's the problem? Was there a problem with a family?"
"No. Nothing like that."
"Well, what is it? Did I miss something? Was there a complaint about
me?"
"Carl, you've helped me with some tough cases over the last ten years.
You've been available whenever I've needed you. You've seen indigent
patients and unfunded patients just as readily as the well insured. I have
no gripe with you. Hell, you've bailed me out of some tough clinical
situations."
"Then what the hell is the problem?"
"The plan, Carl, the plan. Your name is not on the plan's panel."
"Andy, look. I have the greated respect for you professionally. We;ve
worked together for many years and our association has been pleasant and
gratifying. You're an excellent doctor who always puts the patient's
welfare first, and I understand your concern. But you mean to tell me that
you can't refer patients to me because of a plan? I don't deal with plans,
I deal with people. I have and always will see any patient of your
regardless of paln."
"You don't inderstand, Carl. By signed contract, I can only refer the
patient to a plan doctor. That's the rule. The plan penalizes the patient
and me if the referral is to a doctor not in the plan. Why didn't you sign
up?
"I reviewed the plan's contract. It's a morass of prior approval,
review of my recommendations as a specialist by nonspecialists, poor
payment, and a plan that by capitation pressures all involved to bring the
production in under budget to reap a profit. It's care containment, not
cost containment!"
"But it's the future."
"I know it's the future. I'm sure I'll be on some panel at some time
as the system pressures me into signing because of a dwindling case load.
But not this plan at this time."
"Carl, I hope you understand. If I had my way, all patients that
needed a man in your speciality would go to you. All I know about you is
your medical excellence. No cocktails, no dinners, no schmoozing -- just
medicine. I've found that it's the best way to refer."
"Until now."
"Look, I didn't decide on this. My partners felt it was a move for
economic survival. The accountants and office manager liked it too.
"Andy, don't you find something inherently wrong with the channeling
of referrals along largely economic lines? I mean, the panel of specialists
has been annointed by the ledger, not by demonstrated medical excellence.
"Medically, of course it's wrong. In terms of corporate economics,
it's dead right. The patients see the low premiums and the glossy ads and
sign up in droves. The corporations sign them up, then sign us up and the
contract dictates the terms."
"I understand your situation. I appreciate the honesty of this call."
"I'd rather do it straight up front than let you hear it thirdhand in
the cafeteria."
"Hey -- I'll miss working with you."
"Thanks. This was a hard call for me to make."
"All for the greater good, Andy."
"We'll see."
Leo A. Gordon, MD
Los Angeles
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Medicine Is 'Unamerican'
American Medical News, 4/11/86, p.4.
The AMA's recent vote to press for a federal law outlawing
tobacoon advertising and promotion certainly seems "un-American" to me.
It may also be unconstitutional, but since "The American Way" is to
promote more business for your members, it is certainly "un-American."
It is estimated that 50% of all cancers are directly related to
smoking cigarets and that 15% to 20% of visits to physician's offices are
from illnesses due to smoking. It's "un-American" for physicians to try
to put themslves out of business.
But that has been medicine's way for the last hundred hears. It
started with tuberculosis. Medicine was so successful in finding a cure
that hundreds of sanitoriums had to close for lack of patients.
Then it was diptheria and whooping cough, which are rarely seen
now. Millions of lives have been saved, but pediatricians have lost all
those patients.
Smallpox, malaria (*), and plague, the big killers from history,
have been tamed. In fact, physicians and the health organizations of the
world have eliminated smallpox from the face of the earth.
And polio! I remember as a child the fear of drinking from a
public drinking fountain -- the iron-lung for sure. Hospitals were filled
with children and young adults with polio. Orthopedic surgeons did
thousands of operations a year in correcting the deformities left by the
disease. Then medicine went and discovered polio vaccine and lost all
that business. Un-American!
And medicine is still at it. The other night I saw a TV ad paid
for by an emergency physicians association. It was showing the dangers of
drinking and driving. The ER docs sure lost business with that ad.
Physicians instruct their patients how to eat better diets and
exercise more in order to decrease their risks of heart attacks. Bad
business practices.
