Ulcers, Easter, and Truth

Truth is at times unbelievable.

By the early 1980’s medical experts were certain they understood the causes of gastric ulcers. As the stomach is an acid secreting organ, and because acid can damage tissues, everyone knew that acid was the reason people got ulcers. Because ulcers were more often found in urban businessmen, doctors concluded that stress had a role. This theory was “confirmed” by studies in rats that showed ulcers developed when rats were wrapped in straight jackets and dropped in ice water, and when research showed antacids prevented these ulcers.

Enter Barry Marshall, an internal medicine doctor in Perth, Australia. Along with a pathologist colleague, Robin Warren, he gathered evidence that ulcers were the result of a bacterial infection. Further, he found evidence that the bacteria was a root cause of stomach cancer. He started treating ulcer patients with antibiotics, with remarkable results.

The medical community refused to accept his findings. They thought they knew the cause of ulcers, and could not believe that a bacterial infection could be the cause. It did not make sense. Bacterial infections were the cause of acute infections, of pneumonias and ear infections and sinusitis and cellulitis. They did not cause chronic infections, and they definitely did not cause cancer. Marshall’s theory was simply unbelievable.

It was unbelievable, but it was true. Convinced of the truth of their claims, Marshall and his colleague fought for their findings. The medical community took longer than they should have to accept their research, but the eventually did. In 2005 Marshall and Warren, were awarded the Nobel Prize for medicine. They changed the world of medicine forever.

Their story came to mind today as I thought about Good Friday and the Easter Story. The Gospel accounts tell an unbelievable tale. The Bible declares that Jesus of Nazareth, a Jewish teacher of dubious parentage, was actually the Son of God. This Son of God, instead of asserting his right to rule and demanding that all honor and worship him, allowed himself to be put to death at the hands of the Romans who governed the conquered Jewish nation. He was publicly executed in brutal fashion, nailed to a wooden cross where he hung until in agony he died.

The story did not end with Jesus’ death,  the New Testament writers report that 2 days later he appeared alive to many of his followers. He had risen from the dead, in so doing proving to the world that he was indeed who he had claimed to be, the Son of God and the savior of the world.

What an unbelievable story.

So much of the story does not make sense. Why would God decide to live as a man? Why would he choose to die? Why couldn’t he just choose to forgive everybody without going through such suffering? How could someone come back to life after two days in a tomb. There are too many “whys” and “hows”.

The story flies in the face of so much that people know. The story is unbelievable.

That does not mean it isn't true.

- Bart

The Unrelieved Agony of a Dying Man

I never planned on being a hospice doctor. I had almost no training in end of life care during my Family Practice Residency. I learned about ethics, about patient’s rights to refuse care and to die with dignity, but caring for patients during the dying process was not part of the program.

One of my first exposures to end of life care in practice was when my aunt died of cancer in 2002. I loved my aunt and had fond memories of her but we were not close. I had not even been told she was dying. It was not until the last few days of her life that I knew how grave her circumstances were. It was then that I received a call from my grandmother. She told me my aunt was in terrible pain and the hospice doctor did not seem to be doing anything about it.

I drove to her home in south Orange County to see first hand what was going on. She was moaning in pain, even though there was a nurse present. My aunt was not fully lucid, and I asked the nurse what medications were being prescribed for pain. I was stunned at the response. I did not consider myself an expert on the treatment of cancer pain but I knew she was on a very low dose of morphine. The IV was delivering only 1 mg an hour, a dose so low that pain relief was extremely unlikely. I did not know much about cancer pain but I knew I could do better, so I volunteered to assume the supervision of her hospice care. I instantly doubled the dose of morphine. When her pain continued, I doubled the dose again. I repeated the process every few hours until she was comfortable. She did not achieve a pain free sedated state until the next day when the dose reached 100 mg an hour.

When she died a few days later my grandparents thanked me for taking care of her. They had watched her suffer for days, and I had changed that. The experience also changed me. After caring for my aunt I made myself a promise. No patient would suffer under my watch. I would personally manage every hospice patient in my practice. I knew I couldn’t save every patient but I could darn sure make sure they did not die in pain.

For the last 16 years I have kept that promise, making house calls and responding to calls from hospice nurses anytime, any day. I have aggressively managed pain, increasing doses as needed, committed to the relief of suffering. I have been consistently able to make all my patients comfortable.

Until the last few weeks. I had a patient whose pain I could not relieve.

He had aggressive lung cancer in his left upper lobe. The cancer had grown upwards into the soft tissues of his chest and shoulder, compressing the nerves that supplied his left arm. Nerve pain is the worst type of pain, and his was resistant to everything I tried. Multiple medications, from narcotics to nerve medications, failed to reduce the agony. I consulted pain specialists, palliative care doctors and radiation therapists in search of a treatment that could relieve his pain. I tried everything, hoping that the next medication, the next change in dosage, would prove to be the one that worked. After each adjustment in medication or dose I called to ask him how his pain was. The answer was almost always the same, ten out of ten. One the rare occasions when the pain went down the relief was only temporary. The pain would peak again in a matter of days.

