A Jolly Company

Silence and safety

2011-11-28T23:20:00.002-05:00

It's a cold, quiet night, and my current rotation has me on clinic, so I'm not anxiously awaiting the pager. So naturally I'm reflecting. The last nine years have changed me, as I related here, and I've achieved at least one dream in being a cardiology fellow. But tonight, I came across a poem by Sassoon that brought me back to my third year as a medical student, watching a patient die for the first time. The poem, which you should read (assuming I still have any readers, and you care) is called The Death Bed. The part that got to me is this:

Light many lamps and gather round his bed.
Lend him your eyes, warm blood, and will to live.
Speak to him; rouse him; you may save him yet.
He’s young; he hated War; how should he die
When cruel old campaigners win safe through?

But death replied: ‘I choose him.’ So he went,
And there was silence in the summer night;
Silence and safety; and the veils of sleep.
Then, far away, the thudding of the guns.

It is perhaps an open secret that I did several of my medical school rotations in military hospitals, and the perspective I have on war is perhaps more visceral than that of most who haven't been in one. I've never been shot at, but seven years ago, I watched someone who had go through the lines above. It seemed pointless. I probably tried to write the poignancy of the scene, which happened literally minutes after the news station (filming a special on the soldier and his pregnant wife, carrying a baby he would never see) turned off the cameras and walked away. But I am not the writer he deserved. Sasson was.

I wonder what he accomplished. What he saw as the great purpose of his nearly two and a half decades of life. I realize that, as a modestly terrified med student on surgery, I knew far, far more about his vital signs than whatever it was that made him truly vital, truly human. But I wanted to lend him my will to live, nonetheless. I still do.

My last few posts talked about moving away from the direct experience of patients and more into management. I now know that process is what friends warned me against when saying "don't let them change you" as I shuffled off to yet another school that summer in 2003. The change creeps up without the changed noticing how great it is. But sometimes the realization breaks through and a refreshing of humanity comes back.

So it is good tonight to sit in silence, far away, and weep for a soldier.

Fellow

2010-07-03T00:30:00.002-04:00

I've begun my cardiology fellowship. Though my efforts here may not reach their former level, in many ways, this is a beginning anew of the residency process. I am again at the base of a long totem pole, with vast amounts of learning to acquire. Hence, I feel the need to write again.

The first day wasn't terrible. However I did send one patient to the ICU, made two big mistakes while running a treadmill test, and received instruction in no uncertain terms regarding my deficiency there.

Just like being an intern.

Resident

2008-12-20T01:20:00.002-05:00

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.

Hope

2008-07-28T20:50:00.003-04:00

"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.

In conversation

2008-05-13T20:20:00.003-04:00

"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.

Growing old together

2008-04-07T00:19:00.004-04:00

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.

Denial

2008-03-13T15:24:00.002-04:00

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.

No salt

2008-03-09T15:00:00.000-04:00

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."

ER

2008-02-27T22:00:00.002-05:00

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 http://www.emedicine.com/med/topic2963.htm

On Another's Sorrow

2008-01-29T22:13:00.000-05:00

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.

Happy ending

2008-01-19T14:35:00.000-05:00

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.

Cross cover

2008-01-14T20:04:00.000-05:00

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.

Seriously

2008-01-07T00:41:00.000-05:00

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.

Sigh.

Just another patient

2008-01-03T21:36:00.001-05:00

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.

Serendipity

2007-12-31T00:21:00.000-05:00

My hospital is an odd combination of old and new technology, because physicians hand-write orders, but then the nurses enter them in a computer. It's a bit ridiculous, but for some reason some paper pusher somewhere figured it will save money.

Anyway.

Recently I admitted a patient with vague abdominal pain, and since the surgeons decided not to cut him open and the ER attending wouldn't let me send him home, the guy was admitted. (That's another whole story) We gave him a laxative and some Motrin, but figured we'd also try to figure out if anything else was going on, so among other things I wrote for an anti-S. cerevisiae level, as this antibody is elevated in Crohn's. The nurse taking off the orders was new, and unfamiliar with the computer, which will auto-complete the orders as they are written, and instead she sent an Ascaris lumbricoides battery. I've had similar problems with the computer before, and as both of the computer abbreviations for these labs begin "ASC..." it was an easy mistake to make.

Ascaris, for the one or two non-medical readers out there, is a roundworm which is very common in third world countries, but not so much in the yuppie demographic my patient belonged to. I saw the order in the computer later on the night of admission, and went to change it, but the original had already been sent. So we sent the Crohn's lab and thought no more about it.

Flash forward a week. The patient is discharged, and as far as I know still having the vague abdominal pain when his labs start to come back. And though he doesn't have Crohn's, he does have roundworms. It's an easy disease to treat here in America, but we never would have caught it if the nurse had had more training.

To line or not to line?

2007-12-21T11:25:00.000-05:00

This month I'm back on the inpatient wards, and for a variety of reasons (not least of which, I flatter myself, is my outward impression of competency) my senior resident has been very hands off in dealing with me. She lets me know if there's a patient in the ER to see, and then swings by about 45 minutes later to see what my plan is. The confidence is good for me, because I'm realizing I actually have learned a lot in the past few years. Pulmonary embolism? I know what to do. Diabetic ketoacidosis? I'm all over that. But only recently have I started standing up for my ideas against those of my seniors.

From my perspective as an intern, desperate for procedures and learning opportunities, it might have been a bad idea. Mrs. Wilkins was a 70-something year old diabetic with renal failure, and the ER was unable to get IV access on her. Normally they would just stick a central line and call us, but we weren't particularly busy and admitted the patient before they had the chance to. Once we got her up to the floor, my senior told me to get consent and then put in a central line. I was fairly excited about the prospect, because I'm getting close to having done enough not to need supervision for this procedure. But I'm trying to be an internist, so I sat back and considered for a minute. Mrs Wilkins didn't need a central line, she needed maybe a little fluid and the occasional lab. Since we hadn't gotten an IV downstairs we didn't have coagulation labs, and for all I knew she had an INR of 4. So instead I grabbed one of the techs from peds and he got a nice peripheral line on the first try. We gave Mrs. Wilkins her fluids, readjusted her insulin regimen, and sent her home two days later.

It's not a particularly moving story, I know. But it stands out to me as one of the first times I went for something less exciting because I was thinking for myself, and for the patient, rather than for a check box in my training. It was a small step on my road from technician to physician. And even if I still need another central line or two, that step was the more important one.

Don't let them change you

2007-11-10T12:34:00.000-05:00

The past is the only dead thing that smells sweet,
The only sweet thing that is not also fleet.
I'm bound away for ever,
Away somewhere, away for ever.

The one piece of advice I got sick of hearing when friends/family/people I met on the street found out I was going to medical school was "don't let them change you." I think a lot of people see doctors as a bit disinterested, which is probably why my patients are so pleased when I actually sit down and listen to them. Don't let them change you, I heard, as if staying the same was possible and desirable.

I am finding out it is neither. Even during medical school I found myself picking up on the dark humor of my teachers, my attending, the residents I worked with. But it hasn't been until this last week or so that I've really started understanding it.

I walked into the intern work room yesterday when post call, having been awake and busy with mindless paperwork for the last 18 hours, and awake and seeing patients for 12 hours prior to that, and announced "I'm done even pretending to care any more." There were a few laughs, because we all say similar things occasionally, desperately clinging to humor as a defense against the rising tide of futility and anger and sleeplessness and frustration that is internship. But at that moment, I meant it.

The strain of maintaining insane attention to detail that has never come naturally to me is starting to tell. A few days ago I wrote up the plan for a patient, presented it to my attending, and enacted it. Now the patient is dying, intubated in the ICU, and though a relatively small change in my plan might not have made a difference, it also might have. He is 50 years old. Now despite the fact that it is my attending's responsibility, it is also still my fault. And while my resident was pretty nice in the way he pointed out the mistakes, my attending (perhaps to cover her own insecurities) has not been. I feel bad enough on my own, but her "teaching" of me now takes the tone of an owner-pet relationship. I want to remind her that "you signed off on the plan too, doc" but I value my future in this program.

I've changed, I know. I'm thinking maybe there is a finite amount of things we are able as humans to care about, and in the strain of this environment, having to deeply care about lab values, paperwork, physical exams, paperwork, research, paperwork, interpersonal dynamics, paperwork, the opinions of your superiors, and yes, paperwork, the pain of the patient gets bumped from the list, usually right after you bump your personal life from it as well. It becomes easy to see patients as intentionally causing you more work, even nice 80 old men with funny stories, because they are being admitted to your team for the third time this month. And that's mostly because they like the hospital more than home and are able to convince the ER that they need admission.

Probably part of residency is learning to deal with this strain and busy-ness while maintaining some compassion. But I'm finding that the teaching we got in medical school on implying compassion with body language and listening was some of the most important of all. At the time I thought that would come naturally, since I cared about patients. Now I'm finding that much of medicine is acting. Some patients are easy to like. But no one who is solely human has ever loved all mankind equally. And with tiredness and frustration and a tangible link between whining and hours spent in the hospital, an increasing segment of the population becomes difficult to love.

So yes, I've changed. Some of the compassion is acting. But the acting allows me to do my job, to be more dispassionate, to view a patient and their disease as I have to to treat it. Because I'm thinking maybe if I liked that guy less, he wouldn't be dying. But maybe I just need a vacation.

West Indian Girl - 4th and Wall

2007-10-28T23:57:00.000-04:00

This was unexpected. I've written before about being surprised how popular, in terms of comments and email, my music reviews have been, but I definitely did not expect to have music recommended to me by promoters on the basis of my reviews. When, therefore, just such a person recommended this album to me, I was skeptical. However, I gave the promotional track a listen, and was interested enough to check out the whole album.

Electronica and rock have enjoyed tenuous relationships in the past. I'm not exactly a music historian though, so in order to avoid doing any research, I'll just say that a long creative thread runs at least from Emerson, Lake, and Palmer through Madonna's "Ray of Light." It is a genre I enjoy, and though I no longer fall asleep to the Future Sounds of London, the formation of sound and art through digital means still speaks to this 21st century soul.

If in my last review I was complaining about how often mimicry passes as artistry, this album stands as a lesson to aspiring artists. You can work in a given style, but you need your own twist. Putting a twist on an old style for the sake of the twist is obnoxious (like Jet pretending to be the Rolling Stones), but when you do it as part of a coherent vision, like West Indian Girl is doing, it becomes worthwhile. While listening, I was trying to make comparisons, but winding up with absurdities in the process. Folksy Pink Floyd. The Shins meet U2. Perhaps it is best I am paid to be a doctor, and not a music reviewer. But it is true that I have not heard anything exactly like this crew before.

"To Die in LA," opens this album with a distant flute sound, but rapidly picks up, adding drums and synth until the singers (in their first clear words on the track) voice the listeners' own thoughts with a chorus of "here it comes." I'm not certain the lyrics on this particular track are meaningful. They aren't particularly important, as in most trip-hop, but they do get the album off to a fast paced start with a few cool vagaries. Even if I was rocking with the album, I wasn't truly impressed until the track "Solar Eyes," where electronic beeps and an acoustic guitar trade off without jarring the listener. It sounds impossible, but they manage to do it. Throughout the album, with transitions like that, the confidence with which the disparate sounds were melded struck me. Also, I admit (though it is no surprise to anyone familiar with my defense of Keane's first album) that I like songs with a tune. That's why X&Y didn't really do anything for me. But the tracks here are all hummable.

It's not a perfect album. The band struggles with ending their songs, dragging the otherwise strong "Sofia" on at least a minute more than truly necessary. And the lazy, psychedelic "All my Friends" will never rank in my favorite track list. Of course, the Goa-trance meets folk marriage here (there I go again) is bound to have some distinctive offspring, some more palatable than others. Still, there is quite enough to enjoy here, and this one is going to be the soundtrack to my commute for a while yet.

