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22 Feb, 2017

Being Mortal

/ posted in: ReadingWork Being Mortal Being Mortal: Medicine and What Matters in the End by Atul Gawande
Published by Metropolitan Books on October 7th 2014
Genres: Medical, Nonfiction
Pages: 282
Format: Audiobook, Paperback
Source: Library, Owned
Goodreads

Medicine has triumphed in modern times, transforming birth, injury, and infectious disease from harrowing to manageable. But in the inevitable condition of aging and death, the goals of medicine seem too frequently to run counter to the interest of the human spirit. Nursing homes, preoccupied with safety, pin patients into railed beds and wheelchairs. Hospitals isolate the dying, checking for vital signs long after the goals of cure have become moot. Doctors, committed to extending life, continue to carry out devastating procedures that in the end extend suffering.

I find the discussion of end of life matters fascinating.  I’ve lost track of how many times I’ve been asked if I’m not scared about what will happen when I’m old since I’ve chosen not to have children.  That never seemed like a good enough reason to have kids since there is no guarantee that your children will outlive you or be physically/mentally able to take care of you in your old age.

Regardless of your number of offspring, I think everyone is nervous about what will happen with age.  No one wants to lose their independence.  That is the point of this book.  The author looks at several programs that aim to let people continue to live a good life as they age and then have a good death.

I was encouraged by reading about all kinds of different ways that people are rethinking elder care.  I have a dream of a community of cottages for old introverts where you check in once a day so everyone knows that you are still alive and there is a movie playing every night in case you want a group activity where you don’t have to talk to anyone.  No one has quite made that yet but there were some that I wouldn’t mind.

One of the major concerns in allowing a more independent old age is safety.  If you want people to be totally safe, then you can’t let them walk around and make (possibly poor) decisions for themselves.  Children of elderly people tend to value their safety over their happiness.  This leads them to make decisions about care that take away options from the parent.

Has anyone made progress with good deaths?  I still think that the way humans approach death is pretty horrific.  I’m coming to this discussion from my perspective as a veterinarian.  We’re all about palliative care until there is a poor quality of life and then euthanasia so there is no suffering.  The author discusses increasing access to hospice care earlier in the patient’s care to decrease extreme medical interventions that are required of hospitals but don’t ultimately aid the patient.  That’s good but then every story of a “good” death he cites ends with several days of the patient being on all kinds of pain medication so they drift in and out of consciousness.  They may not be in pain but what is the point?  They are past communication.  The families are holding vigils waiting for them to let go.  It seems to me that an overdose at this point is so much kinder.

I hear this all the time during euthanasias.  People start to talk about their relatives’ deaths and how they wish they could have helped them in this way so they didn’t have those last few days.  I understand slippery slope arguments but it just seems like common sense to me.

The author also discussed different personality types of doctors and how they help and hurt decision making.  There are authoritarians who tell the patient what to do without much discussion.  There are doctors who give the patient all their options and let them decide what to do.  I’m the latter one.  We were trained to do this in school.  It can confuse clients because they get overwhelmed.  They then counter with, “What would you do?”  We aren’t supposed to answer that question.  It isn’t a fair one anyway. We aren’t in the same situation.  I could do things at home that you might not be able to.  I might tolerate inconveniences more or less than you do.  The author talks about how he learned to give more opinions about how different choices might affect their lives.  I’ve started to do this too some.  I think it has helped some people.

He also recommends having end of life discussions with your family members before decisions need to be made.  Then if you are in an emergency situation where you can’t talk to them about it, you know what to do.

What would be your ideal way to live out your last few years?

 

Reading this book contributed to these challenges:

  • Audiobooks
  • Backlist Books
  • POC authors
21 Feb, 2017

Every Patient Tells a Story

/ posted in: Reading Every Patient Tells a Story Every Patient Tells a Story by Lisa Sanders
Published by Broadway Books on 2010-09
Genres: Medical, Diagnosis
Pages: 276
Format: Paperback
Source: Owned
Goodreads

Never in human history have doctors had the knowledge, the tools, and the skills that they have today to diagnose illness and disease. And yet mistakes are made, diagnoses missed, symptoms or tests misunderstood. In this high-tech world of modern medicine, Sanders shows us that knowledge, while essential, is not sufficient to unravel the complexities of illness. She presents an unflinching look inside the detective story that marks nearly every illness–the diagnosis–revealing the combination of uncertainty and intrigue that doctors face when confronting patients who are sick or dying. Through dramatic stories of patients with baffling symptoms, Sanders portrays the absolute necessity and surprising difficulties of getting the patient’s story, the challenges of the physical exam, the pitfalls of doctor-to-doctor communication, the vagaries of tests, and the near calamity of diagnostic errors.


