Advanced directives, or this is what I want for end-of-life care

They say sex sells, so I thought I'd see if anyone will bite (pun intended). I felt compelled to continue in my doctor mode and give my observation on one aspect of health care reform, and that is the toxic-laden term thrown around: "death-panels". Thanks to Saracuda and her goon squad, mostly white America has reacted Springer-like in town hall meetings and have emoted about knocking off grandma. Not that most of these people could give a twit about grandma other than her will, because they never come to visit her in the ICU unless a long-lost out of town relative shows up to one-up the rest of the "concerned" family. 

But, I digress. My ideal way to exit this orb is at age 96 to be axe-murdered by the jealous husband of a 30-year-old. But since that's as likely to happen as Karl Rove sending Maureen Dowd a dozen roses, I'll notify everyone ahead of time my end-of-life wishes and bona-fide advanced directive. If I'm dying a slow agonizing death of disseminated dementia in the ICU, if I have an orifice without a tube in it, I want one placed there. I want 10 antibiotics (the most expensive brand), I want a ventilator for each lung, and a dialysis for each kidney. I want 2 critical nurses at bedside constantly, and the most expensive, ill-prepared doctor on-call 24/7. In short, I want to be a burden to society. I deserve it, and expect that. I have herewith notified all the blog world, and the 2 people who actually read this. (Please, download this and send a copy to my attorney).

But this request is not for everyone. I respect that. In fact, most respectable people might find my request a bit over the top, even for me.  But I'll be sure to discuss my requests with my family and caregivers (I'll leave out the axe-murder part). I will have made it very clear how I wish to be treated. You should do the same. Make it clear from the outset your wishes, and sign any & all forms required, including the nursing forms, the ambulance forms, the hospital ED and ICU forms, and forms from Starbucks. But, just do it. That way, no one will have to worry about death-panels. Just heaven forbid you find goofy Sara having found a new career and she's your nurse. If she is let me know, I'll summon the axe-murderer for you. 

VIP Medicine and JFK

With this blog I morph into my doctor mode. No pictures, no alphabet, no feigned surprise at the world, and no allusion to escapades real & imagined (well, not really..but I'll leave the reader to pick and choose). This thought germinated with my trip to Boston about 6 years ago. One weekend before the trip to Woody's L Street Tavern (memorable for more than one reason) I spent a Sunday afternoon at the Kennedy Museum. I'm a fan of presidential museums, and think we should have one in every state. I ran across the book An Unfinished Life, by Robert Dallek. I was intrigued as much by the title as the content, so picked it up and started the read on the plane flite back to Detroit. As usual, the book never saw the light of day after the first few chapters, so it was forgotten. Forgotten until I was given a Kindle as a gift recently. For some reason it seemed the right time to restart the book. It's a bit creepy to me now these years later to reflect on the title, but this time it's the content that interests me.

First to "VIP" medicine. Most doctors including me, squirm when we hear that we are put in charge of managing a bigwig. It's not that these CEO's, lawyers, wives of other doctors, newspaper editors, etc have more complex medical issues, it's just that one feels a bit of pressure to nail the diagnosis and treatment plan without a hint of a mistake, much less a nanosecond of hesitation or uncertainty. It's like the spotlight is on us to be the master clinician. And it's almost entirely self-inflicted. These people are for the most part just like any other sick person, they just want to get better.  But it's us poor slobs of doctors who are always hell-bent on not making a mistake. 

Which leads to VIP medicine being bad medicine. In our effort to be the perfect physician (and mostly not to look really stupid), we order more tests, we make more unnecessary referrals, and  for the most part recoil back to our 3rd-year med school days, and in an effort to "not miss the hoofbeats" we think zebras instead of horses. I've had colleagues who thrive and speak with great pride that they take care of the elite in Louisville. They can have them. I don't want the turmoil and anxiety that goes along with it. Plus, the VIP's have never brought me a sack of fresh tomatoes as thanks for my work.

For his book Dallek had access to records not previously made available to biographers of Kennedy. Especially interesting are the passages about Kennedy's mojo. From teenage years on he had a remarkable uber-narcissism and appetite that would make a grown man blush. The areas on bread & butter politics are worth it if for no other reason as to realize that money talks. Votes, like women are bought unabashedly. On the other hand, I was amazed about the medical facts that were presented. JFK was a victim in my opinion of VIP medicine. I've researched the topic and can find no other reference to this theory. You are reading it here first.

As a teenager Kennedy had recurrent bouts of abdominal pain. He was evaluated by experts from New Orleans, Great Britain, NYC, and other places. But most of his care was centered at the Mayo Clinic. In those days he was submitted to a brutal series of x-ray procedures and colonoscopies. In fact it became so bad, he at one point tried to put a sexual spin on a procedure involving a tube & a light by hitting on the nurse during the procedure (It worked).

Nevertheless, no precise diagnosis was ever given him (although I suspect he had simple irritable bowel syndrome or biliary dyskinesia), but he was given the new drug of the day: corticosteroids. Steroids were for the most part first used at the Clinic, and their long-term side-effects were not understood, although they worked well for his complaints. Of course JFK, being the VIP, was submitted to the most tests and the latest treatments. He subsequently developed the well-recognized adverse effects of steroids including the chipmunk face, Addison's disease, and vertebral fractures. The last two side-effects plaguing him until his death. The patient was in and out of hospitals more than any otherwise healthy young man I have ever seen. If he had been any other Irish-Catholic from Boston, he would have been given a diagnosis of colic, treated with seltzer water, and he would have been better off for it. Perhaps if he wasn't treated as a VIP  in 1940 the world would be a different place today.

I did Tabatha this weekend...

....muscles tense, heavy breathing, perspiration to near-syncope. But Tabatha doesnt compare to Linda, or even Nicole. I won't attempt them yet. Tabatha in weekly succession will have to do for now. These are the nasty girls of Crossfit. Cameron introduced them to me. (thanks son). Here he is doing what he does best, multi-reps on the bar. 

I'm still sore from Saturday. Practice makes perfect. For more info on these nasty girls, check out crossfit.com. 

The Blues Brothers

Sometimes the picture just says it all.

Dear Diary...

Today was like tomorrow, and all other lonely days I spend here. It gives great pause for deep introspection, and I am getting pretty good at that. I started with easy hospital rounds. A 33 yr old man with pericarditis and a 70 yr old former nurse with bipolar disorder who loves me made for a nice distraction. Done before 10 AM, the lawn didn't need much work, but I groomed it once again. I limited my prison time by finally filing my taxes; Sinatra seemed right in the background, and even tho at times he can sound awful, it was the right mood for the task. At least yesterday I learned from the business accountant that our firm is doing quite well, despite the economy. Who knows what's going to happen with Obama-care, so I plan to run with this golden goose as long as she will hang. If nothing else, I got a new boat out of the deal. Last nite haunts me a bit. I have this new uneasiness that enough is enough. I'll see how it plays out tho. I wish I had the wit and edge of Maureen Dowd, and I could convey the topic much more interestingly. Anyway, she'd probably be jealous, or at least have a cool snarky take on the whole thing. In sports news, a guy at the Sawyer triathlon in Louisville got killed today on the bike, and Michael Phelps smacked down the crazy eastern European. I've done that tri, and this is an awful story. He was on a road I've biked many, many times before. Maybe I feel especially down because I miss that, and because I promised to race the event with a new friend, but I just didn't. Hot Lucy served me another great burger at the marina, and I felt like getting on the boat. I had my camera and Kindle and for about an hour I was glad I'm in Appalachia. No morbidly obese, no edentulous 35 yr old females, no mullets, just me and the lake.

I hope tomorrow is the same.