Saturday, December 20, 2008


The bildungsroman that is this blog has been quiet, and perhaps dead, for sometime now. I'm not certain why this has happened, but I think the reason is at least three fold.

First, as I've progressed into second year, I've found that I depersonalize my patients more. This sounds horrible, so let me explain. As an intern, I was responsible for anywhere between six and ten patients at a time, and my one job was to talk to them, find out what was going on, and report it. So I spent a lot of time talking to them. Now, as a resident, I have anywhere from two to three interns below me on the totem pole, and hence I'm less able to spend time with the patients, because I'm listening to the intern's reports, and then formulating plans and managing people. Managing people isn't touching, usually, and it makes for poor stories. So I haven't told them.

Second, and maybe most importantly, I've run out of time. My workload keeps getting heavier, and I haven't got the time to work, sleep, play, and write the blog.

Lastly, I think the journey this chronicles is complete. I am not a finished person, by any means, but I have made the transition from medical student to physician, and for the same reason there's never a story beyond "happily ever after" I've run out of stories.

Which isn't to say I won't be back. The conflicts and triumphs of the future may well be worth setting down, but for now, I've run out of steam. Thanks to all who encouraged me on my way, I will miss hearing from you.

Pax vobiscum.

Monday, July 28, 2008


"My one question is, can I have this at home?"

Those were almost the last words he said before we put the endotracheal tube down his throat and started breathing for him. Mr. Baker was an old, old man with lungs that had pretty much given up on him. Thanks to the miracle of modern medicine, he now has at least a few weeks of drug-induced sleep ahead of him before he can rest eternally.

I've not been able to get those words out of my head, or the next ones, a muffled repetition of "stop, you're hurting me" to the anaesthesia resident who was clamping a bag mask over the man's face prior to intubation.

I like the guy, a lot. It had been a while since I had liked a patient, since I've spent the last month or so in the ICU, dealing with the surprising tide of alcoholics, drug abusers, and the merely testosterone poisoned who wind up, along with the occasional patient rescued from the clutches of the surgeons, on the MICU team.

The work itself is exciting. It's been amazing to see what is possible, and at the same time, I'm now the resident, responsible for supervising the interns, which is more work than I expected.

I wanted to write about that. About how I've been following orders for so long, I hadn't realized I knew anything. About how I've come to realize how much I have learned, and about how much there is left to learn. But "stop it, you're hurting me" was the first thing that really seemed important enough to write.

A lot of this month has been hellish. I've realized that, no matter how good they are with knives, a lot (I'm tempted to say most, but I do have a limited perspective here) surgeons are absolutely clueless where complicated medical problems are concerned. Most than one patient I've managed this month had their conditioned worsened by a surgery resident, and in at least one case, the surgery team managed to induce both diabetic ketoacidosis and a myocardial infarction in the same patient. I've realized that seemingly competent medicine interns still have to watched like a hawk by their medicine residents. And I've learned that even I can make mistakes.

I've changed. The show-cynicism of internship is now mostly heartfelt, as I start to see the same cases of self harm, sometimes even the same patients, and I feel the helplessness than undergirds all of what we do.

This was in even sharper perspective somehow the month before, on the heme/onc service, where I realized that all we are offering people with medicine is time. No one cures anyone. We treat and postpone, but rarely cure. Even when we do, for instance saving the third Tylenol overdose of the month with some well timed N-acetyl cystine, I know the fourth is right around the corner. And who knows, this one may come back with more success in her strivings at a later date.

I treated him, God healed him

In the last analysis, that's really all anyone is doing, even outside of medicine. The gas station attendant, the bus driver, and the coffee shop owner are all united with the physician in that all we are doing is allowing others to continue their lives. Some lucky individuals may even help improve them.

Which is of course the point, and it's what keeps the cynicism at 3am while admitting the fourth intubated overdose patient of the night from becoming full blown despair. We're all here to help people, to love our neighbor as ourselves, in the manner we're most fitted to do it. And if I can maybe relieve a little of the pain I see, and maybe give these people and their families a little more time, I will have succeeded.

