Saints of all Sizes

I'm thinking about Mr. Ashman. More particularly, I've been thinking about his wife. We've admitted him for a very severe pneumonia, but the reason he stands out is more serious. See Mr. Ashman suffers from ALS, a debilitating disease which will slowly remove every muscular function of his body, leaving only his ability to think and be aware of his surroundings. This is oddly helpful if you are Steven Hawking, and your job involves sitting and thinking. But Mr. Ashman is just a regular guy, who found out 5 years ago that his tremors and weakness were a sign that very soon, he would be utterly helpless.

He was 35.

Now he is unable to breathe on his own, as the disease has affected his diaphragm, he is unable to walk, move his arms, or speak. Aside from turning his head, he can only move his right index finger.

But his wife is the reason he is still alive. She takes care of his ventilator, attends to his needs, and when necessary translates the cryptic gasping sounds that remain of his voice. On its own, this would be touching. What is almost staggering is the fact that she is one of the most upbeat people I've ever met. It is cheering to everyone in the ICU to see her.

Cheering and instructive. Through my past few months, I have so rarely seen happy stories that I'm tempted to slide into depression. But here is someone who lives the saddest story of all and is coping magnificently. My hope is that anyone so unfortunate to be in Mr. Ashman's condition could have someone like Mrs. Ashman around. For everyone else, there's just me.

The paths of pain are thine. Go forth
With patience, trust, and hope;
The sufferings of a sin-sick earth
Shall give thee ample scope.

Crazy

So Mr. Brook, who didn't need to be admitted, is gone, but not before bringing some much needed hilarity to the ward. In the first place, he is a raging alcoholic, telling me he has cut down to a six pack of beer a night. Pretty impressive, so we were watching closely to ensure he didn't enter withdrawal while under our care. Amazingly, he didn't. In fact, we didn't notice any signs of withdrawal at all, which had us wondering.

Until one of the nurses surprised him by walking in unannounced and discovering he had actually smuggled alcohol up to the floor. How he managed to hide this for four days straight is beyond me. I never even saw his door closed, and I was on call for 36 hours of that time.

Overall, a wonderful patient, funny and charming despite his intractable health issues. He had a snappy answer to every question. "Do you snore?" met with "none of the ladies complain." "How are you doing?" met with "I want to get out. I bet the ladies at the senior center already miss me."

Maybe oddly lecherous old men are just amusing. I'd be tempted to say it's only because I'm a guy that I found him so, but my resident, a woman, was cracking up at him too.

Camera Obscura - Let's Get Out of This Country

When a guy wearing a plastic sword-shaped cocktail skewer as an earring, with the fingernails on one hand painted black and the those on the other natural colored, tells you an album is worth a listen, it's worth the try, right?

In my book anyway. What's more interesting is that this guy and NPR agree.

So do I. The album is definitely worth a listen.

When I first listen to a band I know nothing about, I tend to make comparisons to other bands. So when I first popped this one, I thought "the Shins, but with a female vocalist." On the next track however, I was thinking "the Beach Boys?" And I went through the Strokes, Over the Rhine...nothing fit. Because these guys are unique. Sure, they have elements of all those bands, but it's always a "not quite...ooooh, I like what they did there, how unexpected" kind of reaction. The summary I keep coming back to is that of 50's pop instruments (organ, guitar with that era of amplification, etc.) with a modern melody and edge. By the way, it probably shows that I'm not a real music critic in that I have no idea what "that era of amplification" means, hardware-wise. Gibson? Les Paul? No idea. Anyone who does, please, let me know.

Though I wouldn't describe the songs as "anthemic," they are largely melody driven, something I like because it is fun to listen to. The lyrics are fitting, but not stand out. But everyone can identify with songs about heartbreak and partings. "The first track here states over and over "Hey Lloyd, I'm ready to be heartbroken" which is a response to a pop song from twenty years ago asking (go figure) "are you ready to be heartbroken?" Tracy's voice is perfect here, quavering but still earnest. Though I can't pick favorites here, a counterpoint to that track is "Country Miles" with the refrain "I won't be seeing you for a long while/but I hope it's not as long as these country miles" where the earnestness in Tracyann's voice lends a poignant air to the song. No real downside to the album, in that I don't notice myself skipping tracks as I listen.

A fun listen, one I'll be keeping around for a while. Recommended.

