Tuesday, February 27, 2007
And about the cartoon to the right. I've felt exactly this way while explaining to a patient in respiratory isolation that they probably don't have TB, we just need to rule it out. But then, of course, sometimes they do have TB.
And today I learned that medications can give you calories. This is no surprise to some intelligent folks, I'm sure, and needs not to be taken too far by others, say Mary-Kate Olsen. (That's a little Angry Medic inspired pop-cultural reference) Anyway, the medicine Diprivan (propofol emulsion, for my Brit readers), which we give patients to keep them sedated while on a ventilator, has 1.1 kcal per mL. Who knew?
The angry dietician, that's who.
On all the tragic scene they stare.
Mr. Smith has recovered from the acute phase of his illness, but has been left mentally scarred by the ordeal. Part of that may be a reaction to a stressful situation, but part of it is, according to the rheumatology consultant, one of the manifestations of lupus cerebritis. Systemic lupus erythematosus is an autoimmune disease, and as it has begun to affect this man's brain, essentially his body is attacking the very cells which make him uniquely him. So though he has returned to making cell phone calls and texting from his bed (prompting a transfer out of the ICU to an intermediate care ward) he is not firing up a lap top and running Sudoku 3D. He probably never will. And I am left, as the med student following and learning, questioning where this leaves his wife and her son, now that her twenty-something husband has lost his mental acuity.
Across the hall, back in the ICU, my newest patient lies recovering from an aborted surgery. Upon exploring a thoracic mass, the surgeons determined they could not remove the tumor without killing the patient. And so this man, in his mid forties, excited to finally be starting a family, with his pregnant girlfriend in the waiting area, learns that his life is likely over, just as it has begun.
I don't speak Spanish, but one of the nurses does. And she just let our team know that the apparently very supportive and ever-present mother of one of our spinal cord injury patients is telling him, in Spanish, that because he can't walk and has lost his sexual function, he'll never be a man again. No wonder he is stressed out and not improving.
Just another day in the ICU.
One of the difficulties of going to medical school and growing up at the same time is the lack of comparison. I have no reference point outside medicine when it comes to conceiving "normal" in workplace environment.
That's a bit of overstatement, but the point is, as I mature as a person, coming more to terms with who I am, and with what life is, and how those two concepts fit together, both of them are dramatically affected by an environment which alternates between euphoria and desolation. Sometimes I wonder, as I'm giving an order to a nurse or respiratory tech, if my developing ability to make decisions and follow through is separable from my environment. I wonder, as I hold the hand of a dying patient, if other people, people who work in office buildings and go home during rush hour, develop responsibility and care for people in a similar way.
I am beginning to drift into medical conceit. But that's another aspect of what I'm developing. I wonder if other professions have the tacit assumption that what they do is so vital, it probably is more important than most jobs. Even if doctors don't admit it, most of them feel that, somewhere inside. It isn't just the environment which draws us here. I've heard more than once the quip that "I would have been a nurse if it weren't for my ego." The hours are certainly better, and the pay is comparable in many settings. But a desire for prestige and power, (which likely includes two or three mortal sins, good thing I'm not Catholic :) ) is part of why I'm here, and part of why every other medical student is where they are, if they are honest. If it was only altruism, there would be a lot more general practitioners around.
Probably everyone develops an ability to get along with others, to care for others, and to make and accept their place in the world. Probably most struggle with humility and with despair created by their workplace. I guess it's just the way I'm doing it that has got me thinking.
Monday, February 26, 2007
The first I graft and increase upon myself....the latter I translate into a new tongue.
One of the frustrations with this rotation has been the fellow on our service. He has had little positive to say about my performance through the entirety of my time here, which would be fine if his criticisms were on point. But he will spend five minutes lecturing me on improving the organization of my presentation, just moments after interrupting me for the fifth time to ask the attending, or another student, about the last patient we saw. Now my speaking skills are not bad, but Demosthenes himself wouldn't be able to remain organized in this environment. At least the sea didn't change the subject of its interruption.
