WednesdayIL: A CADD pump is like a PCA at home. So, PCA (or patient controlled analgesia) is a way of giving pain meds to patients in a hospital where, instead of having to request a dose of medication from a nurse, the patient has a button they can press every so often to give themselves a dose of IV pain medication. There are safety measures so that a patient can't overdose, but studies have shown that patients actually use less pain medication when they have control than when nursing does. Anyways, CADD (or computerized ambulatory drug delivery) is an easier to use system that can be used outside the hospital, when appropriate.
ThursdayIL: Palliative care shouldn't exist. Let me explain. A good definition by the Center to Advance Palliative Care is "[palliative care] focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family." Wait...? Isn't that what all of the medical field should be doing anyways?
On Thursday my classmates and I took a field trip to Calvary Hospice Hospital in the Bronx, the only exclusively palliative care hospital in the country. It's a strange place (but again, it shouldn't be). The average length of stay is just over 20 days and 43% of the patients pass away in the first 9 days of after being admitted. But once you see how they take care of the patients, you realize it's not depressing. These are good deaths or, at least, far better deaths than these patients would have gotten in an ICU or even at home.
Most hospice care happens at home which is usually better for everyone, but for some patients appropriate comfort measures really require acute nursing care. One woman we met was doing fairly well with her terminal breast cancer, but only because nurses and wound care teams were taking care of draining the excess fluid building up around her lungs and in her abdomen. This type of patient would be in agony (or already dead) at home.
The patients at Calvary are treated well. Pain management is addressed immediately. The doctors do not shy away from giving high doses of heavy-hitting narcotics - whatever it takes to keep the patient comfortable. Of course, this is adjusted for each patient; some people are really bothered by the loopiness that comes with some pain meds and may prefer to feel some pain to losing some cognition. But in this day and age, no one deserves to die in uncontrolled pain.
Another big selling point for this hospital is how clean it is. First and foremost, the patients are clean - not something to take for granted when you have 200 elderly bedridden patients who may be incontinent or have non-healing wounds. On the day of admission every patient gets a 2-person assisted head to toe spongebath that can take hours. And everyone and everything is kept clean from there on. I've been in many hospitals and I have never seen such well maintained and meticulously scrubbed hallways. There is also no clutter from disused medical equipment and no chaotic noise. Nurses, doctors and other staff talk quietly rather than screaming over the beeps and pings of equipment alarms. And those alarms are responded to quickly. Especially compared to the crazy hospital I'm working at normally, this place was serenely peaceful.
But my biggest takeaway from the day was that this shouldn't need to exist. It makes sense that NYC could support a full hospital for acute hospice care, but every medium-sized hospital should have unit like this. Or, better yet, patients should be able to be treated like this on any normal unit in a hospital. There is no special technology that these patients require. There is nothing that actually qualifies these doctors and staff to be compassionate, clinically competent providers any more than any other medical staff.
The whole subspecialty of palliative care arose, not because we needed people with special training to do those jobs, but because regular doctors have a longstanding inability to do theirs. I wish every medical and nursing student could visit a place like Calvary, so that someday places like Calvary won't be noteworthy at all.
FridayIL: Blood can keep showing up in stool (as detected by fecal occult blood tests) for up to a week after the source of bleeding has stopped.
[I'm sorry that after such a nuanced middle post, the last one was a one-liner about poop, but such is medicine.]
[[Also, incase you were wondering about the title of this post, I totally forgot to explain it. So here you go: People dying of chronic conditions such as cancer often have a long slow decline for a while and then suddenly, over the course of hours or days, the trajectory of their health falls off a cliff. While doing rounds with one of the doctors at Calvary, I kept thinking of how hard it must be adapting to caring for patients just before and during that unpredictable decline. The patient you admit is chugging along. Obviously not doing well, but usually not doing dramatically worse than a day or week prior. You never know which day you will come into work to find out that a particular patient has been put on critical status (~24-48hrs until likely death) - to find they've gone over the cliff. It must be emotionally taxing living on that border in so many people's journey to death.]]
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