Saturday, September 24, 2011

To Stand There or Not to Stand There

In moments of great distress patients understandably expect their caregivers to do something.  A kind of red alert follows with the common refrain of “don’t just stand there, do something” ringing out.  Action is usually necessary but there are special occasions when a refrain of “don’t just do something, stand there” works better.

An esteemed surgical colleague of mine once told me that he did his best work when he kept his hands in pockets.  He added that the average surgeon knew when to operate, but it was the gifted surgeon who knew when not to operate.

While in my internship, my resident graphically and unintentionally taught me why it is sometimes better to “stand there” than to “do something.”  It was about 3:00 AM and we decided to check on our intensive care unit patients.  We were joking with one man who had sustained a heart attack and was doing well when my resident, looking at the heart monitor, bellowed out that the man had flat lined (no pulse) and he cried out for the defibrillator paddles. 
As my resident closed in with paddles all fired up, the patient demanded an explanation. What followed was a very brief conversation that went something like this: Your heart has stopped. What are you talking about?  I have to shock you.  You better not shock me.  I’m telling you I’m fine and you better not shock me.  This fevered conversation covered about twenty seconds when the resident finally threw caution to the winds and discharged the paddles launching the patient into the air.  The monitor still showed a flat line but there was not to be a second shock as the patient pulled his intravenous lines out and (not what the doctor ordered) bolted out of bed, chasing the resident doctor down the hall.                                                                                                                                                                                               

An explanation for the flat lining became painfully clear when a nurse wiggled a wire above her head that had been disconnected from the monitor. 

In retrospect, one doesn’t have a twenty second conversation with a pulseless patient and the story, once again, signals the importance of listening to the patient.  Moreover, it amply shows why “don’t just do something, stand there” is on occasion strikingly preferable to drive-by action.

On a more quotidian level, conscientious doctors labor to eliminate unnecessary prescriptions for antibiotics in order to contain the menace of antibiotic resistance, a growing problem.  They also labor to be thoughtful about how they deploy technology, realizing that various blood and imaging tests, often spot on, can misfire and provide more smoke than light, so to speak.

Physicians who are cautious and simply stand by are sometimes lauded as thoughtful and conservative.  However, others see them as not being thorough and, in the extreme, uncaring and authoritarian.

There is altogether an important place in our medical deliberations to seize the opportunity to do nothing, at times, beyond caring for the patient and reassuring them that they will be monitored closely. To occasionally do nothing is hard wired into our medical DNA which shouts to us still: primum non nocere, above all do no harm.  This, along with the idea that doctors and patients are best advised to do nothing when they don’t know what to do, has served us well.
L. Blogspeak, M.D.

Sunday, September 18, 2011

First Outing

I am a recently retired physician who practiced internal medicine for forty-two years in the mid-west.  It is my intention, with this blog, to share lessons learned (and yes, by necessity, relearned at times) that could help patients and doctors navigate the choppy waters of medical care.
The blog is not intended to be a scholarly weighing in on new studies fraught with data and footnotes.   My hope, instead, is that it will show how patients and doctors teach each other how to read the medical tea leaves of every day problems and how they individually and collectively can deploy common sense ideas to inform complicated issues.  Moreover, attention will be focused on the special relationship of patients and doctors, a kaleidoscope of personal and medical forces that are undertood best in a climate of mutual respect and an appreciation of how much they have to learn together.
Some of the planned topics include: “Why You don’t Want To Be the First One On The Block To Try A  New Medicine;  Why It’s Often Better When The Doctor Does Nothing Than Something;  When The Doctor Needs To Be The Patient’s Hero.
Postings are planned to be weekly and I look forward to your insights and opinions.