Just another call day, or good nurse, bad nurse II

2007-10-25T19:58:00.001-04:00

Me imperturbe, standing at ease in nature,
Master of all or mistress of all, aplomb in the midst of irrational things

Eleven am. I walk into the hospital, change into scrubs, and within ten minutes I'm admitting my first patient of the day. By mid afternoon, I'm collecting signouts from the other teams, and by 6pm I am responsible for the medical care of some fifty patients overnight.

At about 9 pm Mrs. Stone really lost it. She was frustrated with the primary team's treatment of her husband, and utterly convinced that IV antibiotics were better than oral. So she and her husband decided that was a great time to page me, the night call resident, and demand IV antibiotics. I remained as calm as possible while explaining to her that the particular fluoroquinolone her husband was on had exactly the same bioavailability in either IV or oral form, and that a UTI was not, in this instance, life threatening, but she was having none of it. Her concern I could understand. Her manner I could not, and as her voice reached a level which was probably audible from several adjacent floors in the hospital, as she denounced my ability to have compassion, my intelligence, my understanding of medicine, and virtually every person connected with her husband's hospitalization, the charge nurse (blessings on her and her children) came in and interrupted by saying that visiting hours were over, and that if Mrs. Stone did not remember the way to the exit, the security guards would be more than happy to show her the way out.

Three am, and I am awakened from my one hour of sleep by a nurse who feels that this is a great time to pass on to the night float doctor the results of several perfectly normal, non-emergent tests performed over the course of the day. The sorts of test which will not, by any stretch of the imagination, change the management of the patient in the next three hours before the primary team comes back in.

Eleven am. I am now in the step-down unit, dealing with my patient who has developed mental status changes. I am very suspicious that these changes are due to the fact that he has bad COPD and has been off his oxygen. I need an ABG, quickly, to determine whether the oxygen I'm about to start is going to fix the problem, or whether I need to keep looking for a cause. The patient's nurse has decided that it is far more important to gossip about another doctor to one of the other nurses than to actually draw a lab that might help her patient. I try telling her nicely, but she will not be interrupted. So, exasperated, I draw the lab myself and make a note to write up an incident report.

Four pm. The bed manager finds out, and pages me about, the fact that one of my patients has been off telemetry monitoring for most of the day, because the nurses can't find the tele pack. They've only now decided this is worth passing on. Another twenty minutes of work. That will teach me to think of getting out of the hospital early post call.

Five pm, sign out complete, my patients passed off, my pager off, I drive home. And in just under twelve hours, I'll be right here, headed the other direction, starting all over again.

Back to the ward

2007-10-21T19:29:00.000-04:00

As the title suggests, I've gone back to the inpatient wards. It's a welcome change in ways, since I now feeling like a doctor again, making treatment decisions and actually taking care of patients. However that also means I'm on call, missing sleep, and since I had a month off essentially, I've lost a lot of the good habits I had. My first night back on call was rocky, and it was fortunate that we had a phenomenally light call, or I would have been completely hosed. Now I'm two days in, and getting back into stride.

Of course, that entails sacrifice. I had made plans to go to a play with a new friend of mine this afternoon, but as I was heading out the door, I got a page about one of my patients who was crashing. Two hours later he was safe in the MICU, but the play had already started. Still, that's the kind of medicine that excites me, making actual helpful changes in patient care, rather than the combination social worker-slave-clinician stuff that usually compromises a medicine intern's life.

In other news, Mrs. Roman got that surgery, oddly enough because someone told her exactly the story Judy mentioned in the comments.

Faith healing

2007-10-05T17:46:00.000-04:00

Mrs. Roman needs her lung removed. It has become severely damaged, is chronically infected, does not aerate her blood, and is spilling bacteria into her good lung, causing life threatening pneumonia. However, she will not undergo the lung resection surgery because she believes God told her he will heal her. So she lays in her ICU bed, trusting that God (plus antibiotics) will cure abscess and empyema.

This is (to put it mildly) ill-advised. So much so that it makes me angry to think about it. Without realizing it, I have become the person I feared.

Back in medical school, we had a class on the "human context of medicine." It was our first year, we were still figuring out how to do the whole medical school thing, and for three hours every Thursday morning we sat in small groups and discussed the papers we had been required to write about a variety of topics. Death, end of life care, sexuality, culture, religion. Pretty much we talked about everything your mother told you was bad manners to discuss with strangers. The teacher for this class, who gave us weekly lectures on top of our discussion, was a militantly atheist Reform Jew, and one of his pet projects was to ensure we all kept our religious convictions out of our practice of medicine. At the time, I thought this impossible. I resented his depiction of a strictly empirical physician, admitting the presence of more than flesh and blood only when necessary to gain the trust of a patient. It was an odd, soulless compassion he taught.

But I realized today, standing next to Mrs. Roman's bed, that I have become more like that person than I knew. Through the next three years of medical school, and the first few months of internship, I have come to believe in the power of medicine. I've seen medicine heal the sick and make the lame walk. If we haven't made the blind see yet, we're working on it. More effective than any lecture or any crazy triple-board certified medical school teacher was merely living this life. And standing by that bedside, my first reaction was anger, or at least irritation, that this woman held to a ridiculous conviction that is going to kill her. I was angry that this pleasantly deluded woman didn't share my near-religious conviction in the power of medicine.

At the same time, I share her convictions, at least in part. I am a Christian, but I've never been the "let go and let God" type. I'm more a "praise the Lord and pass the ammunition" type. I figure that no matter what you think about the controversial questions in life, God has given us all a brain and hands, which we ought to put to good use. Because of faith, I allow that God could heal her. But I believe in medicine the way I believe in gravity: it just works. Of course, it works based on principles which are either impossibly serendipitous or intentionally designed, but then that truly is the religious question. Whatever the answer, it is not germane to Mrs. Roman's condition. She is waiting for a miracle, and if she does get better, that's what she'll call it, but I'm intensely skeptical of miracle claims. Remissions happen in many diseases, and we don't always have an explanation for them. It is only when they happen to religious people that they are called miracles.

So the focus on pathology and on biology has made me a skeptic and maybe a bit of an empiricist. Where that breaks down, and where I retain my faith and humanity, is in the big picture. Certainly, the only way Mrs. Roman is going to be cured is with cold steel. But if there is any point in curing her, it is more than molecular; she is more than a broken machine, and the only way to understand that is not found in Robbin's Pathology.

Said the Whale - Taking Abalonia

2007-10-03T00:10:00.000-04:00

So I admit it, I first heard about these guys from perezhilton.com. Perhaps I shouldn't admit frequenting such places, but I figure if you haven't checked that site at least once, you aren't doing your part to be the "Great Satan" that Ahmadinejad sees in the world. Anyway, whatever I think about the color scheme and the content, Perez occasionally has good music taste, and this wasn't a disappointment.

The first song I heard from this album was "This Winter I Retire" which is the most distinctive track on the album. Check their Myspace page to get a taste here. I like upbeat songs with a minor feel, so musically I was predisposed to like it, though the lyrics are nothing spectacular. As I listened to the rest of the album, I was lured into just listening, and forgetting to be critical. But a few listens have me somewhat less enthralled. That first track is still distinctive, but the balance of the tracks are derivative sounding, with the most egregious being the second "Live Off Lamb" which James Mercer could probably sue for plagiarism over. The Shins, the Strokes, the Decemberists...an alert listener can place all of them in this album. None of which says that this is a bad album. It's not. But it mostly sounds like B-sides of bands you already like.

In short, there's potential here, coming out particularly in "Plans for the Future" and the already mentioned lead off track. But the potential has yet to be realized, I feel.

Return to Psychiatry

2007-10-01T19:46:00.001-04:00

If I thought ENT was a step back in time, psychiatry is worse. Don't get me wrong, I loved psychiatry as a med student, but here I'm not even supposed to talk to the patients. My whole experience is to "shadow" a psychiatrist, basically pretending I am a hole in the wall. So clinic was pretty boring this morning, with the only bright spot occurring when I stood behind the front desk looking out. On the back of the desk is a row of photos of people who have made credible death threats against staff in this psychiatry group, along with a short description of last known whereabouts and any other useful bits of information. One guy had the terse line "an FBI investigation is ongoing" beneath his description.

Next month, when I return to the wards, I don't think I'll complain too much about COPD exacerbation patients. At least none of them have ever tried to kill me.

This is a pretty informal rotation, so I ditched the clinic in the afternoon. I joined up with the Consult-Liaison team instead, and had a much better time. C/L psych is something I could enjoy, plus the specialists in it seem to be the sarcastic, screwball humor, polymath types that I enjoy so much in any specialty. We didn't have too many patients, so the attending launched into an impromptu discussion of paraphilias, which is apparently his research interest. Think Doctor George Huang from Law and Order: SVU, only an older white guy and you've got a pretty good idea what this doctor is like. Both entertaining and informative.

He reminded me, at first, why I thought psych was so cool, but after a while he began to remind me why I couldn't end up doing it. Psychiatry can be pretty creepy, and while some of the discussion was interesting, after a while, frank discussion of deviancy gets old, and then painful to discuss. I have been relieved before when a lecturer (usually a pulmonologist) ended a talk, but the end here was a very different sort of relief. That's more of an "awakening from sleep" relief. This was more a "coming out of a haunted house" relief. We'll see tomorrow what a full day in the haunted house is like.

ENT

2007-09-27T17:38:00.001-04:00

One of the more inscrutable whims of whoever it is that determines the requirements for internal medicine residency this year has been to require a "subspecialty month" in which we see a week of clinic in ENT, Ortho, Ophtho, and Psych. This week has been ENT clinic for me, and it's beeen a leap back in time.

What I mean is, I am basically functioning as a fourth year medical student. I don't know any of the surgery, so I can't really contribute there, and my idea of a clinic visit is at least 30 minutes long, so I'm not fast enough for surgery. These guys have are double and triple booked in twenty minute time slots, and they are rarely behind. On the plus side, I've seen a lot of scopes and procedures that I probably won't ever again, unless I go into general internal medicine, get really fancy in my own practice, and decide a nasopharyngeal scope is a worthwhile investment.

I've survived though and today was actually fun, even for an internist. Just when I was about to slide into the quick, only-the-highlights ENT exam on a patient, I figured out she had something more serious than just hoarseness wrong with her, and we ended up needing a fairly involved thyroid workup. That's something I know how to do. And then one of the later patients needed to be scheduled for surgery, and the ENT doc I was working with wanted to do it tomorrow. He looked at me and said "with this guy's cardiac history, anesthesia is never going to take my word on a physical so seriously that they'll approve surgery on this short notice. Can you do the H&P and write 'internal medicine resident' next to your name? They'll take that, I'm sure." So I did, and I don't think the surgeons minded my 25 minute exam, because it meant one more case on the schedule for tomorrow. It was nice to be recognized for expertise in my field, even if it is considerably premature.

Sigh...

2007-09-25T17:42:00.000-04:00

I usually love clinic, even now that the patients I see call me doctor, and I have to have a plan pretty much figured out within half an hour of seeing them. What I don't like is patients like Mrs. Fortnight.

Mrs. F showed up in clinic to be seen for hospital follow up. See my hospital has a policy that every patient is seen in follow up within a month by the intern who admitted them. No matter how complicated, or how many other medical problems they may have. I admitted Mrs. F about a month ago because she was dehydrated and low on magnesium, but of course, this being internal medicine, she also has heart failure, an obscure and ill-characterized propensity to lose electrolytes, chronic diarrhea, Parkinson's, depression, and diabetes. She's the kind of patient who can make almost anyone wish they had picked another specialty.

So she shows up in clinic, and right away the complications start. The triage nurse checks her blood pressure and gets a value of 90/30. This is not good. However, blood pressure machines are not infallible, and any abnormal value they give you should be rechecked. So the triage nurse duly rechecked the pressure three times, getting the same value, but still using the machine. When I came out to see what was holding up my clinic, I found they had not checked the pressure manually. I did so and got a completely normal value. Meanwhile, the nurse had checked a blood sugar and found a value of 232. This is also bad. Especially since my patient hadn't eaten since the night before.

