Wednesday, November 22, 2017

Over the River and Through the woods: A Change of Plans and a Change of Prostate Strategy 9though not personal; I HAVE non Prostate)

The course of my plans has not been altered dramatically in any way. I still plan to be roughly the same place this time next year that I would have told you last week that I would be at that point in my life. 

My day today, which was technically yesterday, however,  did not proceed quite as planned for me.  My maternal uncle by marriage had an only semi-expected surgery. The surgery, known as a TURP (short for "trans-urethral resection of the prostate") was expected, though not quite so immediately or urgently  as it went down. He experienced a complete urinary blockage, which could quite easily have quickly progressed to complete renal failure. Fortunately, due to being in a good place at a good time, renal failure for him was not in the cards.

Because I was traveling through the general vicinity in preparation for Thanksgiving Day, I ended up at the hospital where and when my uncle had surgery. My aunt -- his wife -- was there with him,  but a spouse of s surgical patient more often than not both appreciates and benefits from moral supoort or even simply company during the procedure It probably was not a productive use of recovwry time for my eyes, but sometimes the world does not have to revolve around what is good for my eyes or for any other part of me.  Because this surgery was originally scheduled to have taken place in roughly four weeks, no other relatives were with my aunt and uncle at the hospital.  I drove myself the two hours to the hospital where my uncle's surgery was to be performed from where I had been stationed previously. I, along with my aunt,  met with the surgeon, anesthesiologist, and other pertinent medical personnel. I introduced myelf as the fourth-year medical school student that I am. I highly doubt that even one person to whom I introduced myself as such took me seriously to the slightest degree. I doubt that I came across as eloquent or necessarily even knowledgeable. The others probably thought I was, at best, a pre-med undergraduate student, or, in possibly a even more plausible scenario, a high school student considering medicine as a possible future career. If such were the case, I would have been far from the first person to have verbally enhanced my position or qualifications, not that my present qualifications are that much of which to boast. I have been told recently, though, that I am maturing in a physical sense and that, for the most part, I no longer look like a high school student. Some women in particular totally get their rocks off on being told constantly how ridiculously young they look. I am ot one of such women. I am noy one of such women. I consider it a compliment to be told that my chronological age matches or comes close to matching the age I actually look.  If I'm startting to look my age, it's high time, and I've worked hard to earn every laugh line or other indication of age as related to appearance. I do not claim to look like a thirty-five-year-oold woman, but neither am I any longer turned away from R-rated movies when unaccompanied by another adult.

In any event, I'm reasonably certain that even if the medical personnel I met for the first time today  took anything,  much less everything I said about my status as a medical school student with even a grain of seriousness, they didn't care in the least. Furthermore, had I been in their position and they in mine, I might have felt the same way. My status as a med school student ay my facility gave me no status as a student or member of their staff. For that matter, it wasn't eve a teaching hospital at which my uncle was treated.

At one point, though, they ventured onto territory that was too familiar for me to sit back and be the know-nothing relative. My uncle's surgery produced conditions, including unexpected gravel-like struvite urinary calculi that quite legitimately caused staff members to fear the results of infection. Antibiotics were prescribed, as was appropriate. Additionally, my uncle's system was flushed (with H2O) more aggressively than might have been consideted typical.  This elevated my level of concern. My uncle's father experienced a similar though not identical medical phenomenon thirty-some odd years ago. He, too, was found to have struvite gravel, and with it, the likely presence of infection. The increase of watwr created used to flush his system creaqted an imbalance between the body's  appropriate hydration level and the balamce of electrolyes. in his system. This resulted in cardiac complications that, while it didn't kill my uncle's father right there in the recovery room, caused longer-term complications that ended his life within a few months of the surgical event. The man was not, at that point in his life,  the healthiest creature to walk the face of the Earth, but neither was he expected to be dead within two months of what had been considered to that point to be a fairly straightforward prostrate reduction surgery. 

