'Twas 3 days before Christmas...

Christmas is a time for joy...but not always. I was on call for pediatrics when my pager went off at 5:30 am in the morning. When I called back the nurse informed me that a kindergartner had passed away. I went in to declare her dead. She had fought cancer and lost. Her mother held her body in her arms and wept. Her father and grandparents stood around the bed. There are no words for times like this. I have had this family in my prayers during this holiday season.

Just a few days ago I had gotten notification that a patient of mine had died in hospice. I remembered the phone call from his aged wife a month ago asking me if I would prescribe home health because she could not no longer move him into a tub or onto a commode by herself. By herself! I remembered encouraging her to bring him in. He would not come. When he finally did, he died 2 days later. Once again, losing a life partner of many decades at a time like this must be crushing. When hollywood shows love, it shows beautiful young people, hands and eyes locked together. However, I see love in this elder woman trying to help her husband onto a commode or into a tub. He has nothing more to give her. She will get nothing in return. She does it just because she loves him. They have shared life, home, bed and children for decades.

My prayers go out to these families and other like them in need, sickness or alone.

Let it snow!

Aaah! I finally have a weekend off when I am not working the ER, not staffing wards, not in Urgent Care or the newborn nursery. Actually, I was supposed to go to City on a Hill for the monthly free clinic, but the roads were too hazardous to make the three and half hour journey there and back. So I get to spend the weekend at home (could update the blog too :-) ).

Since we have no place to go, let it snow, let it snow, let it snow....er... okay now, enough, please stop!

Been waiting too long?

It was around Halloween time. The clinic was very busy and a few unexpectedly complex cases had set me behind (can you sense me making excuses yet?). I must have been running about an hour behind schedule.

I walked into the exam room of my next scheduled patient and saw this! I came out as quickly as I could and got my medical assistant to come and look too. We all burst out laughing.

What do you think? Been waiting too long?

Practicing in Resource-Poor settings

At City on a Hill's monthly free clinic, one gets to practice medicine a little differently than at my usual place of work. For one thing, we do not have access to the same resources (labs, imaging, sub-specialties) that one has in a larger clinic, multi-specialty venue or hospital. And yet, patients may have problems that could benefit from this. I saw a woman with an obvious goiter. Interestingly, her mother had the same thing. They had lived their entire lives in the U.S. in a city. She had mixed symptoms of both hyper and hypothyroidism. Management is proving to be challenging. I chatted with an endocrinologist friend who is from India. He suggested some physical exam techniques and history I could obtain to help manage her without further expensive imaging. I benefited from his experience managing patients in a resource-poor setting.

BRCA1

I love taking care of entire familes. It gives me the opportunity to know the pertinent medical history of not just the patient, but his or her relatives too. It introduces me to the support system (or failure thereof), the psychosocial environment and allows me to effect changes that benefit everyone in the home (like in diet, smoking habits and such). Sometimes though, while the opportunities to care for the whole family are beneficial, they are not joyful.

I have one such somewhat disjointed family in my practice. I take care of 3 generations of women -- a grandmother, her young daughter and that daughter's toddler. recently, grandmother -- a somewhat young lady in her mid-40s found a lump in her breast. We got the biopsy and it was positive for cancer. Because of her age, we checked her for the dreaded BRCA1 mutation. She was positive. This means that her daughter and grand-daughter are at increased risk too. Deleterious mutations in the BRCA1 gene may confer as much as an 87% risk of breast cancer and a 44% risk of ovarian cancer by age 70 in women (Lancet 343: 692-695, 1994). This also confers a 20% risk of a second breast cancer within 5 years of the first and a 10-fold increase in the risk of subsequent ovarian cancer. Her daughter and grand-daughter have a one-in-two chance of having this mutation

This is crushing news for these 3 generations of women. Recommendations go even as far as prophylactic bilateral mastectomies (removal of both breast completely to prevent developing breast cancer. The younger women will need yearly mammogram and/or breast MRIs from age 25 upwards.