Things never really went uphill from there. She had stopped the magnesium I had started, which necessitated a stat magnesium check. She hadn't rescheduled two appointments with specialists that she missed (and needed.) She hasn't ever written down her blood sugar when she checks it, and neither she nor her husband can tell me where it usually is. She was surprised when I told her she should check it with every meal. 90 minutes later I am an hour behind on clinic with two patients yet to see in the morning session. Goodbye lunch.

I felt bad for her, but there's only so much I can do, and I'm only supposed to be seeing her for her dehydration follow up. She has a regular doctor who should be taking care of all these other complications. But evidently he's doing a poor job. Maybe though, she's just minimally adherent to her regimen from him, like she was from me. So, schedule follow up with her doc, get her a glucose level diary, counsel on foot care, schedule follow up with subspecialties, refill Sinemet, smile, bid goodbye.

Next patient, rinse and repeat.

Please, dear reader, bear this in mind the next time your doctor is late for an appointment.

On the positive side, I finished my infectious disease rotation, and my attending was singularly complimentary in my evaluation. He asked me to consider applying for fellowship in his department in two years too, so we'll see. I did love it, but the siren song of cardiology is still ringing in my ears.

More jokes

2007-09-17T17:35:00.000-04:00

My attending is just non stop with this kind of thing. So today he was telling us how he modeled coccidiomycosis in mice...

"So we gave the mice some barbiturates to sedate them, a little 'mouse roofie,' if you will, stuck a tube in their noses, sprayed the cocci down there and pulled it out. Then the mice woke up, called the cops, and claimed they'd been violated. All in the name of science."

Unusual stories

2007-09-15T12:49:00.000-04:00

I love old people. That's a huge reason why I'm internal medicine, but even with the exposure I've gotten so far, I am occasionally startled by the stories they tell. So I was when talking to a recent patient the infectious disease team was consulted on. He's a 90 year old guy who fought in WWII, starting in North Africa with the original American landing and going through with Patton to Italy and then landing on D Day in Normandy. The reason we were consulted was because of a positive VDRL test and concern for neurosyphilis, and while asking this guy about it, he told us "yes sah, I knows when I got the syphilis. It was in Italy. We was mostly worried about the gonorrhea, you know, 'the clap' we called it. But the syphilis...it was worth it." Straight out of Hemingway. I actually thought of Papa's story "One Reader Writes" while hearing Nick's side from that hospital bed.

It reminded me of another patient I recently saw too, a very sweet 87 year old woman, who when I saw her was having some adhesive bandages pulled off. The nurse joked to her as she winced that "it's a bit like a wax job, right ma'am?" Miss Elsie (as she insisted we call her) looked seriously at her and said "I used to wax. *pause* When the sailors came to town." She then smiled a look of mischief at all of us as she settled back on her pillow.

So yes, surprised, though I surely shouldn't be, to realize that my patients were young and foolish and wild once. It adds a depth of humanity to them, and I try to imagine what Miss Elsie looked like at the height of the Jazz age, or whether Private Stone, seeing Europe from the back of an Army truck, thought twice about the Italian girl he left behind. I wonder too, what became of her, and whether she's telling some Italian medical resident about the dashing American who contributed to her own medical history.

The stories are often sad or bittersweet, but I like hearing them, and though I'll never know the details or even the endings, it definitely brightens my day knowing there is more to my patients than penicillin. Perhaps 'brightens' isn't the right word. But humans are a tragic, noble, and foolish kind of creature, and seeing them "warts and all" does more each day to help me appreciate our little world and the kind of sense we all strive to make of it.

Subspecialty musings

2007-09-11T21:56:00.000-04:00

While sitting in conference today, I leaned over to one of my fellow interns and mentioned how pleased I was to have had both days off this weekend. He leaned back and whispered "two day weekends are proof of the existence of God."

It takes so little to cheer us now.

That said, my current rotation, infectious disease, is fantastic. Interesting subject matter, a sane patient load, and I'm only in the hospital 12 hours a day, 5 days a week. I could get used to this. Adding to the enjoyment is my attending, with whom I share a rather offbeat sense of humor. While discussing the impossibility of getting a particular lab drawn he quipped "but you might as well follow that order up by writing 'end world hunger' as your second line. The nurses are about as likely to do either." Later he said "that's like writing a progress note with cut out words from a newspaper. You can dream about it, but you probably shouldn't." Oh yes. I am entertained.

A break, for real

2007-09-08T10:20:00.000-04:00

I'm finally finished with the wards, which means that after two and a half months, I have two days off in a row. Having one day off a week is fine, it's the biblical model and all, but I've found that it is tough to really do much with it except sleep. That's all I do anyway. But now, with the glorious luxury of having the entire weekend off, I'm left planning hikes, and listening to music, and enjoying life in general a lot more than I was.

Which leads me to an unrelated topic. A while ago I reviewed KT Tunstall's album here, in one of the sporadic music reviews I post. Apparently that got the attention of her promotion company, because I got an email this week which included a video from Tunstall's upcoming album, "Drastic Fantastic," and a number to reach her agent, along with an invitation to interview her. That's not probably something I have time for just now, but it is fun to get an email offering to include me in something besides obscure bank transfers from shady Nigerians who can't spell.

However, if there is anyone out there who really wants to interview Tunstall, I have the contact info for her agent and will pass it along. I can also report that the video is fairly straightforward, with a vague narrative thread and constant flashing between camera angles showing people having a good time. I don't understand why this is now cool, but no matter how much I like a song, I'm not going to spend any of my free time getting aggravated by the apparent epilepsy or ADHD of a video director. The song itself though sounds like her hits from the last album. Quite catchy, and now it's stuck in my head. I'm betting this will do well too when it comes out September 18.

Now I'm off to luxuriate.

First on the scene

2007-09-02T23:45:00.002-04:00

Even before I wanted to be a doctor, I used to imagine being the first person to arrive at some great tragedy, saving the day with my Boy Scout first aid skills. I've learned a lot of first aid since then, all the way through ATLS and ACLS, but still, I've never had to use it outside of the hospital. I'd never seriously considered it even, for despite the nature of my job, there was still a division between me at work, being a doctor, and me at home, being a 20-something guy with a cheap car and a nice stereo.

Until last week.

I had the unique opportunity, late one night after dropping a friend off at her apartment, to be the third person on the scene of a rather horrific motorcycle accident. When I pulled over and ran up to the site, I did have a vague idea that "I might do something good here," but it was shattered when I saw the one victim. Even though I'm not a surgeon, it didn't take medical training to realize there was nothing I could do for the dead man, who had hit a retaining wall while traveling maybe 100 miles an hour. (He had passed me moments before, and my last uncharitable thought as he sped over the hill was "he's going to get himself killed driving like that.")

The guy who got there ahead of me was taking a pulse when I ran up, and he looked up at me and said "I'm an ER tech, and I don't think there's anything we can do." I looked at the double amputation, the blood all over the road, and the apparent high neck fracture, and responded "I'm a doctor. And there isn't." We called 911, of course, but there was no bleeding to stop, and the EMS guys called him dead on the scene.

Two things stuck with me from that night. One, I called myself a doctor, claiming a certain level of expertise, intentionally. And I didn't feel inappropriate doing so. I also watched, with part of my mind amazed at the change, as the seven or so bystanders now on the scene seemed to relax. I think they all needed to know that there wasn't anything to do, and they felt bad not doing something, despite the horror of the situation.

Two, even as I called myself "doctor" I felt a bit guilty for not doing anything. This bothered me for quite some time actually, until I realized that it is actually my job to make that kind of call. It is my job to take the information I have about a patient, compare it to the knowledge I have of my abilities and resources, and decide how to proceed. And here I had few resources to use on a patient with two major arteries severed and no longer bleeding, implying he had exsanguinated. I think I made the right call, but it still was painful not doing anything while waiting for EMS to arrive.

The crowd started to drift away, having had their fill of voyeurism. The victim's fellow motorcyclist (who had missed the retaining wall and come back) knelt by the body, nearly hysterical. The guy didn't look more than 18 or so, and I realized, with a bit of a start, that I was moved myself. Oddly reassuring, because, having seen so much death in the MICU and CCU lately, I was beginning to wonder if I was losing the ability to really care about my patients.

There are at least two ways of caring, I think. It is possible to be emotional and tearfully connected to another. But this form of caring does a physician little good in an emergency, and that is where I demonstrated, at least at first, another kind of caring, in bringing my assessment of my talents to bear on the situation. There is time for emotion after all the action has been taken.

I'm not sure what this kind of perspective means to my life as an internist. Internists are supposed (especially by surgeons) to be the hand holding type, remaining emotionally connected with patients always. Perhaps I am that on some level, but I think this is why cardiology, and especially interventional cardiology, appeals to me. It will allow me to apply my internist's mind to an emergent situation like that faced in surgery. And if I go that route with my career, I will need that perspective on caring.

Change of pace

2007-08-24T18:07:00.000-04:00

Ahhhhhhhh, ward medicine. Q5 call. Knowing that I'll get to sleep through the night on a normal schedule more than twice a week. This next rotation is going to be nice.

Additionally, there are two interns per team here, and I'm coming on to a team with Rick, one of my better friends from the intern class, so we are going to have a blast no matter what happens. And we have a med student, whom Rick worked with on the last rotation and who is apparently pretty strong. Excellent. The funny thing is, Rick has apparently been talking me up as some kind of uber-intense born cardiologist with no patience for incompetence and laziness. Which I guess is mostly true, but I'm a nice guy about it, I hope. Still, I want the med stud to have fun while becoming the best student in his class, so if I'm hard on him, it will be with good reason and with lots of encouragement in the right direction.

The great thing about medical students is that they encourage me, so recently one of them, to study harder to stay ahead of what they know. Which encourages them to study, and keeps the cycle going. I'm already saving up ridiculous pimp questions to try out.

A joke

2007-08-20T14:48:00.000-04:00

Maybe this is only funny if you're sleep deprived. But then you have to be a huge nerd too:

Resident: "Dude, I think being on vecuronium sucks."

Intern: "Nah, man, I think it rocks."

*cue general hilarity*

Deprived

2007-08-16T21:58:00.001-04:00

One one of the rare occasions I was outside the ~~cage~~ hospital lately, I watched the "Bourne Ultimatum." Partway through the movie, the fearless protagonist is reading a stack of papers describing his own forgotten training and a line flashes across the screen: "subject has been awake for 56 hours." My first thought was "I could do that."

Q3 call is ridiculous. I'm in the hospital for 30 hours straight without sleep every third day. To think, as a medical student I assumed only surgery interns worked hard. At least they roughly keep to the 80 hour work week. And at my hospital anyway, they have call q5 on most rotations. Part of this may be the fact that my hospital is renowned for its medicine program, and the directors feel they have a reputation to keep up. But after two straight months of work in critical care, I'm noting the diminishing marginal utility of this particular learning environment.

Making matters worse is the fact that I am what is known as a "black cloud." Even among physicians, supposedly highly educated and purely scientific minds, there exist strong superstitions. A black cloud is a doctor who, when he is on call, has worse luck than the average. For example, last month, on the cardiac ICU team, my team admitted over twice the number of patients the other team did. And here on the MICU, the story is the similar. A positive side of this is the fact that my attending noticed it, and last time I breezed through presenting nine patients, he said "dude Nathan, you are like Superman."

I feel compelled to add that he's both a)from California and b)about a year out of his fellowship.

But where that was a motivation, and I was pretty energized previously, the flog is taking its toll. My motivation to read (or at least skim) an article or two on each of my patients before rounds has dropped off. Last night I fell asleep sitting up in my chair, in the process of typing a note. Where I was once understanding of being paged for even the dullest questions from nurses, I'm getting dangerously close to snapping out things like "that's exactly what I wrote in the orders, twice, and I just spent 30 whole seconds clarifying it in person."

Everyone is feeling it. One of the nurse managers pulled aside a senior resident the other day and told him he had to be understanding of the nurses aides, because they worked long hours. The guy shot back "You're right, they work four long 12 hour shifts a week, and the stress of filling the rest of their time with boys, alcohol, and sex must be incredible. On second thought, no, I'm not all that understanding. How about you tell them to do their damn job."