Hundreds of millions of dollars are spent each year on medical
research, not to find more patients, but to find the cure for cancer,
AIDS, atteriosclerosis, and other diseases. It certainly seems that
medicine is trying to put itself out of business.
Think of what would happen if other businesses followed medicine's
example. Airlines would advertise for you to stay home and enjoy your
savings. NcDonald's would teach home cooking. Nissan would tell you how
to make your 1980 Datsun look like new for another 5 years. And lawyers
would use their TV ads to encourage you to shake hands and solve your
problems on a friendly basis. All "un-American!"
Medicine may be the most "un-American" of all businesses, but it
is the greatest of all the professions and I'm proud to be one of its
members.
John Withers, MD in _The_Maui_News_
reprinted from American Medical News, 4/1186, p.4.
(*) malaria may be eradicated in the developed world, but it is still a
major problem in the Third World. However, the idea is there.
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A Piece of My Mind
JAMA Aug 2, 1985;254:605
Prostaglandins and the Universal Soldier
He's the univeral soldier
And he really is to blame
His orders come from far away no more
They come from him and you and me
And brother can't you see
This is not the way we put an end to war
- Buffy Saint-Marie
I was walking down the Paseo de la Reforma, the large avenue laid
out 120 years ago by the Archduke Maximillian that cuts through the
center of Mexico City. It was 7 o'clock in the morning and the first
installment of the 11,000 tons of daily air pollution was already
visible. I was determined, however, to get some good early morning
pictures before being picked up for the press conference. The hot
topic revolved around the first synthetic prostaglandin, which had
just been released in Mexico. My task was rather simple and
straightforward: to explain to the press in 10 minutes the meaning of
prostaglandins. I have never felt at ease with explanation unless a
properly chosen, easily understood noun was readily available to
introduce the topic of discussion. Somehow, "a family of 20 carbon
oxygenated fatty acids" didn't seem appropriate. What about "a family
of hormone-like substances"? Well, maybe a definition of
prostaglandins wasn't really needed.
Despite the poluution, the multitude of automobiles, the noise of
rush hour, and my inability to think of a cohesive method of
delivering the prostaglandin message, I was feeling rather well: no
telephones could reach me, my beeper was 3000 miles away, and I was
getting some great shots. I continued my stroll, clicking away, when
I happened to notice Old Glory flying high in the air. The US
embassy, surrounded by thick steel gates, was just sitting there, on
that large avenue, in full view of everone and anyone. It was still
too early for the embassy to open and, except for a few people waiting
in line, the grounds looked deserted. I stared at the steel gates;
clear images of past experiences flashed through my mind. In a few
short seconds I saw the US embassies in Beirut, Tehran, Kinshasa,
Cairo, Islamabad, New Delhi, Addis Adaba, Khartoum, Guatemala...
Guatemala? God, we're getting pretty close. Guatemala borders on
Mexico; most people down there are struggling just to stay alive. With
the shaky economic and social conditions here in Mexico, any spillover
from this struggle could lead to further instability and the collapse
of the government. Despited armed revolution to the south and Big
Brother to the north, Mexico remains fairly stable. Still staring at
the flag, imaging my own internal slide show, I wondered what would
happen if Washington, having already rejected Nicaragua, pressured
Mexico to follow suit? If Mexico succumbed, it would be devastating.
All the ingredients mixed together: armed insurrection from within and
without: refugees fleeing the ravages of war; and the United States,
this time, would not be immune. No longer would we be able to sit
back home and conduct a war from a safe distance. Our borders are one.
It all happened so quickly. From an early morning picture-taking
stroll to a ghastly vision of war. When I finally stopped to collect
my thoughts I realized I was singing that song -- the one from the 60s
and 70s. "The Universal Soldier."
By God, that's it! In the moments that followed, science and
war marched together.
Prostaglandins are the universal soldiers; they are crucial elements
in the accurate, second-by-second control of everything that happens
in the body.