So today was awesome. We had a new attending, so we were going through a more complete presentation of each patient than normal. And one of our patients has elevated liver enzymes unexplained by any of the workup done so far. My (perhaps excessively thorough, for the ICU) classmate was presenting and threw into his schpiel a recent travel history to southern Asia, and the patient's doxycycline prophylaxis for malaria. The question was thrown out to the group. As the fellow scratched his head, I piped up "doxycycline can cause the elevated enzymes, or he could be demonstrating hepatic malaria infection." Both fellow and attending looked at me with new eyes, I felt. A "that's exactly right, excellent thought" comment later, and I didn't even mind knowing the next patient was mine and the interruptions would begin again.
In honesty, he is a solid clinician, certainly more experienced than I, and in a way, his odd manners are forcing my own development as a physician. I am confronted with the problem of how best to present a patient clearly, concisely, and (most important) quickly. His off kilter questions require me to really know every lab value and its significance. While some of the residents are nicer, they can actually hinder that development without meaning to. A new tongue indeed.
Saturday, February 24, 2007
Overall, the quality of nurses in the ICU is better than on a ward. I assume, not knowing much about their training and hiring, that this is due to the higher intensity and complexity attracting the more intelligent, or at least more driven, people. However, I also assume that the more intelligent and driven of that bunch tend to stick around longer, and that they therefore are the more senior when it comes time for shift assignments. That's the way I explain to myself, anyway, the fact that the midweek graveyard shifts seems to collect the less competent staffing. The weekends are usually more exciting, since there is more of the shooting, stabbing, and generalized looting going on outside that brings people to a surgical ICU, so we get pretty good staff then. Anyway, Wednesday night.
One of our patients is a lot of pain. A very, very bad motor vehicle crash got him in here, sans his legs and with a host of other injuries. So he requires a lot of pain control, but it has been difficult to give him enough to control the pain, while not over sedating him. His English is also not great, so when he needs help, he tends to make loud groaning noises that can, I admit, be irritating.
None of this excuses the fact that Wednesday night a nurse decided to start him on a continuous dilaudid drip, without a doctor's order. And while that did keep him quiet, he was almost unarousable the following morning. Not in hemodynamic or respiratory distress, just very much asleep. In his (the nurse's) defense, the order had been on the chart, but it had been stopped over a week ago. My attending's reaction was simple. He told the nurse to stop the drip, and stated if it ever happened again, he would put the patient on Q1 hr neuro checks, with 1mg morphine injections and 15 minute follow up checks. This would (aside from being a complicated order to write) be a huge, almost constant drain on the nurse's time. Thankfully, that hasn't happened again. Dr. Benedikt's popularity hasn't risen any more with the staff though, either.
The second was a good experience. I was putting in an a-line, only my second attempt ever, and after placing it, was securing the tubing. This involves taping it around the patient's thumb, so as to keep them from pulling it out accidentally. First though, and this is key, the site where the catheter enters the patient has to be covered with a dressing. I had, however, forgotten competely about that step, with the intensity of my attending watching. The
Friday, February 16, 2007
Lupus is not, unfortunately, a curable disease. Lupus manifesting itself so dramatically is even less likely to be so, but there are very good treatments and we are getting better. In the meantime, we are making Mr. Smith comfortable, keeping him as stable as possible, and doing what we can to treat his lupus.
The introduction to one of the classic texts on ICU care says, in part, that our role as doctors is not to save lives, but to relieve suffering, as it is impossible to do the former consistently. Sometimes though, you can do both. Though even there, Ambrose Pare, the father of modern surgery, has inscribed upon his tombstone the words "I treated him, God healed him." There is no better epitaph for a physician.
Thursday, February 15, 2007
The first problem is his kidneys are dying. The creatinine level in his blood, a measure of how well your kidney are filtering junk, is going up, from an almost normal value of 1.0 on admission to almost 4.0 now. An increase of that magnitude over a week is pretty ominous, so we called nephrology to get their input.
The second problem is related, and is in his lungs. Mr. Thomas' chest x-ray implies that he has too much fluid in his body, and the cure for that is a diuretic. There is a risk in using diuretics, because they are essentially poisons for your kidneys, but the one we're using, furosemide, is pretty well tolerated.
