Tuesday, January 15, 2008

Second Guessing

My dad is in the next room, and I think he has pneumonia.

I listened to his lungs, and it sounds like a pneumonia. He was coughing like there's no tomorrow, but the anti-cough medicines I've given him seem to have calmed him down. His respiratory rate is less than 30, and he says he's not having a hard time breathing. I've already started him on oral antibiotics with good coverage for a wide range of possible bugs.

So why am I still awake at 2:30 AM trying to decide whether I should bring him to the ER or not?

You'd think that after 3 years of training in Internal Medicine, I'd be sure of what to do next. After all, I've seen already so many cases of pneumonia, seen patients falling into the full range of the disease. As part of my training, I've evaluated these patients in the ER and in the out-patient clinic and have made quick rational clinical decisions about who can be treated at home and who should be admitted.

I've just finished reading the chapter on pneumonia as part of my review, and I don't think Dad needs to be admitted. Sure, he's a diabetic and hypertensive, but those two conditions are stable anyway. I guess he'll be okay here at home. I haven't even confirmed it's really pneumonia. Maybe I didn't really hear anything.

Or maybe I'm just in denial.

I'm bringing my dad to his doctor as soon as the sun is up. His doctor can decide whether to admit him or treat him out-patient basis.

This plan of action is sure to get my parents' goat yet again. We've had this argument too many times to count. They will play the "what's-the-point-of-your-medical-degree-
if-you-can't-treat-us-anyway" card. I will come out looking like their useless child but I will drag them to a doctor's office anyway.

What most people, especially my parents, cannot understand is that once you're dealing with diagnosing and managing your close family members, all that medical training goes out the window.

Objectivity, an essential element in the clinical decision-making process, is all but impossible. It's easy enough to make treatment decisions for people who you can hold at a certain distance, thinking in terms of likelihoods and probabilities. When you're this close to the ones you are treating, this second guessing simply cannot be helped. It doesn't matter that you're supposed to know better - in that moment, you don't.

So while I think my dad doesn't need to go to the ER right now, I still won't be able to sleep - because I could be wrong.

These are the moments when I have to say it really sucks to be the only doctor in my family.


Manggy said...

He has a personal doctor? Maybe you could give him a call, outlining what you've done so far. There are a lot of (non-ethical) concerns (but still very important and personal) when it comes to treating your immediate family. Did he improve? I don't think he has any high-risk criteria, right?

Honestly? I've found it near-impossible to find someone who is consciously being observed for respiratory rate to have an RR of <20. I think the only time it drops to that level in Filipinos is when we're asleep (and sometimes not even then).

Whatever you decide, I hope your dad recovers completely very soon. Maybe his doctor can commend you for your prompt action.

Leon said...

Sorry to hear about your dad. Hope he recovers. I also hope he doesn't really have pneumonia.

aloyloy said...

That, or we are so used to the PGH mindset... "wag munang dalhin sa ER yan, mabwibwiset lang ang POD... OPD kung OPD!!!"

dr_clairebear said...

thanks, everyone, for the good wishes! i figured i should give you all an update, so here i am. :)

as it turns out, dad does have pneumonia, but his doctor decided to treat him out-patient basis. we have to bring him back by this weekend though.

so far so good, though he's still wheezy and coughing despite the meds and the nebulization. he's a bit better compared to yesterday, though. :) i make rounds on him anyway, so the only thing missing is the heplock, hehehe.

thanks again for the concern!

Working Girl said...

Good luck. I hope he recovers quickly. I really related to what you wrote. I am a nurse, but I have actually fainted while watching my child get stitches -- even though I regularly circulate in the OR and watch MDs stitch up the perineum in the delivery room. Everything is different when your family is involved.

morks said...

hope your dad turns out ok. i wouldn't know what to do myself if i were in your position. so maybe i should get another pediatrician for my kid no? i've actually skipped the last 3 months going to her doctor before because i could call my cousin who's training in pediatrics anytime naman. i know, it's still different having her treated with a specialist every month.


dr_clairebear said...

@Working Girl: But for the tick in a check box, I would have been in OB-Gyn and not IM. :) Thanks for the comment! Through the years, I've found that this second guessing is something that all of us in the health profession have to deal with - though some of us are more queasy about treating our relatives than others. I fall on the queasy side of the equation.

Thanks for the comment!

@ris: i guess you can ask your cousin if she's comfortable being your baby's pedia. if she is, great! the regular checks would be nice, though, because it helps you track if Mia is on track in her growth. one thing you can do is to ask your cousin to teach you what to measure and how to do it, so that you can update her if she's too busy to see mia regularly. :) I find that this mental paralysis usually starts to hit me only when it's my parents who are sick and I have to decide how to manage them, I can diagnose my other relatives more easily, though still not as comfortably as I would people who are not related to me. :)

Pats said...

Hi Claire! This is the first time i've been to your site... looove it! Haha. Anyway, back to the topic. I can relate to how you feel. That happened to me when my sister had GDM... i wanted to have her admitted for closer monitoring and to start insulin, but i was so afraid of that decision, and making the wrong decisions in general. i eventually started her on SC insulin, but didn't pursue her admission.
It's hard to be the only doctor in the family. You have to contend with their perceptions of being a doctor, which can be twisted by the current medical soaps. My parents are crazy... they think i can diagnose a disease via a phone call or worse, via SMS!!! Bottom line: they don't know how it's like... They don't know the fears and worries you have if you treat them (and that you CAN'T have these hinder you when you treat a patient).
I hope your dad's better now... may he be in a hospital or out of it. :)