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hdndncnndkdkdndkdke delete this
im the dude
A doctor discovers an important question patients should be asked
This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.
Reading his chart, I have an ominous feeling that this visit won’t be simple.
A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.
He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.
Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.
Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.
With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.
After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.
A cardiologist and a nephrologist haven’t been able to help him, I reflect,so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… .
Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.
Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”
I pause, then look this frail, dignified man in the eye.
“What are your goals for your care?” I ask. “How can I help you?”
The patient’s desire
My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.
He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”
His daughter, looking tense, also faces her father and waits.
“I would like to be able to walk without falling,” he says. “Falling is horrible.”
This catches me off guard.
That’s all?
But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.
A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”
Suddenly I feel that I may be able to help, after all.
“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.
He smiles. His daughter sighs with relief.
“He really wants to stay at home,” she says matter-of-factly.
As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.
“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”
He nods.
“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”
Again, his daughter looks relieved. And he seems … well … surprisingly fine with the plan.
I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.
Back home
Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.
A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.
The nurse confirms that he is near death.
I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?
Two days later, and two months after we first met, I fill out his death certificate.
Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.
Several months later, a new name appears on my patient schedule: It’s his wife.
“My family all thought I should see you,” she explains.
She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.
“He liked you,” she says.
She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.
I ask why.
“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”
Now I know what to do. I look her in the eye and ask:
“What are your goals for your care, and how can I help you?”
-Mitch Kaminski
Source
HAPPY EMS WEEK (MAY 21st-27th 2017)
This week, we celebrate our first responders, the ones who run toward an emergency rather than away from it. Here’s to you.
Patient Care
This may well be a rant but something that I feel needs to be made very clear is that being a paramedic is more than skills and knowledge. Just because you are trained in pre-hospital emergency care does NOT make you exempt from being caring because you’re “not a nurse” (and oh how I hate that statement, but another time).
If you’re doing a transport right before your shift ends and your 80 something year old patient has their catheter removed and has blood running down their arm, clean it up. Respectfully. The extra two minutes it takes to take their watch off, wipe their arm and wrap them back up so they’re warm before you go outside is NOT a waste of your time. Talking to your patient while you do things is NOT “above your pay grade”. We are there to care for people.
The reality is that paramedicine is a community based role. If you want to excel as a clinician then you need to cover all aspects of your job, from assessment to treatment to patient interaction to cleaning up after yourself. Obviously there are times where it’s not appropriate or possible to do so (ie. emergencies, unsafe scenes) but choosing to leave your patient cold, uncomfortable, messy or distressed rather than try and alleviate where possible it is absolute crap.
Be better than a robot.
My photographer friend shot an In-N-Out themed 1st birthday session and I'm dead
Breaking news:
Girls actually love nice guys, it’s just that you’re not as nice a guy as you think you are.
I find this really hard to believe, as every time I’m interested in a girl she ends up with an asshole and I end up friendzoned or worse.
Imagine being the *exact* type of guy a post was aimed at, but somehow remaining blissfully unaware of that fact…
Hard to believe that women aren’t obligated to give you their romantic or sexual attention just because you exist in their sphere of existence and happen to express interest.
Imagine if the friend zone was anything less than a bandage fuck boys like that slap over their bruised egos for women daring to not fall at their feet
Kill me
#‘killing him slowly’ how do you kill him faster
reblog to kill him faster, like to kill him slowly
there is no beauty in abuse. don’t let anyone tell you that you are miraculous because you survived. you survived because you had no choice, and there is no poetry to be made from desperation. you are strong because that is who you are. abuse did not make that, you did.
What I mean when I say "toxic monogamy culture"
the normalization of jealousy as an indicator of love
the idea that a sufficiently intense love is enough to overcome any practical incompatibilities
the idea that you should meet your partner’s every need, and if you don’t, you’re either inadequate or they’re too needy
the idea that a sufficiently intense love should cause you to cease to be attracted to anyone else
the idea that commitment is synonymous with exclusivity
the idea that marriage and children are the only valid teleological justifications for being committed to a relationship
the idea that your insecurities are always your partner’s responsibility to tip-toe around and never your responsibility to work on
the idea that your value to a partner is directly proportional to the amount of time and energy they spend on you, and it is in zero-sum competition with everything else they value in life
the idea that being of value to a partner should always make up a large chunk of how you value yourself
This is excellent
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BOSTON CREAM PIE CUPCAKES
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these respectful memes are what i live for i am 100 percent riding this bandwagon
Imagine showing this video to someone 6 months ago