Son, your ego is writing checks your body can't cash.
Here's where the real problem lies. Nephrology took a look at the labs I had ordered, and decided that Mr. Thomas' problem was acute tubular necrosis, or ATN, meaning his kidneys had just taken the episode of septic shock poorly. Their recommendations were to increase the amount of fluid Mr. Thomas is getting, allowing his kidneys to get more blood flow, and to hold off on the furosemide. My attending though, thinks that the problem is acute interstitial nephritis, AIN, and believes that the chest x-ray is showing increased fluid, not pneumonia. The problem then, is that my attending thinks nephrology is wrong, and the patient needs less fluid, and to have a regular diuretic dose, and the nephrologists think my attending is wrong, and that the patient needs more fluid, and no diuretic dose. Neither has a rock-solid case for their opinion, but nothing in medicine is 100%. So what do we do?
When I became a man, I put away childish things.
The process of moving from medical student to MD involves a steadily increasing level of knowledge, experience, understanding, responsibility and decision-making ability. As third year starts we report facts and accept blindly the decisions of superiors. As that year progresses, ideally the medical student learns, and starts making suggestions, always expecting to be wrong, but still starting to think, to put the patient's picture together. By the end of fourth year, we should be making decisions with a high expectation of being right. After all, for someone like me, starting July 1 of this year, I'll be making treatment decisions for very sick people at all hours of day and night, so I should be getting pretty comfortable with making decisions and giving orders, bearing in mind of course that I am still learning, and that if I'm not sure, I most decidedly should be getting my superior's opinion.
And in the case of Mr. Thomas, I'm making that transition, though perhaps inappropriately. I'm with the nephrologists, in that I think the x-ray is showing pneumonia, I think Mr. Thomas needs more fluid, and that his kidneys are showing ATN. But I can't make that decision over the top of my attending, so I have to write notes that reflect his opinion. It is immensely frustrating to write something I don't believe, but maybe I need to get used to that too. I just don't want Mr. Thomas to pay the price.
We'll see what happens. The good thing is, having done some reading just for this little post, I have a few ideas that might help me sort out what's really going on. And who knows, I might even be wrong.
One of the nurses I work with has forever twisted the way I will hear ventilator alarms. The particular vent we use in this ICU alarms with a little tune: CEGcG, starting one octave above middle C. Yesterday, while we were sitting at adjacent computers writing notes, she started singing along, in actually rather a pretty voice, with the words "Oh sh&t come help me." It fit so well, now that's all I can hear when the alarm goes off.
And secondly, it's a good bet your presentation as a med student is boring your attending when he picks up a magazine from the nurse's station in the middle of it and starts reading. Just a thought. Glad it wasn't me.
Sunday, February 11, 2007
The circulation of the lymph
Are figured in the drift of stars...
There are not many days working this job in which I do not marvel at the capacity and magnificence of the human body. Though my work, and my study, deal largely with things gone awry, even there the ability for recovery is wonderful.
I write this because despite everything described in my last post, Mr. Smith is still alive.
Thursday, February 08, 2007
He was right.
Further investigation showed swollen lymph nodes in his lungs and axillae (armpits) as well, leading to a presumptive diagnosis of lymphoma. Biopsies were taken of the swollen lymph nodes in his axillae, and blood tests sent.
That’s right about when the seizures started. So he was started on anti-seizure medications while the blood test for lymphoma came back. When they returned as negative, and it was noticed that his kidneys had started to fail, the presumptive diagnosis switched to SLE, causing lupus cerebritis and nephritis. This also explained the faint discoloration of his face as a malar rash.
Because a definitive answer was desired, primarily so effective treatment could be begun, a kidney biopsy was performed. This involves sticking a long hollow needle into someone’s back, removing a core sample of kidney tissue. In a normal person, this causes some bleeding and pain, usually requiring just a stay overnight for observation.
Mr. Smith was no longer much like a normal person, physiologically.