It always amazes me whenever I have an encounter with human medicine that they rarely do a physical exam outside of an ER.  I’ve been to primary care appointments that consist of talking about symptoms and then ordering tests.  This book discusses the decline in the role of hands on contact with patients and what doctors are missing because of it.

As a veterinarian, physical exam is sometimes all we have.  I’d love to run all the tests that human doctors do in order to get the information that they have but that isn’t always financially feasible.  On the other hand I get phone calls from people who have an over-inflated confidence in my clairvoyance.  “Doctor, my dog isn’t eating.  What’s wrong with him?”

The answer in my head every time – “How the $%#@ should I know?  Put him on the phone and let me ask him.”

What I actually say – “That can be a sign of a lot of different illnesses.  I really need to see him to start to figure out what is wrong.”

There is also a lot of information here about taking a good history.  This can be hard because people are ashamed to tell the truth or they misinterpret things and present them as facts that aren’t actually true.  I had a person in last week who seemed very confident in his knowledge about his dog until you actually listened to what he was saying.  Every sentence was complete and utter medical nonsense but it was presented with such conviction that I found myself thinking momentarily that maybe I was wrong and you can see bacteria with the naked eye.  The opposite of this is the person (very common) who waits to tell you the key piece of information that will unlock the puzzle until you have put your stethoscope in your ears.  I have all my assistants trained to tell me everything anyone says while I’m listening to a heart as soon as I take the stethoscope out.  It is always important.

In addition to the author’s discussions about not interrupting patients while getting a history, I will add my favorite history taking advice.  Ask the children.  They see things and they love to have information that adults don’t.  They aren’t shy about sharing it either.

Me, looking at a vomiting dog:  “Did he eat anything unusual that you know of?”

Mom:  “No, he doesn’t do that.”

Kid:  “He ate my Barbie’s arm off yesterday and Daddy’s has been feeding him Slim Jims every day.  We aren’t supposed to tell.”

I don’t know how many domestic disputes have been started by kids coming clean in the vet’s office.

If you aren’t a medical person, this book is still interesting because it contains a lot of medical mysteries.  The author was a consultant for the T.V. show House and writes a column about medical mysteries so she has lots of stories to tell.  I was particularly proud that I knew the answer to the first one in the book.  It had been drilled into me in vet school.  I’ve never seen it in real life but I always think of it.  I’m glad I finally found a use for that piece of knowledge.

 

 

Reading this book contributed to these challenges:

  • Backlist Books
08 Jul, 2016

Black Man in a White Coat

/ posted in: Reading Black Man in a White Coat Black Man in a White Coat: A Doctor's Reflections on Race and Medicine by Damon Tweedy
Published by Picador on September 8th 2015
Genres: Biography & Autobiography, Medical, Nonfiction, Personal Memoirs
Pages: 294
Format: Hardcover
Source: Library
Goodreads
Set in North Carolina

When Damon Tweedy begins medical school,he envisions a bright future where his segregated, working-class background will become largely irrelevant. Instead, he finds that he has joined a new world where race is front and center.

Black Man in a White Coat examines the complex ways in which both black doctors and patients must navigate the difficult and often contradictory terrain of race and medicine. As Tweedy transforms from student to practicing physician, he discovers how often race influences his encounters with patients. Through their stories, he illustrates the complex social, cultural, and economic factors at the root of many health problems in the black community.


Damon Tweedy was offered a full scholarship to medical school at Duke University in North Carolina in the 1990s.  That was a deal too good to pass up even though it was well known that Duke had a history of being extremely racist.  Early in his time at Duke a professor mistakes him for a maintenance man and when he says that he isn’t there to fix the lights the professor can’t figure out any other reason why he should be in the classroom.  This spurs him to work even harder to prove that he belongs there.

He is frustrated because over and over in lectures he hears that diseases are more common in blacks than whites.  He worries that frustrating interactions with black patients will turn his white coworkers against black people.

He tells stories about what it is like to be both a black doctor and a black patient.

He talks about volunteer work at a clinic for the uninsured and whether or not the Affordable Care Act could help these people.  He had always assumed that people were uninsured because they didn’t work before helping at this clinic.  That’s a pet peeve of mine.  I’ve had this argument with my middle to upper middle class family members who were against universal healthcare and who have always had jobs that offered insurance.  I’m a veterinarian.  Until July 1 of this year when my practice was bought by a large corporation, I’ve never had a job that offered health insurance.  At least I could afford to buy it when I wasn’t married.  Most of my coworkers who make just above minimum wage didn’t have any health insurance.  Most of them still aren’t opting to get the available insurance now because it is very expensive with huge deductables.  /rant

A photo posted by @dvmheather on

He talks about how he was treated as a black man in sweats and a tshirt with a knee injury and how his treatment changed when he revealed that he was a doctor.