It wasn't the best way to remind the nurse of the truth, but I would have been tempted myself in the same position. But I'm greatly looking forward to my two week subspecialty block coming up in a month. No call, just two glorious weeks of sleeping through every night.

And Jane makes five

2007-08-16T19:59:00.000-04:00

Jane was a nice woman, scarcely old, who was admitted for sepsis and pneumonia. But it was only after we intubated her that we heard from her oncologist the truly grim prognosis of her disease. We didn't do her any favors with intubation and the family made the decision to transfer to comfort care only. I handled this completely without my resident, getting the morphine set up, making her comfortable, extubating her, pulling all the extraneous lines, stopping the drips. After the nurse and I called the family back in, it wasn't much more than five minutes before I was pronouncing someone dead for the first time.

Two years of clinical rotations in medical school and I never saw anyone die. Now more of my patients are M&M subjects than any other intern's. That's not a particularly uplifting distinction to have. Thankfully, nothing I've done wrong contributed to their demise. But it doesn't do much for a mood already dulled by lack of sleep.

The karma gods are angry

2007-08-10T23:52:00.000-04:00

So I realize my last post was all about conciliation, but last night, all I could think about was my anger at the orthopedic surgery team. Orthopedics is a fascinating specialty, I'm sure, but the practice of it trains that tribe to regard anything that cannot be solved with a stainless steel power tool as beneath them. So when, for example, a patient who had a hip fracture repair is semi-stable but has a few co-morbidities that make them nervous, they are quite anxious to transfer her to a medicine team.

Unfortunately, they performed this transfer directly to my staff, without informing me, the guy who would actually get paged to her bedside about an hour later to find a patient I didn't know with new ST depressions of 5mm in all her precordial leads and a tachycardia to the 140s, complaining of chest pain but unable to point to it, because she also developed sudden onset of bilateral paralysis from the neck down. To add beauty to the situation, the patient also had mental status changes and was unable to tell me anything about her history, and the chart was full of worthless surgery notes saying "vital signs stable" and "wound healing without signs of infection" but little else. The nurses were able to tell me that the patient at baseline had left sided paralysis, but that the right was new. And fortunately the orthopedic team had ordered a nephrology consult at some point, so the life-saving nephrology consult note functioned as my understanding of the history long enough for me to get the basic ACLS stuff started and to page my resident with more to say than "please come save me." Even more fortunately, we were able to help the short term things with her. Long term, I have no idea if her apparent stroke will resolve. Probably, even knowing about her wouldn't have stopped all the craziness, but I would have been far more comfortable and would have lost less time.

I'm going to prepare more war paint.

Internecine

2007-08-08T15:25:00.000-04:00

Late last month, Sri Lankan police killed 12 members of the Tamil Tigers, a rebel group with which they have been fighting for nearly 25 years. At issue is self determination for two rival groups sharing a small island with limited resources.

It is easy to see how this is like a hospital. Within the four walls (figuratively speaking, since my hospital was built in about 50 different stages and has long since ceased to be rectangular) of this building are numerous warring tribes, calling themselves internists, surgeons, pediatricians, radiologists, and the like. Through the vicious coming of age ceremonies involved with these tribes, they come to identify all outsiders as unclean, beneath their attention, untouchable. What makes this caste system more complicated than the politics behind Alexios I Komnenos' hold on the throne of Byzantium is the fact that no one group recognizes an ultimate ruler, and no one group is treated equally badly.

Surgeons, for example, tend to look down on internists as nitpicking, reactionary types overly concerned about minor lab values, most of whose conclusions need to be regarded with considerable skepticism. Even nice, earnest surgeons can fall into this category at times. Internists, for their part, are generally frustrated with surgeon's apparent disregard for important but small lab values and seeming inability to document more than the most obvious one or two physical findings, usually in cryptic, barely legible acronyms, but we reserve our most earnest hatred for ER physicians.

Surgeons, we reason, have an area of expertise beyond our ken, and we beyond theirs. I, for one, will never presume to take out an appendix or a liver, just as I wouldn't expect a surgeon to handle renal tubular acidosis or manage diabetes. We only step on each other's toes in presuming outside our area of expertise, and both our specialties can complement one another. An ER physician on the other hand, oftentimes appears to be actively involved in undermining our patient's health. For instance, I recently admitted a patient with atrial fibrillation causing a rapid heart beat. The ER physician though, assumed this was due to alcohol withdrawal, so despite reading the patient's old notes, he started the guy on a Versed drip rather than a diltiazem one. As a result, the patient got more and more somnolent and had to be intubated. Fortunately my resident and I got to him in time to start a medication that would actually treat his condition and prevent damage to his heart.

What gets lost in the griping as the tribes head back to camp to prepare more war paint and weapons is the fact that, even if we aren't shooting radiologists like Tamil Tigers, real people can be hurt in these conflicts. The ER, for example, does see acute alcohol withdrawal, and they did a)realize this was a bit atypical and b) call me before it got out of hand. I'm sure many times they would have been right with the Versed. So despite recognizing my growing attachment to my tribe, and my earnest defense of it in the call room, I'm trying to remember also that most of us have the patient in mind, most of the time. Sri Lanka I can't help. Bed five in the ED? I'll be right down, and sure, I'll consider alcohol withdrawal.

In the Zone

2007-08-01T19:42:00.000-04:00

Maybe it was the phase of the moon. Or maybe it was the fact that my day on call followed Simon's, and in comparison anyone would look good. But I was on today. By "today" of course, I mean my last thirty hour shift, in which I only say down for about 10 minutes total, and never touched my call room bed.

But despite being crazy busy, and rather stressful at times, everything went well in general. I had to bag ventilate a patient for about an hour and a half (trading off with one of the nurses) but he survived while teaching me much more comfort with mechanical ventilators (and incidentally, which are the good respiratory techs in this hospital). I had to get an arterial line on another patient, and did it perfectly it on the first try. I had 30 minutes of free time at exactly the right stage of the night and managed to look up articles which may positively alter our therapy for two different patients. I looked like a superstar on rounds and the fellow and attending both complimented me on my work and my presentations.

Not that I'm complacent. I know how hard it was to keep myself moving for that long, and how much busier the night could have been. Still, good days should be enjoyed.

Stronger

2007-07-29T14:31:00.001-04:00

Growing up means taking responsibility, learning your place in the world, and just occasionally, royally reaming out someone who deserves it.

But this isn't a post about nurses. You know I love you guys.

Or even med students. I was one once.

My program has a rather large array of personalities and capabilities. Most the people are pretty strong, even the ones I don't exactly click with. There is at least one notable exception.

Simon, as I'll call him, is a nice enough guy. Like all of us, his personality is not naturally that of the perfect physician, but unlike most of his classmates, he has not progressed very far down the path of mortifying these traits.

So yesterday, as he was the post-call intern, his job was presenting the new patients and giving a brief update on the old ones. Since this is the MICU, these patients are complicated, and need detailed notes discussing in depth, by system, the problems they have and what we are doing about them.

Rounds got off to a rocky start because (as my friend the senior resident told me) Simon had spent his night on call sleeping rather than working. So when he got up at 6am to round on six patients in the ICU before 8am, he was understandably far behind. He didn't know what had gone on during the night and had, despite the senior waking him up and directing him on what to do, gone back to sleep on several occasions before finishing his work. When I came in at 6:45 to see my one patient, I heard Simon asking his senior to help him with the note writing. He was rightfully rebuffed.

So notes were not finished before rounds. This makes rounding difficult, and what made it more painful (for Simon and the rest of us) was the fact that he had arbitrarily decided that some vital signs were not important on some patients. So, for instance, with one of his patients with acute renal failure and CHF requiring mechanical ventilation, he hadn't written down CVPs, and the blood pressures he had written down weren't the real range, they were what Simon felt were the "normal" ones of the night. Not cool. You can't just cherry pick data to make yourself look good, these are sick people.

There followed possibly the most painful rounding experience I've ever watched, one which demonstrated every mistake I've ever seen a third year med student make. Actually, I haven't ever seen a third year med student refer to his "Gay-dar" in assessing the patient's sexual orientation. Maybe you could get away with that, in the right crowd, with docs you knew and who understood your humor. Not the first day, when you've already floundered through twenty painful minutes.

This was painful, but I was mostly hoping it would be painful enough to make Simon realize his errors and maybe start slouching towards competence to be born. No such luck. Later that afternoon, about 3 hours after he was supposed to have left, I ran into Simon putting a note on a patient's chart. Unfortunately, this was a very short, 10-15 line note, nothing like the three pages you would expect on a complicated patient with decompensating respiratory effort.

So I called him out.

There followed a very tense, even toned conversation that was, nevertheless, my laying out in very clear language about 85% of what I figure is necessary to be a good doctor. I don't even remember all I said, but I do remember saying things like "this isn't about rules about notes you think are silly, this isn't about work hours, or personality, it is about taking care of patients. And if you don't realize that, you don't belong here. Internship is supposed to be hell, but you have to make it that way. If the pressure doesn't come from within you won't succeed." I added some choice things about needing to write notes, to consider every patient carefully by system because if you don't learn to come up with plans on your own, you'll never be able to. You'll always be an intern, and never a real doctor.

About halfway through this harangue, I realized that the entire nursing staff of that ICU pod, about 20 some odd people, were listening, mostly while pretending not to. I noticed the nurse taking care of the patient in question nodding his head in agreement. I am a bit ashamed to say I enjoyed the audience almost as much as the fact that I finally had an opportunity to maybe, just maybe, work for positive change in this guy's life, and more importantly, in the lives of his patients.

To his very, very great credit, Simon took this correction without offering an excuse for his behavior. He actually wrote a real note, and later, he paged me to thank me for the advice. I wasn't really sure what to say, except "you're welcome."

Heck, I could code in front of that guy some day. And it is nice to know, not just believe, that I have what it takes to give constructive correction. It is also nice to be the strong intern on the intensive care service.

30 hours without sleep? I'm still smiling.

Almost coded

2007-07-17T18:43:00.000-04:00

Late this morning, while finishing up the last of my work and hoping for an early exit from the hospital, I rounded a corner of a hallway to have my heart sink within me. For as soon as I rounded that corner, a group of nurses at the other end of the hall turned and said "there's a doctor!"

This is almost never a good thing. But in response to their earnest gesturing, I hurried to the room to see a very pale woman lying on a bed gaping at the ceiling with eyes closed. Meanwhile, in one ear I was hearing "just checked on her, was smiling a minute ago," and in the other I was hearing "there's no pulse on telemetry, just bradyed down and stopped, I think she might be DNR."

I am, in looking back, pleased with my calmness as I said "bring the code cart and her chart, see if she's DNR/DNI." By the time I reached the patient's bedside though, a nurse was standing in the doorway with the chart, telling me this patient was DNR/DNI. The code cart was pushed back to its familiar home and the crowd started to disperse.

I told the nurse to page the resident of the primary team and the staff physician as I felt the carotid for a pulse. Feeling none, and hearing no heartbeat, I realized I had just seen my first death in the hospital. First death ever, actually, which is an odd thing, I think, a sign of our times, a mark of the twenty first century, in which people die in small rooms away from home, attended by a select group of people to whom the experience becomes familiar. And until you join that group, you are insulated from the event, one that comes to us all.

The intern from the primary team drifted in. Though it may not have been the right thing to do, I let him pronounce the death.

"Time of death, July 17, eleven fifty AM."

It would be false to say this affected me greatly. I had never seen the patient before, never spoken with her, never heard her story, except her diagnosis. And I wonder what to make of that. I came into medicine partly because it allowed me to treat people, to be around people, who are dealing with real questions, and to deal with them myself. Somehow the presence of the "unveiled mysteries of life and death" seemed to add profundity to my experiences.

I thought as a medical student. As an intern, I'm harried to the point that thought beyond "what do I need to do now" is difficult. If I'm not moving, there's something wrong. I'm so used to hearing my senior resident say "what aren't you writing this down? You should be writing this down, Nathan" that it has become a bit of a joke. All this action, all this doing, keeps me from thinking.

