Sunday, December 23, 2012

Day 190 - pain is a cuase of delirium

Today was another relaxing day without too much excitement in my household. Ellie had a friend stay over and even at 10:30 (after more than 24 hours together), they were not happy to be separated. I'm so glad it's vacation! Emily and I went to Starbuck's and then I took Maggie for a 3.2 mile walk. You can see the results below.

Yes, a long walk in the woods, turned Maggie into a dog with glowing green eyes. Note the one arm draped over the side of the bed.

One of my old patients stopped by to drop off Christmas cookies and to see how I was doing. I really had a clinic full of the nicest people in the world. She had not gotten the letter from Dartmouth because it did not go to people who switched their primary care doctor and she was worried about me and wanted to see for herself how I seemed. Fortunately, no one who looks at me is worried any more. You can see the incredible cookie plate below.

Additionally, I felt all homemakey and make a batch of cheese puffs which are rumored to be difficult, but not at all. Also, more weaving. It is really a tight race. I am almost finished, but have at least two more stripes to do, followed by the finish sewing. I am not a good sewer. That doesn't look very good. I don't sew well.

As anticipated, I do have more to say about the Dec. 20, 2012 NEJM. There is a Perspective article that is absolutely the best Perspective I think I have ever read. The writer is a pediatric oncologist and he writes about how people always say to him "How could you do that work?" This is a question we, in hospice, hear a lot as well. His answer is broader, however, and says eloquently what is special about doing anything in medicine. Unfortunately, it's only available to subscribers. If your hospital subscribes to the NEJM, it's worth taking a trip to the library to see it and if you are at HHH, I will bring it in to circulate. There is also a nice article on celiac disease. I did a morning report on celiac when I was a resident and it looks like there has been tremendous progress in understanding the pathophysiology of it. That is very nice to see; kind of like an acquaintance's kids who you haven't seen in a while are now in high school and very accomplished.

There were a bunch of articles that did not interest me, but there was one that really got my attention, "A Man with Alcoholism, Recurrent Seizures, and Agitation." It was a CPC, where they present a case and then have an expert discuss the differential diagnosis, come to a conclusion and then they discuss the management of that particular patient. Spoilers ahead if you don't want to know the diagnosis. Obviously, it was alcohol withdrawal, but notably, the patient was very delirious and it lasted longer than you might expect. It turns out that he had a hip fracture, sustained during his seizure. I was very disappointed that the article did not take the opportunity to discuss pain as a cause of delirium. In fact, I thought it was very 1980's of the NEJM. I wrote a letter to the editor about this issue, couching it in slightly gentler terms.

The combination of two recently published articles: the NEJM neglecting to mention pain as a cause of delirium and the JPSM article about how half of all palliative care docs have been accused by other doctors of euthanasia or murdering patients makes me angry. Doctors who did not get a background in palliative care in med school and who have chosen to avoid it as a CME topic make ignorant statements like "palliative care causes people to lose hope," or "we can't treat that patient's pain because opioids will make her delirious" or "benzo's will work better for her shortness of breath than opioids." The NEJM missed an opportunity to help educate a wide physician audience in a slightly paradoxical, but tremendously practical medical problem. Shame on them. Again, if you subscribe to the NEJM, I'd encourage you to read the article and send a letter to the editor if you agree.

For me, for tomorrow, I am going to wish for more wide spread knowledge about the benefits of palliative medicine. For you, for tomorrow, I will wish for progress in an issue that is near to your heart.

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