Residency application

Mine is complete, but I wish it were more stellar. I'd like a medical version of this if you will.

ER docs

I know there are good ER docs. There must be. Unfortunately, it has not been my good fortune to run into many. What got me thinking about this most recently was an encounter from my last night on call.

So my team is down in the ER, seeing a patient. We want the guy to come in, because he has had chest pain which is a bit concerning, but the enzyme levels we look at to detect a heart attack are not demonstrating any damage. So we lay out the story exactly like it is, telling him he needs a stress test, but he'll have to wait until Monday to get it. So he'll be camped out in the hospital over the weekend.

Mr. Brooks (the patient) decides he'd rather spend the weekend at home. Not smart, but it is his right, and we told him about the risk for death, etc., if he checked out.

Enter Dr. Oaks.

He's the ER doc who had been seeing Mr. Brooks, and upon hearing that the patient was going to leave, he swung into the room and said "oh, that's a bad idea sir, one of your cardiac enzymes is elevated, which means there is muscle damage to your heart, you know, that you're probably having a heart attack, so we'd like to watch you here."

This is both true and false, and the result means that Dr. Oaks is a)a liar or b)an idiot.

Let me explain. The enzyme we are talking about is called CK-MB, and it is part of the CK group of enzymes. We worry about it, because one of the places it is released from is the heart, and so if it is elevated, it can mean that a person is having a heart attack. However, we measure two more things as part of this test. One, we compare the total elevation of CK enzymes to the CK-MB elevation, and get a ratio. If the total level of enzymes is high, then the CK-MB part will be high only if you measure the number, but the percentage doesn't change. Put more vividly, if you have a set of marbles, with 10 red and 1 blue, and you combine it with another set of 10 red and 1 blue, now you have two blue marbles, but the ratio of blue to red is still 1/10. Mr. Brooks' CK ratio was normal, and the elevation in total CK (total marbles) is probably just a normal variation.

The other enzyme we measure is called troponin, and it is much more specific to the heart. It's almost 100% specific (but nothing in medicine is 100%) so if the troponin goes up, you can tell someone's probably having a heart attack. If it isn't up, they probably aren't. (Though that has more to do with sensitivity. Nevermind. If you wanted a lecture on EBM, you wouldn't be reading my blog)

So the options: Dr. Oaks didn't know enough about cardiac enzyme tests to be able to tell Mr. Brooks was not, in fact, positive, or he intentionally violated his medical ethics and lied to patient. It doesn't matter that he intended it for good.

My resident was, shall we say, vexed. She called out Dr. Oaks right there, and when he didn't respond favorably, she wrote up a report on the incident and filed it with the hospital.

We'll see if that helps his practice (or his ethics), but it probably won't improve relations between the medicine and ER teams.

C'est la vie.

Full Code

Mr. Grainger is going to die.

Not now, but the time for him is more imminently on the horizon that it is for me or you. He has cancer throughout his body, spreading into his brain. And as with any seriously ill patient, when we brought him into the hospital, we talked with his family about his "code status."

Code status refers to how aggressive the patient wants his caretakers to be in resuscitation. "Full Code" means that if his heart stops, we'll do CPR, and defibrillation as necessary, if his breathing stops we'll put a tube down his throat, etc. A "full code" on a patient is a violent occasion. CPR, if done properly, can break ribs, especially 80 year-old osteoporotic ones. A 30 year old might survive a code. An 80 year old almost certainly won't.

Which is what we tried to convey to Mr Grainger's family. But they were incensed that we would even ask about this and insisted he be "Full Code." So that was entered into the chart, though we didn't agree with the decision.

So this morning, my attending gave us a long talk about the ethics involved, insisting that in a patient like this, where a code has zero apparent chance of success, it is within our power as physicians to simply refuse to perform the code. His exact words were "if they want to sue, let them. There is no way a court can hold you liable for not performing a procedure that is against your medical judgment."

Leaving aside for the moment the fact that he turned, without thinking, an ethical debate into a legal one, the point is that we are to do the best for our patients, and sometimes that means doing nothing. I think I'm on board with that.

What bothered me about the way he defended it was by turning the discussion into a legal one. I'm concerned that so many derive their morality, at least in ambiguous situations, from the law. The reverse should be true, no?

...