I hope, or I could not live.

Tuesday, May 13, 2008

In conversation

"You know doctor, we put down my little poodle last week. I'm still in mourning, but what got me thinking was my husband. We took her little body out to a field to bury her, and he said 'it's a shame she can go like this, the shape we're in, but there's nothing similar for us, with all our problems.' And you know doctor, I'm not sure he's not right. Look at me, all the money people spend on me keeping me going. And all I have left is my china to paint."

It is a young man's conceit that the world is for the young. But people like Mrs. Parkin, who made that declamation as she walked through the door on the way out, force me to wonder about the ends of life. My life now is so centered on doing, on accomplishing, on driving hard to meet ends, that a time without ends, without accomplishment, where I measure success in terms of a hobby, is inconceivable to me.

Looking at the impressive list of maladies plaguing my patient, my entreaties to reconsider her assessment were not wholehearted. She is a life lesson in morbid anatomy, a walking textbook of internal medicine. Diabetes, heart failure, hypertension, obesity and all the complications thereof. Most depressing is that she's reached the point where we can't do anything for her. While weight loss would help, she can't exercise because of her heart failure and hypertension. And until she gets those under control, she can't get gastric bypass.

I've reached the point in my intern year where most the common things are becoming automatic. I can cite studies and counsel this patient for any of her problems individually. But the big picture, the pitiful living compendium of pathology that modern medicine allows still saddens and confounds me.

It is in discussing these patients that the macabre side of the intern comes out. When we toss these stories around the intern work room, everyone has a different reaction, but at the same time, our core thought is the same. While one person may declaim "that's why I exercise" and another "that's why I sky-dive" the underlying conviction is "that will never happen to me." The black humor and macabre attitude hides our discomfort. The discomfort comes from facing our own mortality through the lives of our patients.

All flesh is grass, and all the goodliness thereof is as the flower of the field

Even so, I'd like to leave something more permanent than painted china behind. Something more than the accumulated bits of plastic which mark my life as a twenty-first century man. But I'm thinking it's really only the effect we have on others that we can hope to leave behind. Mrs. Parkin's china may not survive the ages, but it certainly reminds me of the desperate sadness all around me. And though I failed to do more than smile sadly with her, next time, I'm going to be five minutes late for my next appointment.

Monday, April 07, 2008

Growing old together

Twenty years hence my eyes may grow,
If not quite dim, yet rather so;
Yet yours from others they shall know,
Twenty years hence.

Last week in clinic I saw a couple in a joint appointment, and in the course of conversation, I discovered that they were about to celebrate their 60th wedding anniversary. What touched me about the discovery was how very much in love they still seemed to be. When I encouraged the wife to be sparing in her use of narcotic pain relievers for her chronic back pain, her husband jokingly chided her, calling her "you drug addict," but with a twinkle in his eye that made the sarcasm obvious.

"60 years of gentle harassment?" I inquired.

Before the husband could say anything else, his wife replied: "Best decision I ever made. And I figure we're good for another 15 or so."

I've been smiling all week remembering the look they gave each other at that point.

Thursday, March 13, 2008


The certainty of death is attended with uncertainties...

Mrs. Harding is not the kind of woman who seeks help.

She tripped over a dog's leash and fell down the short flight of wooden stairs from her balcony to the grass and discovered she was unable to rise. Despite some pain, she managed to drag herself back inside, and into her bed, where she was when her family returned home. As they had a spare wheelchair around, she just adapted to using it to get around as attempting to walk caused her excruciating pain.

That was six weeks ago. She hasn't walked since then, but her family took her to the hospital against her will finally because she stopped eating. They convinced her, eventually, that going to the hospital, being admitted, and doing everything medically possible was the best course. I'm not sure they were right.