The surgeon who had performed the axillary biopsy had noted that he had to hold direct pressure on the wound site for and abnormally long time to get sufficient coagulation for the patient to be moved from the OR, so some measure of abnormal bleeding was expected. What actually happened was a dramatic amount of abnormal internal bleeding. He bled so much, in fact, that he developed abdominal compartment syndrome, meaning the pool of blood started to pressurize the rest of his abdomen, to the point that his intestines were in danger of dying. He was taken back to the OR to decompress this and returned to the SICU with a vacuum dressing over the hole in his abdomen. He was also on a ventilator now, and it was only with great difficulty that the intensivist was able to keep his oxygen saturation above 80%.
Within an hour, the bleeding had undermined the seal on the wound vac and blood started to pool underneath him. His body temperature, which had not been high enough before, fell to 93 degrees, despite air blankets and stacks upon stacks of regular blankets. He continued to bleed, from the cracks in his lips, from the site where the central line was placed, and from his abdomen.
Transfusion, which had been started when it was noticed that he was losing blood from the vac, despite the dressing and surgical ties, became “aggressive.” In under two hours, he received over a dozen units of blood, multiple units of FFP, of cryoprecipitate, of recombinant factor VII. The resuscitative team began getting desperate. He was given DDAVP, estrogen, anything to encourage coagulation.
None of this, I should add, occurs in a vacuum. While the doctors were having the requisite conversations about the situation described above, the patient’s wife was crying at his bedside, one of the hospital's priests with her, praying comfort to both healthy and insensate. In between passing bag of platelets and blood, I found myself humming silent amens along with them. Outside the room were various family members and friends in addition to the medical students and assorted gawkers. A nurse or tech, I’m not sure which, played with the patient’s young son in another room as his father tried to die next door.
Amongst the vending machines
and year-old magazines
in a place where we only say goodbye
I have yet to actually see a patient die. My first year on the wards I saw a patient crash in the SICU, actually right down the hall from where I stood watching the above, and his abdomen was opened by the surgeons right in front of me. But he was wheeled back to the OR, tenuously clinging to life, and died in that blue-decked room out of my sight. I have had several patients with diagnoses that will kill them, and in some cases, I’ve seen their doctors later and found out about their demise.
Mr. Smith was no different. The estrogen, or the factor VII, or whatever, stabilized him enough to take him back to the OR, the critical care docs giving macabre well wishes and glad I’m not yous to the anesthesiologists taking the case, and life in the SICU continued. Three doors down, another patient with a seriously bad heart and a bad case of Pseudomonas sepsis started to go downhill, and the focus shifted. Mr. Smith couldn’t be considered at present, there were other patients to attend to. But in a small room outside the OR, filled with cheap, easily cleaned furniture and strewn with cast-off magazines, the focus will never shift.
As I walked out of the hospital, I had no idea what was happening with Mr. Smith. I know the anesthesiologists and surgeons were joking in their darkly humorous fashion before wheeling him back. But in a moment of seriousness, the attending surgeon said he didn't favor his chances stopping the bleeding. "Even if the bleeding is stopped," returned the internist, "Smith has been off his steroids to control the lupus for a while now. His kidneys are probably already shot, and his lungs aren't far behind." There isn't really going to be a happy ending here, no matter what.
Though I care about the outcome, I also had to bear in mind the fact that I am on call tomorrow and must get sleep before my 36 hour shift. So it was necessary to leave, to sign out my patients to the on call team, to walk out of the place of grief and go home enjoying my health.
Part of the strain in becoming a doctor is maintaining compassion while bearing in mind the fourth Law of the House of God: the patient is the one with the disease. And so, though I realize when I'm at work that this is indeed where I am supposed to be, I need also to be able to come home and go to sleep, despite all the Mr. Smiths.
I still haven't gotten that last part down.
Wednesday, February 07, 2007
So today was a bit surprising. But first a bit of back story. See, as a fourth year med student, I'm technically not allowed to write orders for patients without a co-signature. This means that after I write an order on the computer, the resident has to add his name to the order before it is filled. So after rounds this morning, I was sitting at the computer next to my resident while we both entered orders on patients. After I entered a batch, he would check them over and sign the lot of them. This system works well, but was complicated by the fact that nutrition orders are different than most, in that the computer, for whatever reason, actually files the order without a co-signature. So, despite my having put both my name and my resident's name on the order, when I wrote a nutrition order on my patient, giving him pretty much exactly what he got yesterday, the computer only put my name on the top, since I was logged in writing the order.