I've also noticed, throughout my time at this hospital, that my concern for my patients has been somewhat lower than previously. My team, and indeed, most of the residents at this place seem to hate their jobs, hate the program, and hate their patients. I know that's not true completely, but the contrast with other hospitals, including my Number One Choice, is stark. I'll be ranking this one pretty far down my list when it comes to the match.

What this means for my blog is that I've realized my tiredness more, I've had a harder time finding touching stories and fun patients to write about, though I've been reluctant to join in the cynicism of my team. So I'm going to try to swim against this tide of negativism.

Hem - Rabbit Songs

This isn't a new album. It isn't even the first time I've listened to the band. But I hadn't paid too close attention to them until I realized that this ad uses Hem's song "Half Acre." I thought the ad was rather touching, and it stands out from the crowd in that it doesn't appeal to prurient interests to sell you something. For that reason, I don't know if it will be effective, but that isn't really the point here.

The point is, I bought the album this song comes from today because of this reminder. And I've had it on repeat ever since. From the opening bars of the lullaby "Lord, Blow the Moon Out Please" through the beautiful "Half Acre" to the closing notes of "Horsey," I was entranced. Very few albums will hold my attention so well that I'm unable to do anything but listen as they play the first time. This is one of them. I don't pretend to understand all of the songs, but it's hard not to connect with lines like "Think of every town you've lived in/Every room you lay your head/And what is it that you remember?" when you're sitting in a hotel room far from home. And if you're given to pensive reflection, as most of the posts here demonstrate I am, it's hard not to agree with lines like "So we carry every sadness with us/Every hour our hearts were broken." And for those interested in the meanings of the songs, this website is a bunch of quotes from the band explaining them.

But the words are far from the only high point of this album. The music is well crafted, and well executed. Between the filigreed mandolin, piano and clarinet of "Half Acre" and the bluegrass-ish "Cuckoo" is wide variety of styles, bound together by the ethereal voice of Sally Ellyson.

The band tried with this album to write something quintessentially American. They've succeeded admirably. Highly recommended.

Patients that make you say grrr

Mrs. Starbuck
Mrs. Starbuck has made a series of phenomally poor choices in her life. She has decided to smoke, two packs a day, for the past 20 years. The second poor choice she has made is deciding, after being diagnosed with asthma, to continue smoking. Her husband, perhaps considering "till death do us part" as incentive to hasten that event, has continued smoking as well.

So it wasn't exactly surprising to get that history from the pale woman sitting in the ER on continuous albuterol nebs, with an oxygen saturation of about 88%. For the non-medical reader, albuterol (in a nebulized form, aka "nebs") is something we give patients to dilate their airways in asthma attacks. Usually, it is administered once every few hours, every two in pretty bad disease, but even every half hour if someone is about to die from airway closure. So continuous nebs means someone is really worried. In point of fact, continuous nebs aren't shown to be much more beneficial than 30 minutes apart, but the exasperation of internal medicine with ER docs will have to wait for another post.

Anyway, Mrs. Starbuck was speaking only 3 words at a time before taking big gasps of the nebs, so we admitted her to the ICU, where she is on a BIPAP machine, something between full out intubation and nasal cannula oxygen.

Why people smoke, I have no idea. Why people with asthma smoke is so far beyond me I get angry with their stupidity just thinking about it.

Mrs. Solson
Real, live, Munchausen's syndrome. This marks the second time I've seen something similar. This patient came in and requested a central line. I've only ever seen that in drug abusers. Sure enough, about ten minutes after she was brought up to the ward, she threatened to leave AMA if she wasn't given IV morphine.

I would probably have stayed strong on this one, and offered Tylenol instead, especially since she didn't complain of any pain at all in the ER. But my resident is nice (or just fed up) and wrote an order for morphine. She didn't completely cave in though, and wrote the order for 2mg q4 hours, which is about enough morphine to cover really bad hangnail pain.

I did enjoy one aspect of this admission though: making the phone call to psychiatry.

Life

The part of life we really live is small. For all the rest of existence is not life, but merely time.

So today was my day off this week, and I spent part of the morning watching ER. I don't actually have TV at home, so when I'm away, living out of a hotel room, the novelty gets the better of me sometimes. Anyway, so I'm watching ER, and the thought came to me that yes, the heart wrenching decisions you see on a show like that are made, every day, in a hospital. But what they don't show you is the fact that sometimes, you don't even notice they are being made. There is humor and tragedy all around, but like the rest of life, if you aren't paying attention, it will pass right by you.