I did a physical exam prior to admitting her, noting her to be dehydrated, malnourished, and unable to move her externally rotated and shortened right leg. She had no medical records because she could not remember the last time she had been to a doctor.

Incidentally, I noticed that most of her upper right chest wall was being eroded away by an obviously cancerous lesion. I asked her how long she had noticed something wrong with her skin there, and she told me "a few years." She hadn't shown another soul.

This kind of story has no happy ending. Trying to fix the broken hip revealed that what was left of the hip socket was a massive abscess, necessitating drainage and debridement, but no hardware to fix the problem. It also dislodged a clot, which went to her brain and cut off blood to the entire left hemisphere rendering her unable to speak clearly or move the right side of her body. Treating the stroke with blood thinners caused her to bleed into the surgical site in her leg. In the end, there was nothing we could do except hope her stroke left her unaware of her last days.

All I could think about through the last days was her last words to me before her family convinced her to change her mind: "just let me go home to die."

I wish we had.

Sunday, March 09, 2008

No salt

Part of medicine residency is seeing at least one half day of clinic a week. And though my patients have generally been pretty good, this is by far the least popular part of the program among the interns. Here's a direct quote from one of my more humorous classmates:

"I woke up this morning and realized I had clinic. And I'm not gonna lie, I had a bit of suicidal ideation at that point."

Maybe that's too dark to appreciate outside this place. But I had another bleak clinic experience a short time ago. One of my patients showed up to see me complaining of shortness of shortness of breath and left sided chest pain. The (hopefully) future cardiologist in me was instantly interested.

"How long has this been going on?" I asked, trying to keep the excitement out of my voice as I planned for an EKG, and possibly a hospital admission.

"About three years," came the measured reply.

At this point my interest flagged a bit. It turns out that my patient, who has congestive heart failure and ought to be keeping to a low sodium diet, ate a McDonald's sausage and biscuit for breakfast. And not just this breakfast, but a fairly steady line of breakfasts stretching back, you guessed it, about three years. But, he responded, "it's only a little, little piece of sausage, and I'm not adding any salt."

I saw another patient upstairs, actually admitted for heart failure, who told an even funnier story. We asked him what a typical meal was for him, and he responded "I ate a pound of bacon and a can of green beans for dinner last night." When we told him that "that's a lot of salt, and you really need to eat less than 2g of sodium a day" his cheerful response was "oh don't worry doc, I don't put any salt on the bacon."

Wednesday, February 27, 2008


Pulseless electrical activity is a clinical condition characterized by loss of palpable pulse in the presence of recordable cardiac electrical activity...

He was 12, a patient I had seen before because of his frequent hospital visits. I remembered him because despite being confined to a wheel chair, he and his mother always had a smile as I passed. Despite being just another face in the oceans of faces making up my hospital, despite being part of a specialty completely apart from pediatrics. Today he got short of breath and was taken to the nearest emergency room. There they discovered a pneumonia, and arranged a transfer to a hospital with a PICU.

…PEA is caused by the inability of cardiac muscle to generate a sufficient force despite an electrical depolarization…

He seemed fairly stable. So much so that a direct admission to the PICU was arranged, with the intention of just passing through the ER on his way upstairs. However, on pulling into the ER parking lot he was not doing as well as could be hoped. His oxygen saturation dropped, his breathing began to decline, and he was intubated in the ambulance. As the ambulance stopped and the EMTs in the back continued their resuscitation, the driver ran inside to get our assistance. Somewhere about that time, his pulse disappeared, though the monitors continued to display cardiac activity.

…The overall mortality rate is high in patients in whom PEA is the initial rhythm during cardiac arrest…

I performed chest compressions while we brought him inside. The code was run quickly and efficiently by the PICU attending, who had come down to meet his patient. Epinephrine, calcium, bilateral needle decompressions, pericardiocentesis. Despite everything, he did not survive.

In the last month in the ER I've participated in more emergent resuscitations than the rest of my internship to date. The good news is that I now am not nervous about running a code. The bad news is that I’ve acquired that calmness through practice.