Should doctors be discussing sterilization with a drug addicted woman who just miscarried?

How do you deal with patients who don’t want to have a doctor of a different race than them?

How does poverty and cultural attitudes tie into poor health in the black community?


3flower

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17 Dec, 2015

Rabid

/ posted in: Reading Rabid Rabid on 2012
Genres: Medical, Science
Pages: 275
Format: Paperback
Source: Owned
Buy on Amazon (affiliate link)
Goodreads
three-stars

A maddened creature, frothing at the mouth, lunges at an innocent victim--and, with a bite, transforms its prey into another raving monster. It's a scenario that underlies our darkest tales of supernatural horror, but its power derives from a very real virus, a deadly scourge known to mankind from our earliest days. In this fascinating exploration, journalist Bill Wasik and veterinarian Monica Murphy chart four thousand years in the history, science, and cultural mythology of rabies.
The most fatal virus known to science, rabies kills nearly 100 percent of its victims once the infection takes root in the brain. A disease that spreads avidly from animals to humans, rabies has served throughout history as a symbol of savage madness, of inhuman possession. And today, its history can help shed light on the wave of emerging diseases, from AIDS to SARS to avian flu, that we now know to originate in animal populations. 
From Greek myths to zombie flicks, from the laboratory heroics of Louis Pasteur to the contemporary search for a lifesaving treatment, Rabid is a fresh, fascinating, and often wildly entertaining look at one of mankind's oldest and most fearsome foes. 


I’ve had this book forever and finally read it after a staff member starting insisting that she had rabies. A stray cat bit her and died a few days later. (In my mind there is an equal chance that the staff member was poisonous to the cat.) The cat was tested and was rabies-free so all was well for the humans involved. It didn’t change things for the cat.

The first few chapters caused mass giggling in my office.

First up this is description of how Louis Pasteur collected saliva to use in developing his vaccines.

“.. watching Pasteur perform this trick with a glass tube held in his mouth, as two confederates with gloved hands pinned down a rabid bulldog.”

 

My confederates can’t hold a mildly pissed off cat with gloves on sometimes.  I pointed this out to them.  They pointed out that the next paragraph discusses how they had a loaded gun on hand in case someone got bit.  They postulated that they could shoot me and get a new job if I tried to get them to do something as stupid as holding a rabid bulldog.

Next it discusses getting the head removed from a rabies suspect.

“The first part of that process — capturing and humanely dispatching a deranged animal — is fairly standard stuff for your local vet.”

 

Well, thanks for the vote of confidence but, yeah, no.  Not routine.  At least not the deranged animal part.

“If the vet is lucky, her hospital has seen enough suspected rabies cases that it has thought to keep a hacksaw handy.”

 

Lucky?  Is that her definition of lucky?  Where does this woman practice?  I think I’m lucky in that I’m not handling rabies suspects every day.

One of my favorite vet school memories though involves putting a head back on after the brain was tested.  I was in my pathology rotation and someone had mistakenly told the owners of a large dog that they could have the body back in pristine condition after the brain was removed.  The pathologists were furious but couldn’t say no after it was promised.  I was just learning to quilt so I volunteered and spent an afternoon hand sewing a head back onto a body.  I matched points and gathered as needed.  The hair laid over the sutures to hide it.  He looked amazing, if I do say so myself.

Anyway, back to the book.  I liked the chapters about the medical aspects of the disease even if some of them made me doubt my medical training.

“Dogs, (Aristotle) wrote with an odd confidence, suffer from only three diseases:  lyssa, or rabies; cynanche, severe sore throat or tonsillitis; and podagra, or gout.”

 

Well, there’s four years of my life in vet school wasted if that’s all they get.

Other portions of this book discuss the idea that fear of rabies inspired the legends of the werewolf and the vampire.  I wasn’t as interested in those aspects as the medical ones.  Your experience may be different.

The end discusses a rabies outbreak started when someone smuggled a dog that ended up having rabies onto the previously rabies-free island of Bali in 2008.  The government’s first response was to order all dogs killed but of course, people hid their pets so that didn’t work.  Vaccination protocols were set up to contain the disease.  And that’s why governments don’t let you just bring pets into their countries just willy-nilly, even if you are a celebrity and think that laws don’t apply to you.

 

 

 

 

three-stars

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