If the significance of water/electrolyte imbalance seems unimportant or irrelevant, try for a moment to recall a radio station contest from several years ago where a young mother lost her life by drinking too much water too rapidly in a radio station's ill guided promotional attempt of awarding a game system of some sort to whomever who could consume and keep down the greastest quantity of  to water in a given period of time. The poor, sweet mother so desperately wanted an X-Box or Playstation or some similar device for her offspring that she made the ultimate sacrifice in order to obtain it for them. (In retrospect, my heart bleeds for this family. I can say in all honesty that had  I known of their plight and of the harm the mother would cause to hersef in order to provide this gift to her children, I would have emptied my bank account of its contents to just buy the damned game for them, but I didn't know, and the point is therefore moot.) Of course the mother would not have done what she did had she had the remotest of clues that the end result even possibly might have been lethal, not would the radio station had come up with the contest had they possessed the slightest clue that such could have been the end result. It seems safe now the presume that the radio station and /or its insurers are now paying out the sum of thousands of x-boxes to the survivors of the woman, but that the woman's family scarcely gives a fling rat's ass about the money. Up to that point, few of us other than medical professionals gave any thought to the idea that dirnking too much water could be fatal. (The radio station was far from my home area. My dad commented after th fact that he was a bit surprised that a medical professional from within range of the station did not, after hearing the contest's promotions,  call and offer the advice that the contest was a poor idea from a safety standpoint. Perhaps someone did actually make such a call, and the radio staion ignored the advice, or perhaps all the doctors and nurses who heard the promotions for the contest assumed someone else would make the call. I for one will never know.) Likewise, medical professionals, who should and usually do know better, can forget that balance in the human body is essential, and tht flushing a system with even something so seemingly benign as water can produce devastating consequences.

My aunt remembered the electrolyte-imbalancing events surrounding the death of her father-in-law, as did I , though I'd only heard by word of mouth; the incident took place before I was born. Thus, when the treatment plan was presented to her and to me in a small conference room directly off the surgical suite, she paled noticeably. I had a good idea of the cause of her concern; she seemed unable to speak coherently, so I spoke for her in the way I best could. 

My uncle's father's medical history had been entered into records, but the significance and similarity of  his father's history with what seemed to be unfolding before us seemed lost on all but my aunt and myself.  I reminded the surgeon, anesthesiologist, and a patient advocate of my unce's father's situation. As the other medical personnel - or should I more correctly say the sole other medical personnel present -- in such a setting, I'm not necessarily even considered medical personnel, period. I'm a mere student, and because I'm not their medical school student, even my status as a student is tenuous at strongest.

Still, this was my uncle -- an uncle by marriage, for that matter, but my uncle just the same. His only other avocate at the moment was his pale and shaken wife. The oldest of his offspring was in Newfoundland on military duty. His second child was attempting to arrive at the scene of the surgery while simultaneously preparing for her engineering final exams at a university across the continent. His youngest child was at the mercy of an automechanic attempting to repair the starter on his vehicle nearly five hundred miles from the location of the surgery. Other relatives would arrive in the coming hours, but action was needed at tht precise time. My aunt tried to explain her concerns buy had litte success in describing the incident involving her father-in-law more than thirty years ago. The only real voice for my uncle at that time was mine. I'm not certain how interested I would have been, had I been the medical personnel present, in hearing my not-quite-twenty-three year old voice.

There are times to embolden one's voice and to embellish one's knowledge and one's experiences with hope that bravado might possible increase authority. At other times, bluster serves only to decrease what little credibility one possesses in the first place. This seemed to me to be one of such times. As humbly as i could while still attempting to convey some sense of confidence, I related what was already in my uncle's medical records, but reiterated that neither my aunt nor I wanted the same result as what had happened so many years earlier to my uncle's father. I conceded a need for elevated hydration while calmly [as I could under the circumstances] advocating  for a a more moderate and measured aprroach to the system -- for modest-as-practical  hydration, for use of the safest antibiotics, and for a chance for my uncle's body to heal what a body can often heal on its own when left to minimal interference.

My uncle drank 7-up and ate soda crackers a few hours ago. He'll be taking moderately heavy pain medications for a few weeks, as he had a few nasty struvite calculi in addition to a grossly enlarged prostate. Did I miracuslously save my uncle's life? In the most likely scenario, no. He probably would have survived whatever reasonable course of treatment that was ultimately chosen had it not involved the use of leeches or the relying upon of the services of an exorcist. 