And so, as I stood in that room, a little nervous, a little relieved that I didn't have to run a code, and a little awestruck by the whole situation, I wasn't really processing. I wasn't having grand thoughts voiced by Longfellow or grim ones by Thomas. I was tired, and after the details were passed on to the primary team, I went to grab lunch before heading back to work.

The beatings will continue until morale improves

2007-07-14T00:26:00.000-04:00

So today I presented my first CCU patient, and relearned a host of lessons I had thought were past. ICU patients, of course, are presented in a different format than ward patients, and I was rusty on that format. I was also very far behind in rounding today, and essentially I failed in every quantifiable area of accomplishment where my patient was concerned. Justly, I received some very stern correction for this, culminating in one of the interventional cards guys drifting from "know the patient" to "have a differential diagnosis." This particular lesson was not necessary in my case, but a few others were, so he can be forgiven for going overboard.

He did say that if next year I saw a patient in the ER with severe, tearing chest pain radiating to the back with blood pressure different in each arm and I activated the cath lab, calling him in from a sound sleep at 2am, then "I will throw you off the top floor of the hospital. Which would be tragic. Because the patient would die."

Maybe it's Stockholm syndrome, but I love cardiology.

Obsession

2007-07-08T23:20:00.000-04:00

To work at my trade by the dozen and never a trade to know;
To plan like a Chinese puzzle -- fitting and changing so;
To think of a thousand details, each in a thousand ways;
For my own immediate people and a possible love and praise.

I used to think I was obsessive-compulsive. It was my strong point. My concern for minutiae made me a great medical student, as I had all the labs, all the studies, all the details of the patient histories, going back as far as the hospital records would allow.

Then I became an intern. As a medical student, I had charge over one, two, or at most four patients. These were acquired gradually, over a period of days, and I came to know them well. Now, on cardiology, I regularly admit six patients on a call night, and then I have to know them well enough to present the following morning. Gone is the obsession. Or if not gone, I realize that I cannot get information the way I am used to, cannot use the same organization. I must move faster, more thoroughly, more efficiently.

Case in point, one of the patients I admitted last night was only in the hospital because on his more recent discharge, his medication instructions were not clear. This resulted in him not taking a medication he needed. Now I know the intern who wrote those instructions wasn't intentionally trying to harm anyone, and in fact, he had all the information on the instruction sheet, he just didn't take the time to format it in a readable way. Even I couldn't figure out the sheet, and heck, I'm a doctor. But he probably fell into the same trap I do, having to discharge ten patients in a morning, typing furiously, dealing with the interruptions of pages needing to be returned, residents updated, patients seen.

I never realized the sheer volume of work that goes into being an intern. I was a good medical student, and a good sub-intern, but it is impossible to know what all is entailed in being a doctor, in being an intern, until it is your signature on those late night medication instructions, your fingers entering all those discharge orders, your head running on empty because you've been awake for 30 hours.

Probably I will never be a success in my own eyes. But when I make stupid mistakes, like today in rounds, actually forgetting to write down half of a patient's chemistry panel and asking my resident for the numbers in the middle of my presentation, in front of the cardiology fellowship director, it is easy to sink farther in my own estimation than usual, even. Sigh. The only positive I can think of is the fact that I'm learning the hard way, which tends to make a more lasting impression. I just don't want to destroy my chances of success here before I even start.

Maybe that obsession isn't entirely gone.

First call

2007-07-06T23:41:00.000-04:00

So my first call night came off relatively well. Though in medical school I thought it the limits of my ability to follow four patients at one time, on this particular 30 hour shift I admitted five, learning all their complicated stories at one time, and without the safety net of an intern above me basically doing the work. I had honestly not realized that it was possible to remain in motion for 30 hours. Not even once did my head hit the pillow in my call room. But it wasn't as horrible as I had feared. The only patient who died was one whom we had transitioned to "comfort care," as the family had recognized the inevitable. And I was able to handle all the questions I was paged without needing to bother the senior. But nevertheless, at about 4am, I had pretty much decided that I picked the wrong field, or at least the wrong specialty. Very few laboratory chemists work 30 shifts as part of a group hazing ritual.

The uneasiness continued to morning rounds. I had not gotten a chance to do more than write down vitals and say "hi" to my patients, by no means getting a thorough exam on each of them, before it was time to start.

My fears were rapidly dispelled. About halfway through my first presentation, my attending stopped me and presented the most welcome piece of constructive criticism I've yet heard. He said "stop. I have no doubt that in three years, you're going to be one of the strongest residents in the program, but you're presenting like a medical student." He then proceeded to tell me exactly how to present as an intern. Noted. Afterwards though, the fear came back, as the fellow drew me aside as said "Dr. Ricker was complimentary, but just remember that your presentations were only acceptable for being the first week. If you are still presenting like that at the end of our weeks, we're going to have problems." Also noted.

Long white coat

2007-07-01T22:00:00.000-04:00

Today I put on my long white coat for the first time, along with my name tag with the initials "MD" after my name. Then I put my stethoscope, notebook, pocket reference books, pens, pen light, EKG calipers, rubberstamp, and spare paper in my pockets, and walked into the conference room to start my intern year. The first thing I noticed was that the coat wasn't appreciably lighter than it had been in medical school, and it had the added pain of stretching down to my knees. The second thing I noticed was that the notebook in which I have been writing immensely useful hints, like the REAL number for radiology, the outline for writing up a stress test, and the proper way to evaluate half a dozen common problems, the notebook I've been working on since third year of medical school, had disappeared somewhere between my car and the door of the conference room. But it is long white coat.

Not exactly a stress-free way to begin my intern year. But, as if in sympathy, the schedule worked out very much in my favor. I wasn't on call, so after relatively brief rounds, I was sent on my way rejoicing, and given tomorrow off. I can only complain by saying, I'm about ready to begin, already, and no, I didn't find the notebook on the way back to the car. Sigh.

Hiatus (mostly) over

2007-06-30T11:25:00.001-04:00

What, without asking, hither hurried whence?
And, without asking, whither hurried hence!

Orientation is finished. I'm not sure how these things work at other hospitals, but it seemed to me that my orientation consisted of a solid two hours of information crammed into two weeks of lecture. The obligatory instructional lectures on our computerized records system, kindly lectures about the importance of sleep, etc. And then the barbecues, dinners, lunches with residency directors, fellowship directors, directors of directors...I can say with certainty that I'm thoroughly oriented.

Which isn't to say I don't feel more than a little nervous. One of our lectures was on the importance of teaching the medical students rotating with us, and I got to thinking, given the slacker attitude of my fourth year, I'm really only about 6 months ahead of the fourth years students in learning, maybe 3 if you count the extensive attrition of knowledge that remains unused for an extensive period of time. I want to go into cardiology (I think) and my EKG reading skills are still not the greatest. The words "electrolyte management" still bring a cold sweat to my forehead.

I am pleased with my intern classmates though. Generally they seem a pretty sharp bunch, which will be important as we watch each other's backs through this next year.

One thing is certain though, my uneasiness will be rapidly dispelled. My first two months are the hardest rotations of intern year so I should be well on my way to at least an intern's level of confidence by the end of that time. At least, I'll find out, starting at 7am tomorrow morning.

Steak and residency

2007-06-15T10:49:00.000-04:00

Captain Jack Aubrey, the chief character in the Master and Commander series I just finished, is a nearly invincible sea captain. He takes undermanned and underarmed ships against nearly insurmountable odds, and succeeds where no one else can. Part of of his success is being able to tell what his opponents are thinking, as he views with practiced skepticism the subterfuge of his opponents. Once off the water though, he is rather more gullible than other men, and at one point in the series he spends nearly his entire fortune on a shady mining venture.

In crafting such singular, but realistic characters, Patrick O'Brian is portraying that facet of our nature which can make even the most cynical man or woman a sucker, given the right circumstances. For "Lucky Jack" Aubrey it was a mining venture. For me, it was the door to door steak salesman.

I view most salesmen with a skepticism I usually reserve for other drivers on the highway at rush hour: generally they want something I have and they're willing to use any amount of deceit to get it. Drivers want my place in the left lane, salesmen want my money. So the pest control guy, the "I'll paint your house number on your curb for the fire department" guy, and the bottled water guy all left my house empty handed. But Joe, the friendly guy from the steak and meats sales company, had a different tactic: flattery. See meat is a bit like wine, in that you can spend a ridiculous quantity of time and effort learning all the cuts, what part of the cow they come from, how best to use them, etc. And if you've devoted just a little time to this, like I have, and someone makes you feel that your knowledge is pretty extensive, like Joe the meat man does, and you have a pretty strong need for affirmation of your intelligence, after say, starting residency orientation that day and freaking out over the fact that you don't remember anything you've learned in the past four years, like I have, then the situation is dynamite. For your wallet that is.

It fairly makes me long for residency, when I won't have time to be at home and get suckered by such tactics. Of course, as I mentioned above, the orientation process, in which we get accounts for the electronic medical records system, sit through lectures on our responsibilities as interns, and get to know our classmates, is slowly driving home the fact that I'm a doctor, and that means I'm going to work harder than I ever imagined possible for the next several years. It hadn't really sunk in until one of the nurses, making sure my N95 mask (for tuberculosis) had a good seal, called me "doctor." Always before is was just a shorthand, or a compliment to my competency as a medical student. Now it is real, and I don't feel ready. I'm just hoping none of my patients know Joe.

Schedule!

2007-06-05T10:17:00.001-04:00

I haven't yet received my official schedule, but my residency program has a online application to check call schedules for the month in advance, and so I've discovered at least the beginning of my year. It looks like I start on inpatient cardiology, which is, as regular readers of my blog know, both my intended specialty and one of the hardest rotations of the intern year. Despite the fact that I want to end up in that specialty, I'm quite nervous about starting there. It's a bit like the first day of school. Except I don't remember Math Expressions being as thick as Harrison's. And Mrs. Simmons was pretty uniformly encouraging.

Looks like I follow cards up with the MICU, so I'm starting with a bang here. A huge part of me doesn't want to embarrass myself and wants to start off with a great impression, but the realistic part of me quietly insists "this is the first month of your intern year. You're going to look like a royal idiot no matter what you do." A major consolation is that my schedule appears to be a bit front loaded, judging from those two months, so maybe the later rotations will ease off. And it also looks like call on cards has gone from q3 to q4, so I might get a little sleep. Orientation starts next week, so I'll find out for sure soon.

Random things

2007-05-30T00:04:00.000-04:00

I was tagged a couple of times in the last month with the random things meme, but given the sporadic nature of my posting lately and the uninspired state of my muse, I'm not sure I can reach eight facts. We'll see.

1. I'll start with the fact that I am now a homeowner. It's a surreal state, to be sure, but a regular paycheck with the promise of relatively certain financial solvency in the future makes me a fairly good candidate for lending money to, apparently. This new purchase actually accounts for much of my silence on the blogging front lately, since there are a myriad little things to be done in a house which can be (and were) safely forgotten in an apartment. My concerns over how to afford a house are somewhat assuaged by the fact that it is an investment, and additionally I won't be around enough to spend any money these next three years anyway.

2. As a continuation of #1, I am inordinately proud of the fact that I managed to put up a respectable set of shelves in my garage, without instructions, manuals, or advice.

3. I meet most of the criteria for obsessive compulsive disorder. Go figure.

4. Despite #3, I still have difficulty closing cabinet doors. I figure, I'm going to open them again anyway, so...

5. This vacation thing is getting old. I may rue the day I said that eventually, but I haven't done anything really taxing in three months. Once residency starts, I plan to work until the day I die.

6. Despite what my mother says, having a good stereo system is more important than having a good dining table.

7. Ditto a TV.

8. I write about two blog posts for every one that ends up being posted lately. Mostly because the lack of inspiration keeps the quality down, and the beautiful weather outside keeps the volume down. Here's hoping I can get back into regular posting despite residency starting (at least the orientation) in about two weeks.

Nathan, MD

2007-05-19T23:18:00.001-04:00

Trust me, I'm a doctor.

