Wednesday, August 1, 2012
Learning things from patients
I've learned countless things from patients over the years, what works, what symptoms are associated with what eventual diagnosis, how to get the leaves separated from the berries after commercial huckleberry picking, recipes for baked fish. Some of these really stand out because they solve particularly pesky problems in creative ways or answer questions that have been bugging me for a long time.
They are also kind of random. But here goes:
One of my patients who had been attending to her dying ex-husband after his cancer diagnosis told me about making an oil extraction of marijuana leaves for appetite and nausea. She just put the fresh or dry leaves in a small bottle of either olive or vegetable oil and used it in cooking. It could be conveniently dosed in various foods and was a non-smelly alternative to smoking. The problem with medicinal THC in pharmaceutical preparations is that it comes in a fixed dose that is too much for some people, and that marijuana is actually different than pure THC and can be more effective for certain symptoms. Also Marinol, the pharmaceutical, is really expensive, and often not covered by insurance.
Large people often have a problem of yeast rashes in skin folds because yeast loves warmth and moisture. After these get going, applying anti-yeast creams is messy and sometimes painful, and annoyingly ineffective. Anti-fungal powders are a little better, but still messy and still slow. I commented to one of my patients a number of years ago that her skin was beautiful in the areas that are sometimes not so beautiful, and she told me that she used unscented commercial anti-perspirant and entirely prevented the rashes, which had troubled her for years. There are prescription anti-perspirants as well, but they are really strong, sometimes irritating and expensive. I've since offered the advice to other patients. We never do this in hospitals, instead we wait until there is a rash then treat it with creams and powders. Hmm.
As people age, they often get swollen ankles, from nonfunctional veins in their legs or heart failure or lung disease, and sometimes for no good reason I can think of. It is painful to have swollen legs and sometimes the skin breaks down and ulcers form. If the swelling can be kept away the skin is healthier. We recommend that people keep their legs up, but this is a little impractical since most people like to spend a certain amount of time standing, or worse, sitting in chairs. We also recommend very firmly elastic stockings that ideally reach above the knee. To work, they need to be very tight. The people who need them most often have arthritic hands and weak forearms and it is nearly a whole morning's worth of energy just to put the things on, if they can get them on at all. A patient of mine who was about 90 told me that she put on thick rubber gloves and with the friction they provided it was actually very little trouble to pull the things up. Medical supply companies make rather more expensive gadgets that don't work quite as well.
Occasionally patients will tell me about wonder cures about which they are so convinced that I check them out and have, on occasion, been disappointed. One patient told me he had been absolutely free of viral infections, as had several of his friends, after starting to taking a certain number of drops a day of grapefruit oil. He was convinced, and I figured that it was about time that someone came up with a cure for the common cold, so I tried it. It was INCREDIBLY bitter. I was unable to complete the experiment. Having regular viral infections definitely seemed preferable. Another patient told me about some exercise program that had improved her well being in some non-trivial way. She gave me an article with illustrations. It took 10 minutes a day and involved rotating the head some number of times among other things. A small price to pay, I thought, for transformation. It's amazing that a 10 minute routine can make me nauseated and vertiginous for over an hour. I gave it a week, and the effect was pretty dang persistent. I'll never know whether it would have worked. Although I try to be open minded, I am not, by nature, terribly gullible, so I have left recommendations such as magnetic shoe insoles and vinegar and honey to cure arthritis in the category of things that are so physiologically unlikely as to be safely left in the "you believe it and I don't" container.
This week, as a hospitalist, was full of learning from patients. Most of it was due to the way they presented and the disease processes they had, since everyone is different and each time I see someone with a diagnosis that I am familiar with, my knowledge of that condition becomes broader and more complete. But there were also a couple of patients who said really interesting things.
The first was an 84 year old woman in the intensive care unit who had a bad pneumonia and really bad veins, and needed a central venous catheter in order to safely infuse all of the various potions she needed to get better. One physician had not been able to put one of these into her internal jugular vein, and, as frustrating as such a thing is for the physician, for the patient it usually involves quite a bit of pain, as the anesthetic wears off with prolonged and repeated attempts. Ow. She asked the next physician "Why didn't that doctor use ultrasound to put in my line? I'm sure he would have gotten it in without any problem." Wow. That out of an 84 year old woman. Where did it come from? It turns out that she worked at a vet's office until she was 80 and he used ultrasound all the time, so she knew quite a bit about it. For pooches they have to shave off some fur and use lots of gel, but it's getting more and more accepted in the veterinary world. For her second attempt, ultrasound was used and the line went in, no problem. Bingo.
So. Last story. Definitely weirder than the previous ones. A very old man was in the hospital because his heart had finally decided that it could no longer push blood through his very tight aortic valve, and so the jig was kind of up. He had a large pleural effusion (free fluid surrounding his lung) and had developed the habit of moaning when he breathed. He wasn't really in pain, but the moaning helped him hold the breath in better. It was a very sad sound. I had decided to do a thoracentesis: remove the fluid around the lung with a catheter and needle in order to improve his lung capacity. The procedure went smoothly, with 2 liters of fluid removed. He had been pretty quiet before the thoracentesis, maybe saving his breath, hard to say. As the last of the fluid came out and I pulled the catheter out, he started talking. He had been a butcher most of his adult life. He started to talk about meat. How people want to buy meat that's red, but meat doesn't stay red that long. So he used to rub it with something that kept it red (I'm thinking probably saltpeter) but that Uncle Sam had not approved of that so he had to figure out something else. So he would use the red serum from a butchered pig to color the meat red. "A pig's spleen covers a myriad of ills," he said. Unfortunately my hospitalist week is over so I can't go back and figure out exactly how that worked.