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Death By Stubbornness: What’s A Doctor To Do?

Over the years that I’ve worked in acute inpatient rehab centers, I have been truly vexed by a particular type of patient. Namely, the stubborn patient (usually an elderly gentleman with a military or armed forces background). I know that it’s not completely fair to generalize about personality types, but it seems that the very nature of their work has either developed in them a steely resolve, or they were attracted to their profession because they possessed the right temperament for it. Either way, when they arrive in the rehab unit after some type of acute illness or traumatic event, it is very challenging to cajole them into health. I suspect that I am failing quite miserably at it, frankly.

Nothing is more depressing for a rehab physician than to see a patient decline because they refuse to participate in activities that are bound to improve their condition. Prolonged immobility is a recipe for disaster, especially in the frail elderly. Refusal to eat and get out of bed regularly can make the difference between life and death within a matter of days as leg clots begin to form, and infectious diseases take hold of a body in a weakened state. The downward spiral of illness and debility is familiar to all physicians, but is particularly disappointing when the underlying cause appears to be patient stubbornness.

Of course, the patient may not be well enough to grasp the “big picture” consequences of their decisions. And I certainly do not pretend to understand what it feels like to be elderly and at the end of my rope in regards to prolonged hospital stays. Maybe I’d want to give up and be left alone too. But it’s my job to get them through the tough recovery period so they can go home and enjoy the highest quality of life possible. When faced with a patient in the “wet cat” phase of recovery (I say “wet cat” because they appear to be as pleased to be on the rehab unit as a cat is to being doused against their will), these are the usual stages that I go through:

1. I explain the factual reasons for their admission to rehab and what our goals are. I further describe the risks of not participating in therapies, eating/drinking, or learning the skills they need to care for themselves with their new impairments.

2. I let them know that I’m on their side. I understand that they don’t want to be here, and that I will work with them to get them home as soon as possible, but that I can’t in good conscience send them home until it’s safe to do so.

3. I give them a projected discharge date to strive towards, with specific tasks that need to be mastered. I try my best to give the patient as much control in his care as possible.

4. I ally with the family (especially their wives) to determine what motivates them, and request their presence at therapy sessions if that seems fruitful rather than distracting. (Helpful spouse input: “Mike only wants to walk with me by his side, not the therapist.”)

5. I ask loved ones how they think the patient is doing/feeling and if there is anything else I can do to make his stay more pleasant. (Helpful input: “John loves ice cream. He hates eggs” or “John usually goes to bed at 9pm and gets up at 4am every day.”)

6. I meet with nursing and therapy staff to discuss behavioral challenges and discuss approaches that are more effective in obtaining desired results. (For example, some patients will always opt out of a task if you give them a choice. However, they perform the task if you state with certainty that you are going to do it – such as getting out of bed. “Would you like to get out of bed now, Mr. Smith?” will almost certainly result in a resounding “No.” Followed perhaps by a dismissive hand wave. However, approaching with a “It’s time to get out of bed now, I’m helping you scoot to the edge of the bed and we’re going to stand up on 3. One, two, three!” Is much more effective.)

7. If all else fails and the patient is not responding to staff, loved ones, or doctors, I may ask for a psychiatric consult to determine whether or not the patient is clinically depressed or could benefit from a medication adjustment. Typically, these patients are vehemently opposed to psychiatric evaluation so this is almost the “nuclear” option. Psychiatrists can be very insightful regarding a patient’s mindset or barriers to participation, and can also help to tease out whether delirium versus dementia may be involved, and whether the patient lacks capacity to make decisions for himself.

8. If the patient still does not respond to further tweaks to our approach to therapy or medication regimen, then I begin looking for alternate discharge plans. Would he be happier in a skilled nursing home environment where he can recover at a slower rate? Would he be amenable to an assisted living or long term care facility? (The answer is almost always a resounding “no!”) Is the patient well enough to go home with home care services and round-the-clock supervision? Does the family have enough support and can they afford this option?

9. At this point, after exhausting all other avenues, if the patient is still declining to move or eat or be transferred elsewhere, some sort of infection might set in. A urinary tract infection, a pneumonia, or bowel infection perhaps. Then the patient becomes febrile, is started on antibiotics, becomes weaker and less responsive, and is transferred to the medicine floor or higher level of care. Alternatively at this phase (if he is lucky enough not to become infected) the patient might have a cardiac event, stroke, blood clot with pulmonary embolus (especially if he is a large man), kidney failure, or develop infected pressure ulcers. Any of which can be cause for transfer to medicine. In short, if you stay in the hospital long enough, you can find a way to die there.

10. After much hand-wringing, angst, and generalized feelings of helplessness the wives and I review the course of events and ask ourselves if we could have done anything differently. “If I had acted like a drill sergeant, do you think he would have responded better?” I might ask. “No dear, that would only have made things worse.” She’ll reply. I’ll see how disappointed she is in his deterioration, staring off towards pending widowhood, engaging in self-blame and what-ifs (E.g. “If we had only had more money perhaps we could have taken him home with 24 hour nursing care until he was better…” “If I had cooked all his meals, maybe he would have gained enough strength to avoid the infection…” etc.) I try to be reassuring that none of this would have made a difference, myself reeling from the failure to get the patient home.

