72 year old woman I diagnosed with incipient dementia several years ago. Got a second opinion from the Geriatric Specialists at the big medical center who, in my opinion, missed the diagnosis and labeled her as having "mild cognitive defect". Meanwhile, we see her routinely, as she needs B-12 shots and lab tests for hyperlipidemia. At each office visit she looks at me earnestly and says that she is "worried about her memory" and begins to run down a long list of questions and ideas. She always has a new memory "work book" or new text on memory from the book store or library. She tells me that all of this has her "depressed" and she is "worried about the future".
If I point out to her that we've had this exact discussion before she either becomes defiant or bewildered. She vaguely remembers the second opinion, but dismisses it by saying that they told her she did not have dementia but "since then" she has begun to notice some memory issues.
I encourage her to continue with her mental exercises, to follow as much of the advice in the workbooks as she can and not to feel guilty if she feels she can't measure up to what the work books are asking of her.
I am always exhausted when she leaves.
Tuesday, March 27, 2007
All for nothing
A 48 year old man I've taken care of for nearly 20 years. He is 250 pounds, but works out a lot, lifting weights. He suffered a right calf DVT years ago with significant pulmonary embolism, and has been on coumadin since. Works at the local "factory", raised a couple of kids, and didn't always get to the office every month to get his INR checked. Basically a good, well-meaning guy. Biggest problem has been struggling with his weight (he likes to eat) and not enough aerobic exercise.
During his annual physical he reflected on the fact that several people he knew from work had dropped dead during the past year. One, a c0-worker, father-husband with no symptoms had supper, retired to his Lazy Boy and dropped dead. 28 years at the factory, struggling to raise the family, hoping one day he'd catch a break, and now-nothing. "It was all for nothing", he said. "He'll never get time to relax. He'll never get to watch his kids, see or hold his grandchildren. Nothing."
I choked up a bit. My father dropped dead from an MI at 57 years old while I was a second year medical student. Was it all for nothing? Do the moments "count"? And what is the point of life, anyway? Somehow, after that "pleasant" mid-afternoon exchange, I still had to put a warm smile on and attend to the rest of the patients that afternoon.
During his annual physical he reflected on the fact that several people he knew from work had dropped dead during the past year. One, a c0-worker, father-husband with no symptoms had supper, retired to his Lazy Boy and dropped dead. 28 years at the factory, struggling to raise the family, hoping one day he'd catch a break, and now-nothing. "It was all for nothing", he said. "He'll never get time to relax. He'll never get to watch his kids, see or hold his grandchildren. Nothing."
I choked up a bit. My father dropped dead from an MI at 57 years old while I was a second year medical student. Was it all for nothing? Do the moments "count"? And what is the point of life, anyway? Somehow, after that "pleasant" mid-afternoon exchange, I still had to put a warm smile on and attend to the rest of the patients that afternoon.
Monday, March 26, 2007
Pawling, NY
A retired dentist with chronic atrial fibrillation comes to the office every month to have his INR checked. Most of the time he's well and simply gets a blood test. I've known him for years. He's a widower, friendly, compliant and a delightful patient. He recently suffered from a bout of CHF which followed a nasty case of bronchitis, so I've had the chance to see him more than usual. Today was a simple follow up to determine if the dose of coumadin was adequate and to see whether we would continue on a low dose of furosemide. Those decisions took minutes, but we began talking about spring. He recalled a spring in Pawling, NY while he was in the army. He was stationed at what is now Greenhaven Prison, but apparently at the time was being used for the military, but also housed hardened criminals. He was assigned there to practice.
I worked on a dairy farm not far from there when I was in high school twenty years after he was there. We both recalled the big hill, which was a challenge for the freight trains coming out of New York City. He recalled watching the cars go by and remembered they often had to have two engines pulling. I shared that we used to hop the trains, because they were going slow enough, and ride them for many miles, while the local boy, Kenny, would drive the tractor around to the next intersection where we'd hop off. He recalled playing on a fabulous golf course that was "just like a wide, green pasture". I recalled that Pawling had one of the oldest golf courses in the country. As far as I know, its still in operation.