Pleasant diversion

2007-05-08T23:06:00.000-04:00

In this, our penultimate week of medical school, the administration has planned for us a variety of classes. Nothing serious or stressful, just refreshers on medical-legal ethics, lectures on how to give appropriate feedback as interns teaching med students, cap and gown distribution, etc. Everything is done by noon, and I think it's mostly a way for our faculty to pull everyone together for one last moment of bonding before we scatter to the winds.

The highlight of the morning came from the feedback/basic educator lecture, in which our learned teacher put up the following slide regarding learning environments, which he called the Starling curve of learning climate as it affects medical students, particularly in lecture:

Then this evening a group of us went to a local pro baseball game, and I was struck with how odd it is to have a classmate from California tell you, gesturing with one hand while the other holds a beer, in between cheers as he tells a story in his very relaxed, almost surfer-dude accent that "this lady had like a lymphogranulomatous vasculitis or something." I realized, again, that all of us are just human, and though we've crammed a ridiculous amount of information into ourselves over four years, and we've changed a great deal in some ways while doing so, we still take that information and apply it with the humanity we brought here, accents and all.

Little to do, little to say

2007-05-03T22:27:00.000-04:00

I'm shockingly unproductive in the blogging sense lately. I think Medstudentitis put the reason quite succinctly in her latest post. If you don't do anything, you haven't got much to say. This is obviously even more true when your blog is ostensibly about one topic and you haven't had anything to do with the topic in weeks.

I have managed to do a lot of reading though, getting through all twenty of Patrick O'Brian's Aubrey/Maturin novels in the past three weeks. When I think how many pages that is, I stop wondering why my eyes have seemed to burn at times lately. But they are absolutely some of the best books I've ever read. I got to the end and wanted to start over. I think I'll read the rest of O'Brian's books first.

And I found a new band, called "A Fine Frenzy", and since they haven't come out with a complete album yet, I'll postpone writing a real review. I'll just mention that going to her website and listening to a few tracks is worthwhile. And if you have iTunes, she has four songs available for download. I have them all.

So that's all for now, hopefully with my last two weeks of classes and graduation coming up I'll have something to write about soon. 15 days to go.

Last Class

2007-04-27T16:12:00.000-04:00

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course,not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

Today was the last academic requirement of my medical school career. It wasn't particularly taxing, simply my final meeting with the professor guiding my last month of reading, but it was rewarding. I had finished reading the two biographies of Osler, along with a volume of his essays and speeches, and then I closed this month of Osler-mania by reading the man's favorite book, Religio Medici, by Sir Thomas Browne.

Much of Osler's writing is directed towards medical students, so in reading his works, I regretted not discovering him sooner. (And if you're a medical student or about to be one, you should drop everything and read Aequanimitas and The Student Life today.) But Thomas Browne is not writing to anyone at all, the work is a sort of confession, as he explores his thoughts on God and life. It is also highly worth reading, and though some parts of it are quite dated, the charitable reader will find much to learn from. Browne was a physician in England, who wrote his book in 1635 (though it wasn't published until later) just before he turned 30. At this point in his life, he had learned 6 languages and studied medicine in all the great schools of Europe. But the book is much more about his relations with God and man than with his profession.

Returning from Browne to Osler, it is easy to see the echoes of the great 15th century doctor in his protege 300 years later. Many of the same thoughts, much of the same style. It is easy, reading him, to see why Osler would state "No other profession can boast of the same unbroken continuity of methods and of ideals. We may indeed be justly proud of our apostolic succession." If the profession is deep, it is also broad, and Osler would say in another place "medicine is the only world-wise profession, following everywhere the samee methods, actuated by the same ambitions, and purpusing the same ends." Both these ideas can been seen, nascently, in Browne.

My question after finishing this three thousand odd pages of reading (two biographies, two collections of essays, and Religio Medici) was "where to now?" Osler brought the "Jovian and God-like" image of the physician in antiquity into the modern era, demonstrating its continuance in a scientific world. But he finished his practice before antibiotics, before most diseases could be cured, and before the era of "informed consent." How does a physician today take the lessons of Osler and transfer them to a modern world? I have reached the end of a class, but not the end of my learning.

My professor's answer was straightforward. Francis Peabody, MD was a member of the generation of medical students growing up under Osler's influence, and he lived long enough to see the new ideas and conflicts start to arise. He wrote an essay called "The Care of the Patient" which at least framed these questions, taking the philosophy of Oslerian medicine and working it into the new world. It is, apparently, worth much more than the famous closing line "for the secret of the care of the patient is in caring for the patient." So I haven't run out of reading material.

5 reasons

2007-04-26T00:49:00.000-04:00

I've been tagged with "5 reasons I blog" by Medstudentitis, so here goes.

1. I started this blog to tell stories. At the time it began, I was discovering that even the most indulgent of friends and family tire of graphic descriptions of hospital life. This was a great way to share.

2. In many ways, sharing the odd and amazing stories that form life in a hospital can seem like showing off. It certainly is an enthralling lifestyle at times, and that exultation can be wearisome to those who do not share it. Here, since I know only the smallest fraction of my readers personally, they cannot think less of me for exulting. And most of you know exactly what I mean anyway.

3. Working in a psychiatry ward, as I was back when this started, can make anyone feel they ought to be a storyteller. However, telling the same story fifty times can be trying, and this was a great way to let all my interested friends get the story without exhausting the teller.

4. As I progressed in blogging, I decided to work through some more difficult issues for me, as a developing physician, through this medium. I certainly learned a lot through writing here, especially the three posts "in sickness and in health," "as long as you both shall live" and "Parenthood" which are linked in the sidebar under "Key Posts". Probably others were just as good, but those are the ones that come to mind.

5. Less of a reason why I blog, and more of what's been going through my mind lately: I've been away from the hospital, in the legendary lull of fourth year medical students, cramming what enjoyment they can into the last few weeks of freedom before we all start actually working for a living, and so I haven't been blogging a whole lot in the last month. I've questioned whether I will start again once residency begins July 1, and if I do, what shape that will take. A commenter here a while ago took exception with one of my posts, believing that I was laughing at a patient's expense. Though I wasn't, it caused me to more closely consider the Hippocratic Oath, specifically the line "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal." I'm not sure how much of what I do, and how much physicians do in general, "ought not be spread abroad." Certainly, there is a rather considerable precedent for blogging about the hospital, but precedent does not make ethics. If there are any medical bloggers out there who have actually made it this far, I would truly appreciate your input on the subject. I'm not worried about HIPAA, as I've very clearly stated multiple times that all names here are invented, but I do think law is a poor substitute for societal moral pressure, and I'm trying to determine where that lies here.

Slowing down

2007-04-23T13:54:00.000-04:00

Osler was a bit of a bore, truly. I got about 300 pages into the 1200 page behemoth of Cushing's work and decided to switch to Michael Bliss's bio, which at 700 something pages seemed more manageable. Cushing wrote to an audience already familiar with Osler, in an atmosphere of hero-worship. Bliss, though certainly not as accomplished a writer, had the advantage of distance in time from his subject, and gave a perspective I could more easily understand. Still portraying a medical hero, surely, but without assuming I already knew why he was heroic.

But as heroes go, I found Osler more demotivating than otherwise. He certainly had an incredible amount of energy and a singular drive to learn everything he could about medicine. And he balanced his pursuits with reading classics and modern literature, so what's not to love? But I think, upon reaching the end of four years of toil towards an almost mythical end, with "MD" on a paper after my name, that I'm a bit demotivated. Certainly, the end is exciting, but I have to re-examine my motivations for coming to medical school. Most of my friends through high school and beyond wanted to go into medicine, or at least we all said we did. I often point to that as the reason I got here at all: peer pressure. Is that going to be enough to sustain me in residency? Time will tell. But reading about Osler, who published over 700 articles in his lifetime, while writing a textbook that would become the standard work for some 50 years, leaves this particular audience feeling inadequate.

But more than just Osler, my motivation for work has been pretty slim. Given the freedom of a month almost entirely without responsibility, I've been desperately visiting all the museums and restaurants the metropolis has to offer that I've missed in the past years while studying. I've been catching up on reading for fun, sometimes combining the two pursuits, sitting outside some particularly interesting animal's cage at the zoo while poring over the Patrick O'Brian novel I'm finishing. (and as an aside, I find that the higher the animal, the more disheartening the sight of them in a zoo. Fish are fine, and the smaller birds seem to enjoy their large faux-jungle enclosure, but I could see in the eyes of an orangutan the same look I've noticed in depressed patients.) All of this has left little time or inclination towards medical reflection.

I have, however, found a place to live at my residency site, begun packing my things, and started the process of saying goodbye to friends, beginning indolently the next step in this journey. 25 days to go till graduation.

Osler on nurses

2007-04-13T23:02:00.000-04:00

As I mentioned a while ago, my current rotation, bringing the fourth year to a gradual, relaxed close, is medical history. I've been reading about Sir William Osler primarily. Osler is probably the most famous clinician of the modern age, and eventually, almost any medical professor will quote him. I am reading about him for that purpose, because despite his fame, I knew nothing about the man before arriving here, and my knowledge was still limited to the quotes heading the various dull sets of PowerPoint slides I've suffered through. When I actually finish slogging through Harvey Cushing's 1200 page biography, I'll write something about that, but since it's been quite some time since I posted anything, I thought I'd put something up.

Osler, I have learned, was a remarkably widely interested and learned man. While a professor at McGill medical school in Canada, he also managed to maintain a professorship in the veterinary school across town, conducting basic research and publishing in both fields, all the while maintaining an amateur interest in microscopic freshwater animals, travelling extensively, and nearly singlehandedly sustaining several professional organizations. (though my source of information is Cushing's biography, which is rather more hagiography at points it seems.) So it is probably unsurprising that a man of such parts should give a graduation address to a nursing school. In a collection of essays I'm also reading, I found the follow example of eloquence which will doubtless be appreciated by the nurse readers here. It may bear mentioning that this address was given in 1891.

If, Members of the Graduating Class, the medical profession, composed chiefly of men, has absorbed a larger share of attention and regard, you have, at least, the satisfaction of feeling that yours is the older, and, as older, the more honourable calling. In one of the lost books of Solomon, a touching picture is given of Eve, then an early grandmother, bending over the little Enoch, and showing Mahala how to soothe his sufferings and to allay his pains...

In the gradual division of labour, by which civilization has emerged from barbarism, the doctor and the nurse have been evolved, as useful accessories in the incessant warfare in which man is engaged. The history of the race is a grim record of passions and ambitions, of weaknesses and vanities, a record, too often, of barbaric in-humanity, and even to-day, when philosophers would have us believe his thoughts had widened, he is ready as of old to shut the gates of mercy, and to let loose the dogs of war. It was in one of these attacks of race-mania that your profession, until then unsettled and ill-defined, took, under Florence Nightingale—ever blessed be her name—its modern position.

The entirety of the address is singularly quotable, which is probably why Osler is so often quoted, but if you are interested in reading the rest of what he said, the full text is here.

How doctors think

2007-04-02T14:00:00.000-04:00

A short while ago, while listening to NPR, I heard about this book, written by a doctor who both teaches at Harvard Medical school and writes for the New Yorker. I bought it expecting a grand revelation, because as I understood it, the purpose of the book is not only to explore how physicians think, but to help them overcome the shortcomings of the heuristics used in practice. The perspective I got was that it was targeted at both physicians and patients.

I was a bit disappointed. Perhaps the fact that I am in medical school, in an environment keyed to understanding exactly the concepts laid out here, makes me more informed that the target audience. Certainly, to a layperson, much in this book might be shocking. But to someone behind the scenes, it becomes a set of anecdotes similar to dozens I've heard in the last four years, interspersed with familiar teaching points: maintain an open mind, listen to the patient, consider all the options. The condemnations are familiar as well: insurance under compensates primary care, insurance doesn't cover enough, doctors leap to conclusions. All of which is true, but not new.

