HOPE: A POSITIVE PRESCRIPTION – PART II
Medicine is not a pure science
First, I discussed about his diet and how he can live without much salt. And enforced some fluid restriction. “Only about six glasses of fluid total,” I warned him. “And one more thing,” I added. “You can’t simply sit at home and brood, waiting for death to come and grab you. Nobody in the world can make any predictions. But maybe, we can beat death at its own game. What do you say?”
He looked at me balefully. He must have thought, however provocative the idea is, it was still a wild, mostly hypothetical concept. “How long one lives or when one is likely to die is a guessing game. And every individual is different. We must give it all we have before accepting defeat,” I tried to encourage him.
Suddenly, his ears perked up. He became more attentive; there was a twinkle in his eyes now, which I never noticed before.
“You mean I have a chance?” he said incredulously.
“Of course, nothing is written in stone here. Together, we can stretch this heart to work a few more months or even years. Count your blessings, Ted, at least you don’t have a rapidly spreading metastatic cancer.”
Maybe that was what he was waiting for. The look on his face told me that he has changed from a timid little man to an intrepid soldier ready to fight for his life. “That is the spirit! Let us give it our best shot,” I reassured him, knowing well that this would be an arduous journey.
During the next several office visits, I gave him a gentle exercise program suitable for heart failure patients and for a while, he even went to the hospital cardiac rehab program tailored to his needs. Got him a home health care agency to set up oxygen and administer occasional IV Lasix as needed. Although he was only mildly overweight, I managed to get rid of a few pounds off him.
Next I went to work on his drug therapy. He was put on some of the newer drugs such as carvedilol, which had only just come to the market at that time. And all the other concoctions – a diuretic, potassium supplements, amiodarone for his ventricular arrhythmias, ace inhibitors, later a dual chamber pacemaker when he nearly coded on me one day with slow heart rate. Finally, he started walking short distances without much shortness of breath. As he continued to improve, hospitalizations became less frequent and the quality of his life got better. He even started coming to our special cardiac rehab program, carefully tailored to his needs.
When he passed the much anticipated first year mark, both Ted and his family were exhilarated and brought me a nice card. “So, it looks like I am going to make it, eh?” he asked my office staff with a smile.
It is often quoted that in the United States, heart failure (HF) is the single most frequent cause of hospitalization in older people and the death rate from HF exceeds all forms of cancers combined. When not treated and monitored closely, HF progresses inexorably shortening the ultimate life expectancy. Hence, it is important to teach the patients and their relatives how to take good care of themselves and follow a strict regime of treatment along with lifestyle modifications. The new treatments have certainly helped to halt the progression of the disease and in some cases even reverse it.
Being scientists, physicians generally put a lot of emphasis on the technological data of a patient while trying to gauge the prognosis. But medicine is also an art and there are many other factors to be taken into consideration. Yes, words do matter, so does the body language of the attending physician, when communicating with seriously ill patients. Just like the physical body, the mind also has boundless potential and when used properly, can aid in the healing process. We must find time to dispense compassion, sympathy and understanding when treating seriously ill patients. Instead of saying “You have only six months to live,” a better statement would have been, “You do have a serious illness but we will do everything possible to forestall your illness and make you feel better.” None of us can predict the future.
Ted Nolin lived five more years and finally, when I turned him over to hospice, the wife sent me a sweet note, “Thanks for giving Ted the hope he badly needed and then making all this happen. God bless.” This whole episode reconfirmed the general dictum, “Always give hope to your patients and never let anybody take it away from them.”
* With permission from Medical Economics where an edited version was published on Dec. 17, 2010 under the title “Prescribing Hope.”
Dr. M.P. Ravindra Nathan is a Brooksville cardiologist and director of the Hernando Heart Clinic.
Guest Column
INTEGRATIVE MEDICINE PROMOTES SEVERAL FACTORS FOR HEALING
“These days, our culture encourages patients to find a doctor who understands their needs best, and to seek out treatment that best suits them,” health experts say.