The last week of his life, as the end was clearly approaching, I encouraged the nurse to get more aggressive with his medications. His dose of morphine reached a remarkable 400 mg every few hours, yet his pain remained. I called the best end of life doctor I know, and he recommended a change to methadone. The pain persisted. We added sedatives, hoping he could find a way to rest. He ultimately passed in his sleep. I can only hope that he did so without pain.

I was a heartbroken when he passed. I mourned the loss of man I considered a friend, of my inability to be at his side in his final days (I was out of town), and most of all, the knowledge that he had suffered so much. I was, and am, grateful in the knowledge that his suffering has ended, but find myself wishing I could have done more.

He suffered. He remained positive and kind to the end, but he suffered every day.

His passing makes me acutely aware of the limits of my profession. No matter how hard I try, there will be conditions beyond my reach, diseases I can’t cure and suffering I cannot relieve. It is the reality of life.

Even more, his pain causes me to again wonder as to the purpose of suffering. It is hard to see the good in circumstances so bad, hard to see the hand of a loving God in the midst of such agony. For this patient and I, it was our shared faith that sustained us. We both clung to the hope that his faith assured an eternity free from suffering, and reminded each other of this hope in our times together.  We also prayerfully shared the hope that God would somehow, someway, use his last days to touch the lives of those he loved, that God had a purpose.

I do not know what these purposes are or might be. The answer may not come in this life. All I can do is focus on the purpose that I know God has for me right now, which is for me to do the best I can to love his family and encourage them. I can share the story of his faith with others, of the hope that we shared, that others may find similar assurance. And I can do all I can to comfort and care for the other dying patients God brings my way.

- Bart

Thanks for reading and sharing. If you are so moved, consider saying a prayer for the man's family. There loss is profound. Comments and questions are always welcomed. I can be reached via the contact button on this website, or followed on twitter @bartbarrettmd.  

The Wealth of a Poor Young Man

Money was tight. He had left a job that met his financial needs because there was no opportunity for advancement, and instead took a job with the promise of a future, getting hired on as an apprentice electrician. Sadly, the contractor’s promises of work proved empty and within a month he found himself working only a few days a week and struggling to make ends meet. To make matters worse the physical nature of the job caused an old back injury flared. He was left wondering if his body would be able to tolerate the demands of an electrical career. Injured backs and pulling cable through tight spaces don't mix.

He is only 27, he has very little money and an uncertain future, yet he is one of the most impressive young men I have met. He is poor, but he has something most men lack. He has values. He is looking not for material wealth or pleasure, but for a job that will one day provide for his family. The mere fact that he wants a family to provide for is unique among men his age. He has no interest in casual sex or one night stands. He is looking for commitment, for a woman to marry.

In spite of his financial challenges he talks little about the things he lacks, or about things he wants to do our buy. He prefers to talk about the people he loves and cares about. Relationships matter to him, and he speaks proudly of his younger brother and his mother and what they mean to him. He is poor but still thinks of the needs of others. He recently moved into a new apartment, and when his parents offered to buy him a new living room set he refused to consider expensive furniture. He walked out of the high priced store store they had taken him to and chose instead to go to a discount store. He did not want them to waste money.

He is a man of faith. He is active in his church, and the ability to have Sundays off was a major factor in his decision to change jobs. He has meaningful relationships with people in the church and participates in a small group every Thursday night.

He has had a difficult life but he is not bitter. His father died of leukemia 7 years ago, a loss that could have made him angry at God and the world. His faith remains strong and his belief in the goodness of God has endured. He has embraced his mother’s new husband, rejoicing in her happiness and welcoming the man into his life.

He is a former patient who has become a friend, and we get together every once in a while over breakfast. When we talk I often think of the many other men his age I have met over the years, men with better pedigrees, engineers, lawyers, medical students and other professionals. So many of them are chasing wealth, prestige and pleasure. Although he is less successful in a worldly sense he stands out for the things he has that others lack- purpose, peace, and character. He is rich in the things that matter, a reminder that there are still good young men in this world.

- Bart

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Saving Lives by Showing Up

Woody Allen said, “80 percent of success is just showing up.” I am realizing a similar truth in my office practice. 80 percent of success is just letting the patient show up.  You can’t help patients who can’t get into your office. We have experienced the benefit of showing up in dramatic fashion over the last few months.

In the middle of the busiest flu week of the year a young man called our office. He had complaints similar to so many other patients seen during that time, high fever, occasional chills, loose stools and abdominal pain. Our office policy is to see anyone who wants to be seen for anything at any time, so the receptionist worked him into the schedule of our Physician Assistant. She walked into the room expecting to see her umpteenth influenza victim of the day.

He didn’t look like the other flu sufferers, though. He was paler, covered in sweat, and his abdomen was extremely tender. Concerned, she called me into the room for a second opinion. I took one look at him and had him lie down for a repeat abdominal exam. His abdomen was rock hard and he felt pain with the lightest touch. Minimal movement made the pain worse, as even tapping the soles of his feet was agonizing. I knew something was wrong.