In its defense, the book is probably very good for the moderately informed layman, and rereading the laudatory quotes, I see it is not really intended for a physician audience. Certainly, few patients are familiar with a statistic Dr. Groopman cites early in the book, that an experienced physician reaches a diagnosis within 17 seconds of seeing the average patient. Bon mots like that abound for someone who has seen little or been taught little of the workings of a hospital. And the fact that the author is a writer for one of the better-written magazines of our time is evidence of his style and capabilities with language.

Certainly too, the advice he dispenses to patients may be new, and is valuable. Ask good questions, don't be satisfied with cursory explanations, ask what else besides the diagnosis your doctor has settled on could be the problem.

Overall, I enjoyed the book, but my attention was flagging by the final few chapters as it become clear that the exploration of thought was not aimed at a professional audience. The anecdotes serve as warnings and reminders to me, but no more so than any others I've heard. The exhortations to lateral thinking and open-mindedness are no different than that I've heard from my better attendings. And truly, that probably summarizes what this is: an excellent medicine attending writing out his advice to younger physicians in a format a lay audience can understand. Taken for what it is, on that ground, the book is solid and worthwhile. But fellow med students and physicians: don't bother.

And so it ends

2007-03-26T17:05:00.000-04:00

The next time I introduce myself to a patient, it will be as "doctor." Today was my last clinical day for the rest of my medical school career. And so Mr. Jefferson, who is in his 20s and just discovered he suffers from narcolepsy and sleep paralysis, will be the last patient to have heard me introduced as "a medical student in here today."

I was trying, on my drive home after my shift, to remember the first patient I saw in the hospital, just for comparison. But I can't remember him well. I do remember he was an elderly gentleman, with heart failure and a body suggesting no immediate danger of starvation, but I can't place his name.

More instructive, perhaps, is to try and remember how I interacted with him. I can recall my checklist, the 3x5 card crammed with obscure questions I generally forgot. And I also recollect that I had not yet learned the physical exam, so my three quarters of an hour in his room was solely to gather his story.

Most of what I've learned has been piecemeal, I think. Starting back in first year with interviews, progressing to the physical exam, learned in parts with a classmate first, then practiced as a whole on patients, trimmed under the influence of surgery attendings and residents mocking the "medical student exam" for its thoroughness to a cursory affair, lengthened during medicine, and focused when my knowledge expanded sufficiently. I remember first year, picking up a copy of the New England Journal of Medicine, forcing myself to read through an article, understanding half the the words at most. Now I can pick up that same article, and at least understand 95% of the words, usually I can follow the concept, and I'm beginning to think how I would apply that article to my own practice.

Though it is still scary to think of calling myself doctor, to think of being a doctor, to make life and death decisions, it is easier, thinking how far I've come.

The next two months are pretty laid back. A month of reading medical history, and a month of "transition to residency" classes. Then graduation, vacation, and the specter of July 1.

Amy Winehouse - Back to Black

2007-03-23T12:05:00.000-04:00

There's a lot to be said for the beer test. As in, which of two people would you rather sit down over a beer with? Certainly this factor played some role in the last American presidential election, though whether of not that was good is completely inseparable from political presuppositions at this point.

But enough about politics. Here's the question for this review: given your choice between the following attractive, brunette, female, Jewish, pop musical stars, who would you rather have a beer with: a)Regina Spektor or b) Amy Winehouse? Now the smart money's on Spektor, because if the British tabloids are to be believed, Winehouse would probably finish off a case, and then belt you over the head with a bottle, just for the hell of it.

But to make judgements on such grounds is not always the best course of action. And just listening to this latest offering from Winehouse is enough to make me want to write a review of it. It's the sort of music that makes me want to use trite music review words, like "rollicking" and "infectious." But I'll refrain.

The music is obviously influenced by Ray Charles and his contemporaries, that era where jazz could still be heard beneath the rock. But there's a modern edge too. So yes, saxophones, piano, and a nod to Phil Spector on the production, but we've got drum loops too. And her voice is pure soul.

There are on iTunes the "Explicit" and the "Clean" versions of this record, which should tell you something about the lyrics. But either way, when the first words on the album are "they tried to make me go to rehab, an' I said no, no, no" you know this is probably not a girl you take home to mom, no matter how poetic she is. She is poetic though, and clever too, stating in the title track "we only said goodbye with words," implying the end of a relationship that was more. In "I'm no good" she is frank about infidelities of her own.

This is the blues, and Winehouse is writing what she lives. But it's hard not to hum along, and it's that invitation to share in her musical catharsis which makes this a great listen.

More from the ER

2007-03-22T17:52:00.000-04:00

I've discovered that some traditional rumors are false. Surgeons are supposed to be very difficult to consult and intimidating to talk to. But I've found that if you know the basics of your patient, and have a legitimate question, they are fine. The tough ones to consult are neurologists, or cardiologists. Surgeons basically want to hear "belly pain, blood in rectum, pulse." Cardiologists want all sorts of labs, and an exquisitely detailed accounting of the nature of chest pain before they deign to descend to the ER. At least in my experience. And this is from someone who wants to do cardiology. And neurologists? Oh, boy.

About ten days ago I consulted neurology for the first time in this hospital. The patient in question was experiencing severe pain in her hands, in a median nerve distribution. The pain had come on quickly, with no inciting event, and my attending and I were at a loss to explain it. She was a bit hyperreflexic on one side, at least in the large tendons, though I didn't check the Babinski reflex. (more on that later) She had no surgeries, no neck pain, no trauma. X-rays showed no fracture. Lab values all normal, except for an elevated ESR. The pain was, in the patient's words, as bad as labor pain. As she was crying and rocking back and forth while cradling her arms, I believed her.

At this point, I wanted to call rheumatology. There was some distal clubbing, and I was ready to start a scleroderma workup, but my attending wanted a neurology consult first. So I called the neurologist, and gave him my presentation.

I got reamed. The neurologist was not, to put it mildly, having a good day. The first words out of his mouth were "tell me a story and get in line." And at every point in my presentation, he either swore under his breath, or rattled off lists of obscure eponymous neurological tests that I should have performed. When I stated that the patient was bit hyperreflexic, but that I hadn't checked her Babinski, he reached boiling point. He spat something about "this case being completely inappropriate for an ER consult," and then got very silent. I finished my presentation quickly and asked if he had any questions, and received the reply "nothing pertinent!" When he got into the ER (seven hours later), he didn't speak a word, even to the attending, saw the patient, wrote admission orders, and disappeared. I still have no idea what he thought the patient had, and I thought this was one point at which I probably ought not let curiosity guide my actions.

This is my chiefest frustration with emergency room medicine. The concern is, in the words of one of my attendings, "to make sure the patient doesn't have the five worst case scenarios possible with his symptoms." Often, it isn't even that many. Once we rule out the two or three quickly diagnosable possibilities, we move the patient either back to the street or upstairs, where the real problem solving begins.

Obviously, I'm not destined for the ER. Good thing I matched to internal medicine, eh?

Ah, yes, Match Day

2007-03-15T19:34:00.000-04:00

I was hired by my first choice residency program. Much exultation occuring here today. Even the crazy patients in the ER can't dampen this mood.

The truth is out there

2007-03-14T21:48:00.000-04:00

Tonight I had a patient who told us all he had Morgellons disease, a completely factitious disorder in which the patient has sores on his body from which he believes "fibers" can be extracted. These can vary in type, depending on the patient, with some believing they are organic fibre (cotton, etc) others believing they are actual worms. Apparently, some patients pull tiny bits of their own bodies out (muscle, nerve, connective tissue, etc.) in the desperate attempt to remove these foreign bodies. Some of the literature refers to a "positive matchbox sign," meaning the patient brings in a matchbox full of fibers he believes he has extracted from his body. Our patient believed he had worms in his body, and was very upset that we didn't believe him.

The difficulty with this disease is that these patients are undoubtably sick. Healthy, sane people, do not tear their own bodies to pieces seeking imaginary worms. There actually is a DSM-IV diagnosis which covers most these patients: under the delusional disorders is delusional parasitosis. Like any delusion, this is a powerfully fixed false belief, and patients refusing to believe they have a psychiatric diagnosis is probably the reason for another term for the condition. At least one article* (of the six total I could find in the medical literature) accepted the name Morgellons disease as a "a rapport-enhancing term for delusions of parasitosis." This article, in the finest rational skeptical language, mentions the fact that "Morgellons disease is not located in modern medical texts or online journals. But a Goggle search will produce approximately 15,400 hits." The author describes a patient he had claiming to have the disease, and mentions that he used the term with her to great effect. He also mentions the hub of the hype, a website which looks very scientific, but which is rather light on evidentiary support. His cautionary closing remarks: "we stress the importance of clarifying to all delusions of parasitosis patients that their condition is not a result of an infectious agent. However, we found the term to be of paramount importance in establishing patient confidence and in developing patient–physician rapport throughout this patient's care."

These patients need psychiatric care, and long term anti-psychotic therapy, but in our patient, we couldn't get him to understand this need. Since we lack inpatient psychiatric capability here, we transferred him to a larger, long term care facility.

So why the alien picture? There are some crazy, crazy theories out there regarding Morgellons disease, revolving around secret government labs and strange escaped biological experiments. And I can see an episode of the X-Files (back in the first few seasons, when it was good) with Scully insisting these patients are psychotic, while Mulder, playing fast and loose with the rules of evidence, agency conduct, etc, sneaks into some Area 51 clone in rural Tennesse, and is captured by a pair of unsmiling guards just short of opening a drawer marked "Top Secret: Morgellons." The truth is out there. Until we find it though, use risperidone.

*J Am Acad Dermatol. 2006 Nov;55(5):913-4.

Ugh...nurses

2007-03-13T18:37:00.000-04:00

So today I had a rather poor experience with one of the ER nurses. I grabbed a patient's chart from the rack, headed into their room, and had started my history, when the new nurse coming on shift decided that was the best time to perform an assessment on that patient. Nevermind the fact that she had three other patients to see, and could certainly have waited on mine. So, in the middle of my history, this nurse comes in and starts rattling off unrelated questions, listening to the patient's heart and lungs, telling the patient to be quiet right after I asked a question, generally making a nuisance of herself. I finally had to leave, as it was impossible to continue the exam with the nurse in the way.

Now I will grant that I am only a medical student, but in 66 days I will be the doc, and I'm going to ask such interfering persons to kindly permit me to finish my exam before they get in the way. I'm not trying to be mean, we both have jobs to do, but since neither of them are emergencies, is it too much to ask that the nurse wait to perform her assessment until after I've finished with mine? I think not.

On the plus side, I had the opportunity to teach one of the techs a few things today as well. A patient of mine needed an EKG, and as I was in the room reevaluating her when the tech came in, I stayed to see the EKG when it was done. As it turned out, the tech had only done three EKGs before, and so I answered her questions on how to set up the leads, and then showed her some basics of reading the results as they were printed. I realized (again) that I love teaching, and I hope to make that a huge part of my practice in the future.

Stories

2007-03-12T11:17:00.000-04:00

We are no other than a moving row
Of magic Shadow-shapes that come and go
Round with the Sun-illumin'd Lantern held
In Midnight by the Master of the Show.

The ER, on the last few busy days, has been much like any other rotation, but sped up. I imagine the kind of physician who is attracted to this specialty is the kind with a shorter attention span than most. No matter who it is, they certainly all have a healthy sense of defensive medicine. So for instance yesterday, a man and his son came in together. The dad was worried that they both had pneumonia, despite having no symptoms except those of a typical cold. The son, through this interview, was active enough to begin (like any good five year old) the destruction of the triage room. Obviously, he was oxygenating just fine. But my attending insisted on getting chest x-rays for both dad and son. His explanation was that, in the last conference he went to, there was a presentation on malpractice, and the speaker made the point that patients come to the doctor for the show, and if you can do something to make it look like you're doing something, even if they don't need it, they are less likely to sue you. Maybe that's smart, but I wouldn't have x-rayed them. Radiation isn't benign either.

The next patient was a little 2 year old who fell off something at his day care, landing on his arm, and was now complaining of elbow pain. We checked it out, felt a click when manipulating it, got some x-rays, and settled on a diagnosis of nursemaid's elbow. So we applied the textbook treatment for it, heard a click, and gave the kid five minutes to recover.