“What we noticed in the last 10 or 15 years, is the patients are now better at advocating for themselves. They are more critical of their options. They have the resources to make better-educated choices and, in turn, they know to make their preferences known when they seek medical help," said Dr. Alan Christensen of the University of Iowa, who studies patient-provider interactions and health services.
“Now, not only are physicians learning to be better listeners, they are also learning to translate what they hear into more personalized care for their patients,” Christensen said. “This is a shift from the old relationship, in which doctors took paternalistic roles and patients merely followed their directions. The shift toward more equal ground in the relationship is bringing better medical care, studies have shown.” (See the full article in the Health section, www.nbcnews.com 02/27/11)
Technology is changing the information advantage between doctor and patient. It used to be that doctors were the only ones empowered by the science of medicine. But with a single leap and bound to the computer, patients can become quasi-doctors on the internet in the blink of an eye (assuming you survive the gauntlet of a Google search about your symptoms). They know a lot more about their issues before even setting foot in the doctor's office. Information technology has changed the face of health care and it barely resembles the old times when your doctor would visit your home, know your entire family, tap into the lifestyle causes of your ails, and then advise on medicinal and non-medicinal options for your symptoms or disease.
However, there is hope. Serving as a veritable tour guide of the human body and its potential malfunctions, modern medical doctors are transforming their positions on the healthcare team, rising from the ashes of their old paternalistic ways like the phoenix in a Harry Potter storyline. (As you can see, my daughters are in the midst of their requisite Harry Potter stage of development!) Doctors have a new opportunity to have a meaningful relationship with their patients. They must learn to really listen to the patient’s whole experience in order to satisfy what patients are figuring out … the truth! Patients have vital information regarding their bodies and are seeking the humble wisdom of a thoughtful clinician who listens, processes and incorporates her/his ideas so that both can create the best strategy satisfying the needs of the doctor-patient relationship. The cycle of old coming new again!
The terrain of human disease is changing drastically and the culprit is poor lifestyle. Unfortunately, the fast-paced, high-tech, magic bullet, pill and scalpel-based healthcare is not the answer … in fact, it may be the cause. Doctors are slowly realizing that they are not only going to fill prescriptions, but will have to take the responsibility of translator and teacher of health information. It is still uncertain if physicians will take on the massive responsibility of teaching and correcting patients’ diet, exercise and stress management as therapy, but there are those of us that are forging this new path. Doctors such as Dr. Andrew Weil, Dr. Mehmet Oz and Dr. Mark Hyman are modern-day healthcare evangelists preaching these truths.
Integrative and functional medicine physicians like us promote a thorough and thoughtful approach to disease management and health promotion, examining nutrition, movement, mental health and spirituality as key factors to an individual’s capacity to heal. The science and art of medicine will continue to heal its modern wounds as it finds itself paralleling our ancient Ayurvedic principles – that we are a microcosmic universe in and of ourselves and returning to our root constitution (prakruti) from the imbalance our environment creates (vikruti) is the key to lifelong health and happiness – the loftiest goal of any great healthcare model!
Dr. Shilpa P. Saxena is the founder and Medical Director of SevaMed Institute in Lutz. She seeks to educate patients and physicians in the expanding fields of Integrative and Functional Medicine. She leads Living Wellness University, an online Integrative Medical Education Community, which provides beneficial lifestyle tools for all. Visit www.livingwellnessuniversity.com for more information.
Guest Column
PLANNING A TRIP TO SOUTH ASIA? HERE IS SOME INFORMATION YOU COULD USE
The world has seen a lot of change and travel to places far and wide has become the norm. From an infectious diseases standpoint and infection control perspective, it has become imperative for the international traveler to be aware of health care risks and health care preventive initiatives necessary to make such a trip safe and healthy. In this discussion, I will try to focus on travel to the Indian subcontinent.