Fast forward 3 hours. A small, striking woman standing perhaps 5 feet 2 inches tall bursts into the room and announces as the top of her voice "WE have A PROBLEM. WHERE is Dr. Benedikt?"
"He's not here at present" comes the reply.
"And ANOTHER thing! WHO is [insert my full name here, in caps]"
"That would be me" I answered.
"Are you a PHYSICIAN?!"
"Then WE have a PROBLEM. I'm going to speak with your STAFF."
I was a bit concerned. I had no idea who this woman was, but about five seconds after she stormed out again, I realized she was probably from dietary medicine and she probably had some issues with my name being the lead on a dietary order. Not really a big deal, but hey, some people make the most of their postage stamp sized area of control. And heck, she was speaking to my staff, who writes my grade. Maybe this would be bad.
Anyway, the Battleaxe saw the shocked expression on my face and said "Don't you pay her a bit of mind, child. She's like that all the time. Dr. Benedikt will give her what for." Then she went back to scowling at everybody.
Tuesday, February 06, 2007
So, as Mr. Smith was being settled into the ICU, accompanied by his lovely wife, I asked him if there was anything I could get for him. In a sleepy but still forceful voice, he shot back "a bevy of blondes and a coffee."
It's a pity he was NPO. I couldn't even help him out halfway.
Monday, February 05, 2007
Yesterday was my first day on the ICU side of this environment. One great thing about the SICU is that it is run by an anesthesia/critical care attending. Anesthesia docs tend to have a healthy regard for balance in life, without the hospital junkie attitude of most surgeons. (And cardiologists, I'm sad to say) So rounds are at 8, signout is at 4, except when I'm on call. This translates to working about 6-4, which is absolutely wonderful hours as a sub-intern. I think I'm going to like this, even if it didn't mean a return to more medicine, and less surgery.
The catch here is, my attending, Dr. Benedikt, is legendary, and not in a very good way, around the hospital, for his style of pimping. Once, last year during surgery, he quizzed me for nearly half an hour (I could see the clock over his shoulder) on the physics of the Bovie electrocautery. So today, presenting my first patient, it was no surprise that despite the reading and preparation I had done, he still managed to ask the one question I didn't know the answer to. *sigh* I guess this will force me to read more on my patients.
In other news, I've enabled comment moderation. I know it's a bit of a hassle, but some recent comments necessitated it. My apologies.
Saturday, February 03, 2007
"So, I'm working as an intern, horrendous hours, I haven't seen the sun in weeks, and all of a sudden, this, vision, appears out of nowhere and says "Doctor, have you heard about the efficacy of [drug X]?" Now, no, I hadn't, but it really didn't matter. This beautiful creature, she called me doctor. I stared, open mouthed, as she gave me the paper discussing the drug and said some things I barely recall. And I prescribed [drug X] several times after that before really thoroughly reading that paper."
Once he read the paper, he discovered that the techniques used to show the efficacy of the drug were almost unheard of. The study used a variety of complicated statistical tricks to evidence Twain's quip about three kinds of lies. And when he did further research, he found that the study's problems were noted before publication, and the only way they got the article published was by calling up the editor of the New England Journal and telling him they would purchase 10,000 reprints of the article, enough to cover the Journal's operating costs for a year.
The story did more to change my opinion of drug companies than anything has. I tend to be fairly reserved in my opinion about them. Some drug reps are nice, some are obviously salesmen (actually, usually saleswomen, see above) and I take everything all of them say with a shaker of salt. I know from my chemistry background how difficult and expensive drug design is, so I find the arguments the average "bring down those on high" politician makes to be completely laughable. I still do. But hearing this story of subversion in the foremost academic medical journal in the world made me reconsider a bit.