Still, I was able to be what too many times in my career I will not be,  which is an advocate for a patient. The role of patient advocate should be a part of every doctor's job at the back of his or her mind at all times even if it's not his or her primary job. The job of advocate will not look the smae from whatever angel it is approached, but still, the idea should be there -- that if no one else is present to advocate for the patient, the job ultimately must fall upon the doctor, who must advocate without regard for what is beneficial to the hospital's administration or reputation or what is good for the insurance carrier's bottom line. And we, as medical professionala (I'm once again calling myself a medical professional prematurely in this sense) need to forget that every patient deserves an advocate, and  on rare ocasions the patient has no advocate unless the doctor steps out of his doctor shoes and into the role of advocate. 

I wsn't entirely the most diplomatic advocate, not was I entirely as humble or as reasonable as I might have been. I have time yet to work on those skills, and I have faith in my ability to improve in those areas.

It's late, and I still have, along with the proverbail promises to which I'm obligated, many miles to travel before I'm givn the luxury of the opportunity to sleep.  I have a review -- which i'm looking forward to writing for my friend Craig. I haven't done my poor and ailing eyes any favors today. My eye muscles were so weakened by the day;s acivities activities that I was unable to drive my aunt home; we took Lyft instead. Both of our cars remain in the hospital's valet parking section, whih=h leaves then their in excess of the time upon which we had agreed to leave them. We'll deal with them tomorrow. A generous tip mends fences where most of such things are concerned. We arrived at her home safely. which was and should have been our major objective.

My sub-internship has been a bit of a bust. Injury, illness, and real life sometimes get in the way of the best-laid plans of mice and medical school students, or at least did in the case of this particular medical student. I haven't burned any bridges as far as this sub-internship is concerned; my supervisors have been pleased with what work I have completed for them. There just hasn't been enough of it from where I stand. Fortunaely for me, I have a urology clerkship rotation I can scratch in place of a fresh sub-internship from mid-January until mid-February.  Meanwhile I'm off duty until Monday, when I will begin  a new rotation in hematology. The career of no doctor of whom I've ever been aware was every harmed by extra knowledge of the field of hematology. 

Plans go awry from time to time. We as prospective physicians and as prospective adult humans must learn to adapt or to go with the wind a bit from time to time.

My guess is that both Davey and Goliath would be fully in agreement with my new plans. Furthermore, should it not work out, the remake of Davey and Goliath may need a new studio musician, which I personally could be if all other options were cut off to me. Options are a nice perq for just about anyone, I'm not sure anyone benefits form them more than do medical school students.

Most likely this time next year will find me in a residency somewhere in the Great White North, but even if not, there are other great places to be and other whorthwhile things I could be doing.

Happy Thanksgiving Day, all!  Remember that much is expected from those to whom much has been given, and for most of us, in one way or another, a whole lot truly has been given.  Soon, for me, I will travel over the river and through the woods to my aunt's and uncle's home for a sumptious meal and a few extra hours of blessed and much needed rest. I wish everyone wthing rading distance the same.


  1. I always liked Urology when I was in the lab. I found urine to be one of the least offensive bodily fluids, generally.
    Patient advocacy is increasingly more important as technology and treatment options increase. The lay person is fairly clueless without a lot of research and who has time for that when illness strikes?
    I am happy to hear that you are getting past the "Doogie Howser" issues. Long term stress and sleep deprivation can help with that.
    Whether you end up as a musician or doctor you will be great. I just know it.

    1. Thanks. Who really knows what the future holds for any one of us? I could have a child and not be able to bear to leave him or her, or I could decided to take violin more seriously and that the symphony is where i belong. Either way, the kid or adult seated near me will be in a better position because i have at least some medical training.

  2. Talk about being in the right place at the right time. An enjoyable and insightful post, especially the last paragraph. Curious about the flushing process - PO, IV, bladder irrigation?

    - ThatRN

    1. Flushing was primarily iV but some extra bladder irrigation as well. I acted a bit diva-ish considering my position (which was one of being basically no one) and insisted on a cardiologists's consultation. She persuaded med. team to be moderate in flushing approach.