I remembered that there was a man who worked as a prison guard at Greenhaven who rented a room at the dairy farm I worked at. On the weekends he would help out around the farm, out of boredom. He said he was from "upstate", near Syracuse, and that he was working to send money home to his family. He rarely went home. He never got a phone call. He had a tatoo and very black hair, which he kept slicked back. He was a quiet man and had very conservative political views. I always had the feeling that he could explode at the least provocation and imagined that he was capable of killing a man.
The dentist remembered that he lived in very nice army housing with his wife, and this memory made him smile. He admitted that they were being pampered beyond what was necessary. From there he was sent to a post on the Jersey shore. He remembered that a famous radio announcer lived in Pawling, but he couldn't remember his name. I didn't know it, but looked it up when I got home. Edward R. Murrow. His ashes were spread over his farm. I never went into Pawling that much, my farm was up the road in Poughquag, but we did occasionally go to the farm supply store near the train tracks. I think it was an Agway.
Years later, when I was in college we took a field trip to Wingdale, the mental institution there, as part of a class on genetics. It was the most uneasy I've ever felt in my life. We were ushered into a dingy room in an old, industrial style building. Like something I could imagine in communist Russia. The room was filled with abandoned children; all malformed and bizarre. One was just an enormous head, and tiny limbs. One had a face as narrow as a turnip. One appeared to be part boy, part monkey. Most were in stainless steel hospital style cribs. Like little prisons. A few were being held by nurses who, I remember thinking at the time, had significantly more inner strength than I had.
All of these memories of Pawling were far more interesting than CHF and atrial fibrillation, but the dentist and I were much better off for having spent the time recollecting.
I worked on a dairy farm not far from there when I was in high school twenty years after he was there. We both recalled the big hill, which was a challenge for the freight trains coming out of New York City. He recalled watching the cars go by and remembered they often had to have two engines pulling. I shared that we used to hop the trains, because they were going slow enough, and ride them for many miles, while the local boy, Kenny, would drive the tractor around to the next intersection where we'd hop off. He recalled playing on a fabulous golf course that was "just like a wide, green pasture". I recalled that Pawling had one of the oldest golf courses in the country. As far as I know, its still in operation.
I remembered that there was a man who worked as a prison guard at Greenhaven who rented a room at the dairy farm I worked at. On the weekends he would help out around the farm, out of boredom. He said he was from "upstate", near Syracuse, and that he was working to send money home to his family. He rarely went home. He never got a phone call. He had a tatoo and very black hair, which he kept slicked back. He was a quiet man and had very conservative political views. I always had the feeling that he could explode at the least provocation and imagined that he was capable of killing a man.
The dentist remembered that he lived in very nice army housing with his wife, and this memory made him smile. He admitted that they were being pampered beyond what was necessary. From there he was sent to a post on the Jersey shore. He remembered that a famous radio announcer lived in Pawling, but he couldn't remember his name. I didn't know it, but looked it up when I got home. Edward R. Murrow. His ashes were spread over his farm. I never went into Pawling that much, my farm was up the road in Poughquag, but we did occasionally go to the farm supply store near the train tracks. I think it was an Agway.
Years later, when I was in college we took a field trip to Wingdale, the mental institution there, as part of a class on genetics. It was the most uneasy I've ever felt in my life. We were ushered into a dingy room in an old, industrial style building. Like something I could imagine in communist Russia. The room was filled with abandoned children; all malformed and bizarre. One was just an enormous head, and tiny limbs. One had a face as narrow as a turnip. One appeared to be part boy, part monkey. Most were in stainless steel hospital style cribs. Like little prisons. A few were being held by nurses who, I remember thinking at the time, had significantly more inner strength than I had.
All of these memories of Pawling were far more interesting than CHF and atrial fibrillation, but the dentist and I were much better off for having spent the time recollecting.
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