Thankfully, the editor responsible for that fiasco is gone. But the story demonstrated the lengths some companies will go to in order to sell drugs. Scarier still is the direct marketing to consumers, something which almost certainly leads to abuses in the system.
During the whole process of thinking about this post, I was listening to my iPod, shuffling away random selections, and oddly enough, the Rolling Stones "Mother's Little Helper" which has the line "And though she's not really ill, there's a little yellow pill..." came on. The song recalled a factoid I memorized during my psychiatry rotation: fully one third of people in developed countries are depressed at some point in their lives. Which of course brings up two questions: one, is there something about our lives that makes us this way; and two, are we just giving a name to something natural in order to sell something? These questions can (and should) be broadened to include most diseases, in the mind of the doctor.
I think ADHD is almost certainly over diagnosed, in a culture averse to the time commitment involved in raising children. It was frightening on my peds rotation to hear mothers say (and I heard it twice, in two weeks of clinic): "I just want you to give him something so he'll sit still." Um, hello, you have a 5 year old boy, sitting still is the last thing on his mind when he's not in school. Why don't you take him to the playground and let him run around instead of giving him an XBox to teach him that immediate gratification is a universal, and drugging him up for the occasions when he finds that isn't true? Sometimes I think the surest case for our culture being locked in a death spiral is the fact that we spend millions of dollars on getting children addicted to amphetamines.
A long time ago, the ending of a Choose Your Own Adventure novel I read had the protagonist wind up attached a machine that kept him warm and comfortable, but trapped, for the rest of time. Periodically he would be lowered into a warm pool and forced to swim, keeping his muscles from atrophying, but otherwise, the warm, senseless oblivion was all he would know forever. For the majority of people, this vision, I am afraid, seems less like a nightmare and more like a paradise every day.
Thursday, February 01, 2007
First, I'd have to say that, when the interviewer asks you about your hobbies, don't list "surfing the internet" first. That may be true, heck, it probably is for most people today, but we do not want to hear that. We want at least the pleasant fiction that you are well rounded. And if, on the topic of being well rounded, you say in your essay that a given subject, say Oriental ceramics, is a vital interest of yours, and that you love to talk about them, you should actually be able to talk about them. I'll ask. And yes, that was supposed to be an easy question.
I try not to be mean. I do, however, want to put the you on the spot, and make you sweat a little. Medicine is a horrendously stressful job, and the five minutes of nervousness you have in this warm little room is nothing compared to what you'll face (if you are successful) in four years when there is a patient in front of you coding. I've never been in that situation, but I was stressed the few times I've seen it just watching my residents. And if you can't take my question asking how, exactly, you manage to volunteer 50 hours a week and still find time to study, then maybe medicine isn't the right place for you. Ditto if when I ask why you are interested in medicine, the answer is not only not convincing, it sounds like the question surprised you.
The other topic I love to cover is ethics. As I explained to an interviewee after his ordeal in front of me today, there may be a wrong answer, but there isn't really a right one. I just want to surprise you and make you think in front of me. The best way to do that is to ask something totally unexpected. Here's a tip: pausing before answering is fine. In fact, it is way more impressive than the other guy who shot from the hip and rambled for about two minutes about nothing. I'm a past master at talking without saying anything, and trust me, I can see it in others.
The process does bring up ethical dilemmas of my own that I admit I didn't expect. For instance, one of the people I interviewed was a singularly attractive young woman, one whom I probably would have asked out for drinks in another setting. (Maybe, I'm just saying.) Anyway, because I found her attractive and interesting, it would have been very easy to be softer on her than on another applicant.
Fret not, gentle reader, I neither abused my power by asking her out, nor did I succumb to the temptation not to ask her tough questions. The whole thing reminded me though, of a class I had my first year discussing how we are to deal, as physicians, with such situations. For doctors are human too, and patients can be repellent or alluring, and similarly, it is inappropriate and unethical for us to allow those emotions to affect the way we do our job. Simply denying them is impossible, but we do need to recognize them and work past them. I definitely don't have this whole doctor thing figured out, but I am learning. That's positive I guess, with only 106 days left before it isn't pretend anymore.