PEA quotes taken from

Tuesday, January 29, 2008

On Another's Sorrow

Can I see a falling tear,
And not feel my sorrow's share?

As the intern year has gone on, compassion has been harder to feel, and later, even to fake. Patients mean work, and when your work is this draining and frustrating, the real people behind the mountains of paperwork become frustrating.

All this was put into perspective last night. I was on call, shambling back and forth with as much celerity as I could muster at 2am, when the overhead intercom burst forth with "Attention in the hospital, code blue, labor and delivery, room 9."

Codes are never easy to deal with, but with most of the geriatric medicine codes I've seen, there is a sense of resignation despite the furious efforts. After all, there are very few 85 year olds who will make anything like a full recovery after two minutes of CPR. A code on L&D is a different matter entirely.

When I arrived, the anesthesia and surgery teams who work on the same floor had unsurprisingly beaten my two-floors-of-stairs-sprint to the scene. I stayed just long enough to get a general idea of what had happened from one of the residents, and then I turned to go back to my work. The patient had HELLP syndrome, a rare but not unheard of complication of pregnancy, and had coded shortly after a crash c-section.

Walking out through the waiting room, I ran into the woman's husband. He was scared, worried, and completely in the dark. His first question was "how is Susan?" His second was "what does code blue mean?" Realizing his need, I started talking to him, answering what questions I could, both as a physician and as someone who genuinely cared.

And that was the shock. I realized, despite the bitterness, despite the pain, despite everything that over the last few months has brought so many undesirable characteristics to the fore in my personality, I did care. I'm not sure anyone who hasn't gone through a similar situation can fully understand this. The point of it was, I really did care, I do care, and though I am saddened to know it took something so extreme to remind me of it, I am enheartened that I have been reminded.

He becomes a man of woe,
He doth feel the sorrow too.

Saturday, January 19, 2008

Happy ending

A number of months ago I discharged a patient to a physical rehabilitation center. This is pretty common, and it seems especially so in internal medicine, where there is a large proportion of old patients with multiple problems complicated by poor physical condition.

Mr. Sigursson was not happy about going to this place though. I had tried to walk him around the ward, and he got short of breath just getting out of bed. He was too deconditioned to brush his teeth. But his wife had died six months before in a similar institution, and as he expressed at length to me: "I'm 93 years old, I've been an elder in my church, I've founded charitable organizations, I've done all the fishing I'll ever do, and now I've sold my house, my boat, and everything else that I used to do to live in an assisted living apartment. I'm done with life, why the hell do I need rehab?"

In short, he was ready to join his wife.

Honestly, I didn't know that rehab would do him any good. He was pretty sad, and he had great reasons for being so. He wasn't motivated to succeed with physical therapy, and as he said, he had little to look forward to once he got out. I always feel a little out of place, being 27 and telling people nearly four times my age that "there's a lot left to live for."

So it was with great pleasure, and not a little amusement, that I saw him at the grocery store today, pulling his walker out of the bed of his pickup truck without lowering the tailgate.

He was smiling.

Monday, January 14, 2008

Cross cover

Being on call overnight gives an intern a great idea how strong his fellow interns are. The weaker of my fellows will have signed out patients who lack pain PRN meds, have restraint orders that need to be signed, or a host of other administrative issues guaranteed to keep me awake.

It also demonstrates some of the odder quirks of humanity. I was paged by one of my favorite nurses a few nights ago "because one of the patients up here has a present for you." I tried cajoling the nature of the "present" out of her, but she insisted I come and see it for myself. She's one of the nurses I know fairly well, and more importantly I know she doesn't page me unless it is necessary, so I headed up four flights of stairs to see what was going on.