I think the most important moments of our lives often occur without a second thought. We don't always see them coming, and we don't necessarily notice while they are happening. It is only afterward, looking back, that we notice, and either exult or regret. Families don't think about living wills until after their loved one is comatose, and then they argue in the ICU over what is to be done. Mothers think two children is enough, and then, five years later with a new husband, listen with tears in their eyes as they are told the tubal ligation reversal didn't work, and that is all the children of their own they'll ever have.

I used to think (and maybe still do, in my conceit) that working where I do throws life into harsh perspective. That it makes each decision about life or death, and therefore more meaningful. But I'm becoming convinced, oddly enough sitting on a cheap mattress in a hotel room watching a mass market drama, that this is just life, and the perspective is what makes it meaningful.

September 11

I wasn't going to write about this day here. I don't know still that I have anything unique to add, that anything about my experience of a clear autumn day five years ago is much different than what 250 million of my fellow Americans experienced.

But I've reconsidered. I do think it is important to remember September 11, 2001. On that day, civilization itself recieved a blow from the barbarians, and just as those who sacked Rome in 476 AD, these barbarians want nothing less than the destruction of our way of life. It is important we never forget, for if civilization is to stand against barbarism, we must remember what makes us different.

I had here written a lengthy description of what I did that day. That really doesn't matter though. What matters, as I wrote for my school paper the next week, is how we respond. Yes, preservation of civilization is necessary. And yes, to defend a flock of sheep, wolves must sometimes be killed. It is important that we do not allow that killing to make us killers, and that we remember why and what we defend.

Though I wrote a poem on that day, like most poems attempted by amateurs, it isn't any good, so I'm going to close instead with some lines by a real poet, who saw the world change nearly one hundred years ago, and similarly, he recognized theat things would never be the same. He could have written this yesterday.

Never before such innocence,
Never before or since,
As changed itself to past
Without a word - the men
Leaving the gardens tidy,
The thousands of marriages
Lasting a little while longer:
Never such innocence again.

From MCMXIV, by Philip Larkin


image link

Medical antagonism

Another of my residents told me a story I'm not sure I believe, which I was reminded of by writing my last post.

Some patients no one likes. But most of the time, the way you deal with this is by doing your job, taking care of the patient, and realizing that your reaction to the patient can tell you something about them too. It's called countertransferrence. Ok, maybe I should have been a psychiatrist. The point is, this unfortunately doesn't always happen.

So one of the residents in the program I'm checking out right now was at the local county hospital, and he was completely fed up with a patient. I don't know all the details, but I know that patients can be aggravating. This resident made a highly unprofessional decision though, and wrote an order for "Fleet's enema, q1hr, until AMA."

What this means is that the patient was to be subjected to an enema every hour until he signed out AMA. Completely uncalled for, but what is more sad is that when this story was told, almost everyone in the room laughed. Yes, it was a long day, and yes, even the best of doctors has probably had a similar thought cross his mind transiently, but to actually write the order is malpractice. To laugh at the story is is bit inhuman too. Isn't it?

I'll admit, I laughed.

Maybe I'm becoming more jaded than I thought.

AMA

Today, for the first time, one of my patients left against medical advice, or "AMA." It was tough, because I had really developed rapport with him and I could see his side of the reasoning. He's 40, but as I told my resident, "doesn't look a day over 65." He's been smoking two packs a day since before he can remember. He drinks a half case of beer a day. And he has cavitary lesions (massive, rotting holes) in his lungs that need to be treated. Finally though, his exasperation with "being poked" got to be too much, and he signed out.

Like I said, it's tough. Part of me really wanted him to stay and get the further tests we need to treat him effectively. But part of me was fed up with his behavior, and wasn't sad to see him go. It was, by our count, the third time he changed his mind about leaving AMA, and we were all as tired of the paperwork as he was.

But I had to force myself to step back and consider, not what would make me feel better in the short term, which would be to stop writing notes on someone who is so inconsiderate and self-centered, but what is best foor the patient. And so I tried my best to get him to stay. My resident pretty much surrendered to (understandable) jaded feelings and though she tried to convince him to stay, it wasn't done very emphatically. I could read between the lines. I sincerely hope I don't ever reach that point of disillusionment.

Now the hope is he'll actually survive to make it to follow-up appointments.