And they really are to blame; found in every cell except erythrocytes,
prostaglandins, just like soldiers, can be good or bad as they
regulate the workings of each organ. They have received the medal of
honor for protecting and stabilizing the cell; they have been
court-martialed for their role in inflammation, allergy, and pain.
Their orders come from far away no more; unlike classic hormones,
which are produced in one organ and exert their effect on a distant
organ, prostaglandins act locally at the site where they are produced.
Prostaglandins are formed directly from essential fatty acids;
soldiers are formed from essential elements of society called
children.
Every body cell has an essential fatty acid store; every state
has an essential store of children.
When needed, essential fatty acids are brought out of storage,
converted to prostaglandins, then rapidly destroyed. When needed,
children are recruited from their protected havens, converted to
soldiers, then rapidly destroyed.
They come from him and you and me, and brother can't you see;
naturally occuring prostaglandins are untrained soldiers; they are
relatively impotent, short acting from desperate bursts of unwanted
energy, nonselective for shooting at everything that moves, narrow
minded -- effective if only produced endogenously by the cell, and
short-lived -- rapidly destroyed by the enemy.
To develop synthetic analogues is to educate and train those
soldiers. They will be stronger and therefore more potent and longer
acting; wiser and therefore more selective; and able to adapt to a
changing environment -- orally effective.
This is not the way we put an end to war. I had reached the monument
to Juarez before realizing that my presentation was all prepared; the
universal soldier seemed like a good introduction for a drug being
trained for a war against illness. Somehow, I suspected that science
would put an end to illness long before man would put an end to war.
Stephen J. Sontag, MD
Hines, Ill.
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A Piece of My MInd
JAMA June 27, 1986 255:3408
Incident in Haiti
I saw her standing in line one afternoon in the hot Haitian sun,
a young woman, perhaps 18 or 19 years old, with an infant cradled in her
arms. Her tiny child was bundled up in many layers of clothes and a
kerchief despite the searing heat, a custom the Haitians beleive helps
in fontanelle closure. This woman, along with several hundred other
villagers, was patiently waiting in long lines to be seen by the
American doctors and other health professional who were staffing a local
clinic for two weeks. Many people had walked for miles to seek medical
attention, and some of the sicker people had been transported to the
clinic by burro or dugout canoe.
The numbers of people were almost endless and, as the clinic
closed each day, the line was already formed with the next day's
patients, who would wait through the night. Often the staff would work
for 14 hours and seemingly not made a dent in the number of patients yet
to be seen. At closing time each day, the people in line would become
anxious and sometimes a small riot would develop. Panic-stricken people
would try to tear open the doors of the clinic, so desperate was their
need.
I don't know why I noticed this particular young woman and her
child among so many, but the thought of her waiting made it difficult
for me to sleep that night. The next morning, I could hardly wait to
get to the clinic and start seeing patients. When we were finally able
to see the woman, she laid her child on the examination table and
painstakingly undressed him while she explained the the interpreter that
the child had had diarhhea for the past several days. Her boy was less
than 2 years old, and I could tell by his lifeless posture that he was
already dead.
When I listened to his chest, there was no heartbeat, and my own
heart sank as I asked the interpreter to tell the mother that her child
was dead. The mother refused to believe that her son had died and kept
repeating in Creole, "But the baby is still warm." We explained to her
that her own body heat was what had kept the baby warm as she clapsed
him to her, but she would not believe us. The nurse with us gently
tried to take the baby from her, but she clutched him even more tightly,
frantically pleading with us to save him. Finally, my friend Dave, a
pediatrician, came over, listened to the child's chest, and confirmed
that he was dead.
He carefully pulled the blanket over the baby's face, and I saw
the mother's look of bewilderment change to agony and grief. I turned
away and wept. I felt overwhelmed by a sense of helplessness -- the
apparent futility of a few doctor's attempts to change things in a Third
World country they hardly knew.
Jeffrey W. Gaver, DVM
Oconomowoc, Wis.
--
Craig Werner (MD/PhD '91)
!philabs!aecom!werner
(1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517)
"If it weren't for politicians, who would fashion disorder out of chaos."