When I got there, the nurse dropped a small white object into my hand and told me the story. Mrs. Culloden, a pleasantly demented, frail lady in her 80s who is constantly threatening to leave AMA to go smoke, had become convinced that the vancomycin in her PICC line was "invading her body." Her logical response, rather than asking a nurse for help, was to take the plastic knife from her dinner tray and cut the port off her PICC line. So the vancomycin was on the bed, and the wanderingly apologetic Mrs. Culloden was one step further back on her cellulitis treatment. Clamp, wrap, and place on 1 to 1 monitoring. All in a day's work.

Monday, January 07, 2008


I'd just like to say that I'm, well, I'm searching for the right word to describe my feelings towards a certain pain management doc. The one who told my patient, perhaps the most difficult patient I've ever had to deal with, the one with a fragile ego and chronic pain and a sense of entitlement and probably borderline personality disorder, the one I spent two weeks getting stabilized on a pain management regimen while an inpatient, told this patient that "methadone is a drug for heroin addicts." So now the patient is back, refusing the one drug that got him out of the hospital, and I guess I really want to transfer all of his pain to the idiot pain management physician.


Thursday, January 03, 2008

Just another patient

I occasionally read other medical blogs, and the posts I usually enjoy are the ones with a gripping story. I've told a few myself. But there haven't been many in my own field. Unless I'm dropping lines or coding people in the ICU, my job is a lot of talking to people and writing long notes. It isn't all that surprising to me that I'm interested in the more procedurally oriented subspecialties.

All of which made it easy to overlook Mr. Arthur. He suffers from Parkinson's disease and dementia, so when I read that on the chart in the ER and then heard him say "I've never had a tremor before" I discounted his story, chalking him up as another demented patient with poor historical skills. I had gotten called on two patients at once, so I left Mr. Arthur to tremble in his bed a little longer while I got the much more exciting acute pancreatitis patient upstairs.

Coming back to Mr. A, I got his story a little clearer. He was worried. Worried that his home blood pressure cuff was giving widely variable readings, worried that the ER doc told him his heart was in trouble because of "a tremor in the way it beats" (the ER resident meant atrial fibrillation) and worried because his baseline tremor was getting bit worse. I was able to fix one concern right away, (and this illustrates my irritation with the ER residents) by just looking at his EKG. There was certainly an EKG showing atrial fibrillation in Mr. Arthur's chart, but the problem was it said "Betsy Rosengard" across the top. Mr. Arthur's EKG was not completely normal, but it certainly hadn't changed from the last time he had been admitted, a year previously. The tremor I wasn't sure about, but his blood pressure concerns, especially in a 90 year old man, were enough to warrant at least a 23 hour observation period. I got him upstairs and promptly was swamped by the other 30 or so patients requiring my attention.

Later that night, I was going through Mr. Arthur's clinic notes in a bit of downtime, and I noticed that his primary neurologist mentioned he was a writer. I checked his name on Amazon and found that my patient had written 11 books, several on the Korean war, in which he fought, and a few on other American conflicts. So when I swung by his room on my evening rounds, I asked him about it. He brightened up immediately, and began telling me his life story. Though his mind wanders at times, he is still quite sharp, and he told me about joining the Canadian Army in 1940 because he was desperate to "kill them Nazi bastards." While there he met King George VI. He transferred to the American Army after Pearl Harbor and was made a tailgunner in B-26s. He didn't want to fly and so transferred to the infantry, where he went to Germany after the surrender to guard POW camps. He still remembers the names of the SS officers he was charged with keeping under lock and key. After WWII he came home and married, staying in the Army and going to Korea, where a lot of the experiences in his books come from, apparently.

I was amazed I had ever seen this fascinating man as just another patient. I realized that I just hadn't given him a chance to tell his story, and that all of his concerns were valid, he just didn't talk fast enough to convince me in the 30 seconds I had given him.

I didn't want to leave, but I had to let the man rest, and I had other patients to see, but I came back to his room the next day and chatted for over an hour after I had signed out, and could have been at home, asleep.

I may regret not sleeping that extra hour this afternoon, someday, but I doubt it.