Friday, July 28, 2006

Untold Stories of an FP

The small town where I practice is a favorite place for the nearby entertainment industry to look for locations to shoot various movies and commercials. It's a lot cheaper to film in a pre-existing Craftsman style period house than to construct it on a set, for example. Still, I was surprised to get a call from a location manager looking for a doctor's office to use to film a Nexium commercial. She had gotten my name from the city's film liaison who knows me. (You know filming is big business when your city has a film liaison.)

Sadly, I had to explain that my office was really very small and probably not what they were looking for. She agreed saying how there'd be about 50 (!) people running around for the commercial shoot. So I gave her the name of another local doctor who has a larger office. Hopefully he'll have a good story to tell me.

Speaking of which, Hollywood is all about stories, some good, some not so good, some that are better left unspoken. Some of these stories come from real life, as I found out about a month ago when a producer for "Untold Stories of the ER" called me. He heard about me through this blog, and wondered if I might have any potentially interesting stories that could be suitable for his TV show.

Unfortunately, I explained, I didn't. As a family doctor, most of what I saw in the office was minor and not very exciting (except to the patients themselves) compared to the bloody life and death drama that occurred in the ERs. He agreed that wasn't quite what he was looking for, and I suggested he try contacting some other bloggers with ER experience. I was sorry I missed a chance to have my name in the credits of a TV show, but as I thought about it, I was glad NOT to have experienced very many "interesting" cases (as in the curse, "May you live in interesting times.").

Here are a few of the more memorable stories I have shared with medical students through the years:
1. During internship, there was a guy (whom I'll call Joe) with Munchausen syndrome who went from ER to ER complaining of a heart attack. As residents who rotated through the ER, we all saw Joe eventually at least once. Through the years, Joe had had every single cardiology test they could think of, including angiograms, and they were all outrageously normal. The worst part about it was he wasn't paying for any of it. Joe had no insurance, but the county hospital was required to treat him regardless of his financial status. And his tab was so high that there was no realistic chance of ever collecting a penny from him.

Dr. Raphael, our hospital's cardiologist, was fed up with this guy. He printed Joe's name and photo on a flyer and posted them in every local ER with a brief summary of his history. But even that didn't stop Joe, as no one had the guts to rule him out for an MI without giving him some morphine and running some kind of test. In those days, we didn't have troponin levels so it could take 3 days to rule someone out for an MI. Finally, Dr. Raphael told all the ERs to call him personally the next time Joe showed up. Sure enough, late one night Joe presented at a local hospital ER complaining of his usual crushing chest pain. Dr. Raphael quickly jumped out of bed, drove over and greeted the man. "Hiya Joe. Remember me?" Joe got a quick evaluation, then was quickly discharged by Dr. Raphael as having non-cardiac chest pain. A few days later, he tried a different ER. But who should show up again but his pal, Dr. Raphael. This time, Joe took one look at Dr. Raphael and without a word, stood up from the wheelchair and walked out of the ER. He was never seen in any of the local ERs again, but we knew that he was still out there somewhere complaining of a heart attack that wasn't real.

2. Donor kidneys have always been in short supply and usually given selectively to those who seem to have the best chance of a successful transplantation. Which is why I and my supervising resident were so surprised that Sam had gotten one. Sam was a schizophrenic who had trouble taking his antipsychotics, much less the immunosuppressants that would help prevent organ rejection. By the time Sam got to us this time, he was nuttier than a fruitcake and a danger to himself. He was incoherent and behaving irrationally, so for his safefy he was secured to his bed with a leather arm restraint. We had to get him back on his meds and wait for him to calm down.

One night, my resident and I were making the evening rounds and we looked in on Sam. He had a big goofy grin on his face as we asked how he was doing. "Aw, man, I'm feeling great. Everything's great," he said. "The doctors are great. The nurses are great. The food is great. Even the beer is great." Beer? We looked at each other. He hadn't had any visitors that we knew of. "Where did you get the beer?" we asked. "I don't know. It was just there. Kinda warm, though." Uh oh. "Was this beer kind of yellow and in a plastic container hanging off your bed?" "What? I don't know. I guess so." We looked at his empty urinal container hanging on his bedrail. No wonder his creatinine levels were so high. Sam managed to get better and was eventually discharged. But to this day, I don't drank beer.

3. Esther had was an older woman with diabetes, multiple heart attacks, and respiratory failure to the point that she was on a ventilator machine to help her breathe. She was swollen everywhere like a balloon from her congestive heart failure. She couldn't talk, couldn't eat, but she was awake although how much she was aware of we couldn't say. She had been in the ICU for 6 months, and despite many attempts at weaning her off the ventilator, she was not strong enough to support her own breathing. She was stuck in limbo. She had 2 children, a daughter who lived nearby and visited regularly and a son who lived in another state. After a while, the attending physicians felt that her situation was hopeless. It was left up to us, the residents, to try to secure an okay from her family to withdraw the ventilator so as not to needlessly prolong her suffering. Otherwise, she could continue in her miserable state for who knew how long.

Her daughter, who saw her mother's suffering in person, readily gave her OK. But her son, who never visited her, adamantly refused and wanted us to continue to do everything we could for her. When it was my turn to rotate in the ICU, I also tried to convince the son that keeping her alive like this was not a good quality of life, that turning off the ventilator was not killing her but allowing nature to take its course. On the other end of the phone, he steadfastly refused. After another month, I handed off my ICU duties to Dr. Kuartei (now Director of Public Health for the island nation of Palau). He decided to play hardball. He told the son that he was going to call him every day and give him an update on how his mother was doing. And he did just that, adding in various descriptions/opinions of how much she was suffering day after day. After 8 days of this, the son changed his mind and gave his consent to pull the ventilator. Surprisingly, Esther continued to breathe on her own off the machine, though with a lot of oxygen supplementation. She lasted for about a week before she passed, her suffering finally over. Modern medicine can be a wonderful thing, but it cannot substitute quantity of life for quality of life.

Those of some of the stories that I remember from my residency training days. If you want to share your interesting ER medical experiences with Untold Stories of the ER, they want your untold story. Who knows? Your spleen (or other body organ) might become a star.