“It could be flu,” I said, “but your symptoms are consistent with a surgical abdomen, what we see with a ruptured appendix for example.” I told him that because there was a possibility that he was seriously ill I wanted him to go straight to the emergency room.

The next day his mother updated us on his condition by sending us a message. “Thank you for saving my son’s life,” she said. Tests had shown that not only had his appendix ruptured but that he was septic, with life-threatening bacteria found in his blood stream. Has my receptionist made him wait a day longer, the delay could have been fatal. We all breathed sighs of relief. We knew that his life had not saved by brilliant medical acumen. He was saved because he was allowed to show up.

We had another close call a few weeks later. A man in his 60’s called saying he did not feel well. He was unable to give the receptionist more specific information. He just felt weak and sick. She told him to come on in to the office. As luck would have it, he was also seen by our PA. Although his blood pressure, heart rate and oxygen levels were all normal, she did not like the way he looked. It was my day off, so she called me at home to discuss the case. It was immediately apparent to me that she was unusually worried about him.

“Do you want me to come take a look at him?” I asked, “I am not doing anything and I can be there in 5 minutes.” She did not require convincing. She definitely wanted me to take a look. Attired in jeans and a t-shirt I went in to see him. When I entered the room I instantly understood why she was worried. He just looked wrong. He was pale, and his face was covered with glistening sweat. He looked like someone who was sick, even though his vital signs were normal.

“I am worried about you,” I said, “and in order to make sure you are okay I need some answers, answers I can’t get fast enough outside of the hospital. You need to go the emergency room, because they can get the results quickly.”

I had no idea how quickly the answers were needed. A little over an hour later in the emergency room he on the verge of dying. He went into respiratory failure and needed to be put on a ventilator. Further tests showed the cause, he had blood clots in his legs that were traveling to his lungs. Only the grace of God and the skill of the critical care team saved his life.

The next day in the office the topic of conversation was what would have happened it we hadn’t had him come in right away, or if I hadn’t come to the office, or if we hadn’t sent him to the emergency room. We shared the draining realization that we came so close to losing him. It was clear to all of us that his life was saved because we allowed him to show up.

I wish I could say that this was always the way I practiced medicine, that same day access without explanation or questioning has always been our response. A little over 7 years ago we started offering same day access to sick patients who called before noon. We only began guaranteeing the service to all callers regardless the time they called in 2015.

It is the best thing I have ever done in medicine. I have realized that while I can’t always be right, I can always be available.

Somehow, I think there is a lesson here for all of us. Showing up is important.

Bart

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Learning From "The Greatest Showman"

I have a confession to make. I’ve seen The Greatest Showman four times. One might think that was more than enough, but I have already checked Amazon to see when it will be available on Blu-Ray. Critics didn’t care much for the movie, but my wife and I loved it. The music and the story resonate with me in a powerful way.

It is not the story of the circus and its performers that stirs me as much as it is the story of the Barnum character himself. The movie portrays him as the son of a poor tailor, scorned and mistreated by the wealthy father of the girl he loves. He finds motivation in the man’s rejection and dedicates his life to a single endeavor, showing he is deserving of respect by achieving worldly success.

As a result of this consuming passion no amount of success satisfies him. Making his circus a success is not enough, he needs to be considered a serious producer of art. City wide fame is insufficient, he needs to be known around the world. Touching the lives of those he is close to does not bring satisfaction, he needs the adoration of strangers.

The futility of his pursuit is described in the words of the song sung by another unsatisfied character in the film, the world-famous opera singer Jenny Lind-

“All the shine of a thousand spotlights
All the stars we steal from the night sky
Will never be enough
Never be enough
Towers of gold are still too little
These hands could hold the world but it'll
Never be enough… for me”

This is Barnum’s curse. He is so consumed with the praise of people he has never met that he fails to appreciate the love of those around him, those who should mean the most to him. It takes the burning down of his circus building and financial ruin for him to recognize his mistake. The moment when these tragedies lead him to realize his foolishness is a powerful point in the film, expressed in the song “From Now On”-

"For years and years
I chased their cheers
The crazy speed of always needing more
But when I stop
And see you here
I remember who all this was for"

At the end of the movie we see that Barnum’s transformation is complete. As he sits in the theater, his arm around the woman he loves, he watches their children and sings, “This is the greatest show.”

This scene is profoundly moving for me. I grew up unwanted, unloved and abused, the child of a father held me in disdain. I spent years of my life trying to prove to him, myself and others that I was good enough, that I was worthy of praise. I drove myself to succeed in every area of my life, in education, medicine and even church. Toiling in the shadows was unthinkable, I needed to be the best, I needed recognition.

It took too long for me to realize that the only love and appreciation I needed was from those who love me. My wife believes in me, supports me, encourages me and loves me. Together we have built a family, a home filled with love and laughter. When I stop and consider my wife and my children I realize that they are indeed, “enough” and “I remember who all this was for.”

Forget the praise of the world, ignore the awards shows and the faint, vanishing praise of strangers. The moments of love spent with family are the Greatest Show.

-          Bart