This 10 step process happens far more often than I’d like, and I certainly wish there were a way to head off the downward spiral with some kind of effective intervention. Would it help to have a volunteer unit of ex-military peer counselors in the hospital who could visit with my patients and help to motivate them to get better? (Operation “wet cat” perhaps?) Should I change my approach and put on my drill sergeant hat at the earliest stages of recovery to force these guys out of bed? Can educating younger law enforcement and military workers about illness help to prepare them to be more compliant patients one day?

I don’t know the cure for stubbornness, but it sure leaves a lot of widows in its wake.

What To Expect If You Get The Flu

One of my dear friends just came down with influenza, and she asked me for some advice. Top of mind questions included – When can I go back to work? And when will I get better? So in a nutshell, here’s what I told her (borrowing heavily from the CDC website):

  1. The most common flu symptoms are: Fever or feeling feverish/chills; Cough; Sore throat; Runny or stuffy nose; Muscle or body aches; Headaches; Fatigue (feeling very tired)
  2. Adults shed influenza virus from the day before symptoms begin through 5—10 days after illness onset. However, the amount of virus shed, and presumably infectivity, decreases rapidly by 3—5 days after onset.
  3. Most experts believe that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth, eyes or possibly their nose.
  4. Uncomplicated influenza illness typically resolves after 3—7 days for the majority of persons, although cough and malaise can persist for >2 weeks.
  5. The 2011–12 U.S. seasonal influenza vaccine virus strains are identical to those contained in the 2010–11 vaccine. Annual vaccination is recommended even for those who received the vaccine for the previous season. Vaccination is the most effective prevention strategy available to reduce your risk of catching the flu.
My suggestions: Don’t go in to work (if you have the option) until 5 days after illness onset. If you go in earlier, you can wear a little face mask (and use Purell or other alcohol-based hand sanitizer) to prevent spread of the virus. Next year, get your flu shot early in the season.
As far as treatment is concerned, the Mayo Clinic recommends: LIQUIDS, REST, and TYLENOL or IBUPROFEN for pain. No vitamins or supplements have been shown to shorten the course of the flu.
P.S. My suggestions are relevant for “garden variety” flu sufferers. If you are immuno-compromised, elderly, or otherwise in a high risk category, please check out the CDC website for more information.

Expert Offers Tips For Preventing Diabetic Neuropathy

[Editor's note: In recognition of American Diabetes Month, Harvard Health Publications is collaborating with on its Stop Diabetes initiative. Today's post, published on World Diabetes Day, is the first of several focusing on this all-too-common disorder.]

People tend to think of diabetes as a silent, painless condition. Don’t tell that to the millions of folks with diabetes-induced tingling toes or painful feet. This problem, called diabetic neuropathy, can range from merely aggravating to disabling or even life threatening. It’s something I have first-hand (or, more appropriately, first-foot) knowledge about.

High blood sugar, the hallmark of diabetes, injures nerves and blood vessels throughout the body. The first nerves to be affected tend to be the smallest ones furthest from the spinal cord—those that stretch to the toes and feet.

Diabetic neuropathy affects different people in different ways. I feel it as Read more »

*This blog post was originally published at Harvard Health Blog*

Husband Disapproves Of Wife’s Decision To Get Breast Reduction Surgery

Jeanette’s story:

For as long as I can remember my nickname has been ‘Jen Big Boobs’. Friends joke that the first thing they see when I walk through the door is my chest. I know they mean no harm – just as ­­I know that my husband, Steve, adores them ­­– but it’s reached the point where they have ­­got to go. They simply dominate my life. Whether I’m trying to get comfy in bed or walking down the street I can’t forget them for a moment. They are always there, getting in the way of everything I do. In primary school I was the first in class to wear a bra. So when my pals changed in the classroom for PE, I’d change in the loos. Big boobs weren’t a huge surprise – they ­run in my family. But it was embarrassing and ­I didn’t like being different. They’ve singled me out for loads of attention. Buying bras has always been and still is a nightmare. I have to order specially-made ones that are ugly and cost up to £50. By the time I was 20 I’d already gone to see ­my GP about a reduction operation. He was ­sympathetic but said I was too young for ­surgery.

Steve’s story:

I love my wife’s big boobs and don’t want them reduced. I don’t mind admitting that Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

Antibiotic Resistant Bacteria Kill Tens Of Thousands Each Year

Antimicrobial resistance is a world-wide problem and increases the difficulty a variety of infections. In the United States, the major threat that is faced each day by millions of Americans every year is posed by bacteria that are resistant to antibiotics. Studies to obtain precise estimates for all types of resistant infections is ongoing, but we do know that every year, almost 90,000 people become ill with infections caused by one of these resistant bacteria—methicillin-resistant Staphylococcus aureus or MRSA. Of these people, over 15,000 die.

Tremendously effective strategies have been developed to prevent infections, especially those likely to be caused by resistant bacteria. Readers of this blog are very familiar with the wide range of evidence-based, proven-effective interventions that reduce the incidence of infections and prevent the transmission of dangerous pathogens between people, especially hospitalized patients who are most at risk.

But a critical strategy for preventing the development of drug resistance in bacteria is to use antibiotics carefully and judiciously. Scientists have known for 70 years, Read more »

*This blog post was originally published at Safe Healthcare*

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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