One of the most dreaded infections that could be acquired in the Indian subcontinent is malaria. One should be aware that most of the malaria acquired in South Asia is chloroquin resistant. So if you are ill with malaria, while there, chloroquin should not be the drug of choice. Therefore, prevention should also be based on this resistance factor. The current standard is Mefloquin 250 mg that is taken at weekly intervals starting with the first tablet taken a week prior to the start of the trip; the second tablet taken on the day of the trip and then one tablet to be taken weekly until four weeks after the return to the United States. Bad dreams and nightmares are the most common side effects. Doxycycline taken daily for a similar duration is an alternative; though this is not recommended for children less than 7 years of age and for pregnant women. Another key is the use of insect repellent containing a high percentage of DEET, picaridin or oil of lemon eucalyptus, especially during dusk and dawn when most of the mosquitoes are active. Avoiding the outdoors during these times and/or wearing long sleeved clothing and/or staying inside screened enclosures are other additional prevention methods. Staying at hotels or resorts where regular insecticide spraying is done and where there do not appear to be stagnant bodies of water is also desirable. Report any fevers that are accompanied with shaking chills and rigors to a health professional. Malaria can be life-threatening and should not be taken lightly. Pregnant women are at particular risk.
Vaccinations against typhoid that is usually acquired through contaminated food and water are available as a live oral vaccine series or a killed intramuscular vaccine. Either vaccination is to be taken at least three to four weeks prior to departure for optimal effect. Vaccination against cholera is not effective and not routinely recommended. A frequent traveler taking the killed vaccine against typhoid should repeat the vaccine in six to 12 months to acquire prolonged immunity for at least six years.
Hepatitis A is another food- and water-borne illness that is vaccine preventable. It is a two- vaccine series, the intramuscular shots being given six months apart. Once again, the first dose should be taken at least three to four weeks prior to departure. It is generally a good idea to have a Hepatitis B vaccine series, as this disease could be acquired through blood transfusions or could be sexually transmitted. There is a fairly high prevalence of Hepatitis B among the native population in South Asia and should you require a blood transfusion during a visit, you should be aware that quality of transfused blood may not be of the same standard as in the United States. Also, if you have to receive shots of any kind while there, insist on disposable needles. Haircuts and shaves are cheap in the subcontinent but be aware of the razors used as the blades are frequently reused creating a health hazard.
Traveler’s diarrhea is the most common and rehydration and immodium are usually helpful in countering this social activity destroying annoyance. Nevertheless, some of the more serious diarrhea illness is also associated with a fever and if that occurs, then antibiotic therapy usually in the form of ciprofloxacin is recommended. I usually ask my patients to fill a prescription for ciprofloxacin prior to departure, but only to take the medication if there is a fever associated with diarrhea.
Polio is water and food borne and precautions described above are useful here too. Vaccines are available although this is not routinely given. Childhood vaccines that you may have received while in Asia may have lost their potency after several years.
Dengue fever and Japanese B encephalitis are now being encountered more commonly. There is a live vaccine for Japanese B encephalitis. This illness is seasonal and regional and it is always good to check the Centers for Disease Control and Prevention (CDC) Web sites for more information. There is no vaccine against dengue fever and avoiding insect bites is the only way to prevent the illness.
A few helpful hints that one should keep in mind while traveling in the Indian subcontinent.
1) Avoid ice in drinks as they may be made out of non-bottled or non-boiled water.
2) Only eat fruit that can be peeled.
3) Always eat food that has been cooked well. Avoid raw vegetables and salads.
4) Avoid petting animals as rabies is fairly frequently encountered and routine vaccinations of animals are not frequently observed. Therefore, animal bites could be dangerous.
5) Wash hands frequently with soap and water especially after traveling outdoors.
6) Do not assume that since you were born in South Asia that you still have immunity to these illnesses. Most people lose their naturally acquired immunity after a few years of living in the United States.
7) Check www.CDC.gov for the latest information before departure.
8) Don't forget to have fun.
Dr. Naresh P. Menezes, a specialist in infectious diseases who practices in Hernando County, can be reached at [email protected]