On Call...

I just finished my second work day here. My second work day here was 31 hours long. Believe it or not, I'm still upbeat. I realized a few things. One, MS-IV (medical student, fourth year) is almost as magic as MD when it comes to writing orders. Also, I still love internal medicine. My two patients are pretty typical of the range you see on the wards.

Mr. Wish has CHF, and as part of that disease, he is supposed to watch his salt intake, keeping it to an absolute minumum, I think off the top of my head, it's supposed to be less than 2 grams per day. A can of pop has about a fourth of that. So it takes some discipline.

Discipline he lacks.

Mr. Wish informed me that "yes, doc, I'm keeping a real low salt diet. I don't put salt on anything at all anymore."

I should state before going further than the reason he is in the hospital is because he gained about 15 pounds over the past three weeks, solely from the salt he "isn't eating."

So I asked him what he had for dinner, say, the night before he came to the hospital.

His answer was "we went out for Chinese." In case you were wondering, the average single dinner, without sides, at a Chinese resturant, has well over 2 grams of salt in it (not to mention upwards of 50 grams of fat)

He also firmly belives, despite taking diabetic medications including insulin, that he is only "pre-diabetic."

Some patient education is in order, I think.

The next patient...will have to wait for another post. It has been 31 hours since I've slept, and I'm going to enjoy this.

Back to the Fluorescent Tomb

I'm quite excited. On Tuesday I start back doing what I love to do: seeing patients in the hospital. It will also be a new city, and a hospital I've never worked in, so some sense of adventure as well.

It is one of two hospitals I'm considering for residency, so there will be an element of tension, but on the plus side, I know what I'm doing, and I'm pretty well prepared for it. Now if I could only find my stethoscope, I'd be done packing...

The interview with the program director is going to be the most stressful part of this. They always ask "do you have any questions" and I never have a good answer. What percentage of graduates go on to fellowship, what percent of graduates pass their boards on the first attempt...once those are answered, I've got nothing. Any brilliant ideas anyone?

Delicate conversations

One of the new experiences every medical student knows is that of having his friends and family members ask for medical advice. On a certain level, this is entirely understandable, we are, after all, studying medicine in order to relate our knowledge to others (probably wiser) who haven't given ten years of their life to its study.

But on another level, this is an intensely difficult situation. Medicine deals with the most intimate secrets of a person's physical existence, and, (not being a dualist) with their most intimate spiritual secrets as well. There is a certain level of secrecy which decorum demands we keep in our interpersonal interactions, and while it is jarring enough to see beyond that veil in a stranger, with friends and relations it can be staggering. The other side of this is that, as we get more used to knowing about people, and to reading the small details which betray so much about them, a comfort with that greater level of familiarity grows. Probably this explains the propensity of physicians and other health care workers towards crude humor.

But I am being sidetracked. I was reminded of this today, but only in passing. More important than any level of personal discomfort with medical knowledge is understanding the impact medicine has on others. Most people in medical school are young, and generally healthy. To practice medicine we have to have some level of health, and sometimes we forget how important that is. It is easy to forget how scary the unknown is.

Combining the two thoughts above, today I was asked by someone I know relatively well about a fairly involved medical issue. I've long gotten used to this sort of question, and I'm not far enough in my training to have tired of it. The second point about came to mind as I did some reading before getting back to my interlocutor. With any medical problem, from hang-nails to amputations, there is a range of severity in outcome. And this range is apparent in the medical literature. It is easy, when dealing with a person about whom you did not care one way or the other before they walked into your office, to rattle off percentages, and follow them with concern and cooperation in forging a treatment plan.

When you actually know and care for the person before the serious conversation, it puts a different perspective on things. You question how frank to be, how best to couch what you say, and what effect every single word will have on their perception of the problem.

Fortunately, the problem I was being asked about has an excellent prognosis. But even that phrase "excellent prognosis" can sound like medical evasion. And in explaining it, the necessity arises of discussing worst case scenarios along with best case ones. I suddenly understood, better than ever before, the paternalistic attitude of previous generations of physicians.

But the nervousness I experienced was instructive. For I realized that I should be that concerned with every patient. I think I am empathatic, to at least some degree, but I've never been so careful to relate pro and con, positive and negative. I very much wanted to convey exactly what I knew, without causing undue concern, but without hiding anything either.

This is why medicine is the art of science.