He didn't improve, and still held his arm like it hurt. We tried twice more to reduce the injury, with no more luck. We paged orthopedics. They tried four times. Finally, we decided to get full arm and shoulder x-rays, and discovered a Salter-Harris type IV fracture of the humeral head. Lesson learned? That back in second year clinical labs, when they told us to x-ray the joint above and below an orthopedic injury, they weren't kidding. Also, just because a two year old tells you his arm hurts while pointing to his elbow doesn't mean his elbow is what he means. The kid got a sling, a bunch of stickers, and congratulations from the ortho team for playing hard.

I also saw one patient who made me question my choice of specialty. A first time mother was concerned about a rash her one month old daughter had. The kid was fine, just a little baby acne, but kids are cute, and healthy ones more so. The mom was the second mother to look crestfallen when I told her I was not going into peds. But I steel my resolve with the memories of Sarah, the first peds patient I had on my inpatient rotation. For whatever reason, dealing with adults facing death is much easier on me.

And I'll close with a word of advice. If you come into the ER complaining of fever to 100.5 degrees, for which you have not taken Tylenol, and have no other complaints, you are not allowed to complain when you wait 4 hours to be seen. There are actual sick people in here.

The ER

2007-03-09T19:08:00.000-05:00

I've begun a new rotation, the ER. As can probably be surmised from my lack of posting, it has not been eventful. I made the decision, a year back when my class went through the rotation-picking-lottery, to use the good number I got for this rotation to go to a small, community ER that is closer to my apartment than the inner city monstrosity where I did my SICU rotation.

This may have been a bad decision. Though I most decidedly have easy days, and I'm within cycling distance of the hospital, nothing happens.

Nothing.

I've spent hours at a time reading, waiting for a patient to show up. While this may help my book knowledge, I feel my physical exam and history taking skills are rotting through inactivity. About the most intense thing that happened today was a medicine resident getting paged out of the ER to a code. I wanted to go with him, because it was certainly going to be more entertaining than this.

So (despite my feeling bad for wishing pain and suffering on the world) hopefully this is just a slow few days, and things will pick up. But with the attending I've had for the last few days, that might not even make a difference. A lady came in today who needed sutures, and he did them rather than let me. *sigh* Only three more weeks.

Two lighter notes, and an odd one

2007-02-27T21:13:00.000-05:00

My Dansko clogs arrived today, and now, for whatever reason, I feel more like a house officer. The fact that I'm bouyed in spirits by the arrival of shoes amuses me. Also amusing is the fact that my choice of styles was limited by the large size of my feet.

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.

Every accidental crack

2007-02-27T17:17:00.000-05:00

There, on the mountain and the sky,
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.

SICU

2007-02-26T21:05:00.001-05:00

The pleasures of heaven are with me, and the pains of hell are with me,
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.

Good nurse, Bad nurse

2007-02-24T13:09:00.000-05:00

Given the past popularity of my posts about nurses and nursing, I thought it best to break my week-long posting hiatus with another one. Fortunately, I have two stories to tell.

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 ~~nurse~~ angel assisting me noticed this before my attending did though, and rather than letting me look like an idiot, or even helping me out obviously and revealing my idiocy, she just asked "did you want a larger cover dressing?" Though I admit this doesn't prove anything about her ability, this reminder saved the day. Thank you, Florence.

Mr. Smith, part two

2007-02-16T15:11:00.000-05:00

In response to some concerned commentary, an update. Against most the odds, Mr. Smith is still alive, though he's making trips back to the OR roughly every other day to stop bleeding. No-one expected him to make it this far though, except, just maybe, that priest. We'll see.

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.

Development

2007-02-15T15:21:00.000-05:00

Mr. Thomas is not doing well. He was admitted to the ICU because the surgeons taking care of him thought his atrial fibrillation was beginning to give them difficulty managing his blood pressure and heart rate on the ward. About two hours after being transferred to us though, Mr. Thomas proved the surgeons wrong by going into septic shock, taking several days to recover. Now he has two problems, which have taught me another rung on the ladder towards being a doctor.

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.

Memorable quotes

2007-02-15T05:21:00.000-05:00

My apologies for not having the energy or concentration necessary to string a story together just now. The SICU has been, as ICUs can be, quite busy over the past week or so. So just a few quick anecdotes I found amusing lately.

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.

Fearfully and wonderfully

2007-02-11T22:16:00.000-05:00

...The dance along the artery
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.

Another day

2007-02-08T18:29:00.000-05:00

Mr. Smith, a young man in his twenties, with a wife and small child, came to the doctor about two weeks ago, concerned that his fevers and chills at night, accompanied by some swelling in his neck, were signs of something serious.

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.

Good nurse, bad dietician

2007-02-07T20:09:00.000-05:00

The battleaxe of the SICU is an elderly female nurse who, I am convinced, thinks smiling or cheerfulness is wrong. Or maybe she thinks they are good, but just enjoys being wrong herself. Anyway, she has steadfastly refused to smile or make any effort to appreciate levity on my part.

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?!"

"Not yet."

"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.

Patients say the darndest things

2007-02-06T16:24:00.000-05:00

Apologies to Bill Cosby. One of my patients was wheeled into the SICU this afternoon still quite groggy from the anesthesia. Midazolam, which had been given to this patient, acts on the same receptors in the brain that alcohol does, and some of the effects are therefore similar. The effects we want are the amnesia and the sedation, so patients don't remember what happened, and they are pretty sleepy, even without the more powerful drugs that knock them out. But after those drugs have worn off, the effects of the midazolam often linger. And the side effect which makes this humorous is the disinhibition.

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.

I was prepared for every question, except that one

2007-02-05T18:23:00.000-05:00

I don't know what other people see when the walk into an ICU. For a medical student starting third year, the way I used to see it closely approximated Mark Twain's definition of adventure (we're on a Twain kick this week): long hours of boredom punctuated by moments of stark terror. As my exposure to and familiarity with the environment has grown over the past years, I've started to develop a sense for the vast coordinated effort that goes into running this operation. Vast amounts of data, very ill patients, and the inconstant stream of relatives: sad or mad, directive or pleading. But always before I was only there briefly, to pick up or drop off a patient, or to round postoperatively and very quickly.

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.

Drugs

2007-02-03T22:13:00.000-05:00

I just recently found this hilarious picture via Kevin, MD, which is a shot of Pharmaceutical Rep Barbie. And it reminded me (since, thankfully, neurosurgery is over and I don't have to think about it this evening) of a lecture I had a while back from one of the cardiologists I have worked for. Great guy, ridiculously intelligent, and coiner of some of the all time greatest hospital aphorisms. Anyway, he was talking about drug reps, and how they get doctors to prescribe their medications. Strategy number one, said he, is the "Catherine Zeta-Jones Approach." I'll attempt to recall the way he described his first exposure to this phenomenon:

"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.

Both Sides Now

2007-02-01T18:35:00.000-05:00

One of the more interesting opportunities afforded me in the past few months has been the task of interviewing prospective medical students. The experience has been illuminating. I've learned a few things about how to interview, and vastly more entertaining, I've learned some prime lessons about how not to interview. So I offer a few bits of advice to the prospective medical student interviewee.

* * *

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.

Shaka and Surgeons

2007-01-29T20:55:00.000-05:00

I have read (though it may not be true) that Zulu fighting regiments killed their own wounded if they were no longer able to keep up with the relentless pace held by the impi. And relentless it was. Zulu regiments would cover 100 miles over three days of campaigning, with a large battle thrown in there somewhere. The point here though, is not military history. The point is, anyone who doubts this capacity to turn on one's own, those who have fought and endured beside you, has never sat in the surgery intern's call room in a large hospital while the occupants discoursed on their brethern.

It is often true in surgery programs than not everyone makes it. Many programs accept more interns than they intend to graduate, realizing that not everyone can hack it. This used to be institutionalized, with the programs stating up front that they would not allow all the interns to progress, turning the already stressful intern year into a competition between, say, eight hapless souls for five spots. Thankfully, this is now illegal, but still, surgery programs do not have a 100% graduation rate.

As the interns warmed to their subject, they became very specific, pointing out the faults or strengths they saw in their classmates who had dropped out, or even in the residents and staff ahead of them. Most of the faults were unsurprising, and it was fascinating to see how willing how willing these doctors were to forgive almost any fault in someone decisive and thick-skinned. Dr. Neversmile, for instance, came up and was "pretty damn talented" or "gotta respect him." Even my former chief resident, aptly decribed by one of the interns as having his "default set to hating people" was not castigated further, because he is a "solid surgeon." But one of their classmates who dropped out was described in language that was ridiculously over the top. I've never met the individual, so I can't speak to the truth of the calumnies, but as soon as they all agreed that this person was "not decisive" and "thin skinned" anything was fair game. (full disclosure, the single vulgar word used for "thin skinned" was one I am not real comfortable typing out.)

The strongest language denouncing another resident I heard in my residency of choice was "weak." Medicine is a very intellectual specialty, so there is a lot more emphasis on thinking than on action, but more essentially medicine docs are not as "cool" as surgeons. Now medical school isn't exactly a random sampling of spectators at TRL, but there are always people everyone wants to be around, people everyone else wants to be like, people for whom an easy atmosphere of hip collegiality comes naturally. The kind of guys who can do those complicated handshakes without thinking about them, or looking awkward. At least, so it appears. And most of these people seem to wind up as surgeons.

Medicine is like high school, and you've got all the groups. Surgeons: the cool kids. Ortho: the football team. Nephrologists: the chess club. Neurologists: the Dungeons and Dragons kids. Ob/Gyn: the stuck up cheerleaders.
- a surgery resident

So it makes sense, to my mind, anyway, that the qualities praised in internists are different than those praised in surgeons. And it also makes sense that those who don't quite fit in, who are a bit more self-conscious, don't last long in this environment.

Though I've managed to get along with the residents here, sharing musical tastes and movie quotes, it has been an effort. And I'll be glad to move on. Tomorrow is my last full day here, and I won't be sad. Despite the stories, and the atmosphere I've attempted to convey, I haven't learned a great deal. At least about neurology.

The Weepies - Say I am You

2007-01-27T15:36:00.000-05:00

It's been a while since I've written a music review, largely because I've been too busy either having fun on vacation or working 14 hour days to listen to much music. But after getting out of the hospital early yesterday, I celebrated by going to Borders and picking this album up, on the recommendation of several friends over the past few months.

I must say I am impressed. These guys (guy and gal, rather) toured with the Indigo Girls last year, and it's easy to see why. Largely acoustic, with tight harmonies. The guitar work, notably on "The World Spins Madly On" is very Indigo Girls in style. However, my limited exposure to the Indigo Girls gives me the impression that they are a lot more sad than the Weepies. Here we're mostly hearing stories about love, requited and not, but even the sad songs aren't devastatingly so. The music makes you feel that, despite the hurt, there is light around the next bend. Contrast, for example, the Indigo Girls' "Closer to Fine" which despite the driving chords and thrilling harmony is shattering philosophically.

Though the Weepies may not be saying anything new, you have to love the way they say it. The chorus from "I've Gotta Have You" has been stuck in my head all day, even when listening to the rest of the album. "No amount of coffee/No amount of cryin'/No amount of whiskey/No amount of wine/Nothing else will do/I've gotta have you." The rest of the album continues in this vein, clever lyrics, pleasant harmonies. Song you feel along with.

Recommended.

Oops

2007-01-26T19:48:00.000-05:00

Q. How do you hide a $100 dollar bill from a surgeon?
A. Put it in a book with no pictures.

Q. How do you hide a $100 dollar bill from an internist?
A. Put it under a dressing.

It's meant as a joke, of course, but there's a bit of truth to it still. And I'm ashamed to say, I lived out the second half of it today. Last night I did a post operative check on a patient who had spine surgery. And I'm getting into the swing of neurosurgery, so I check his reflexes, muscular strength, etc, which is all they really care about usually.

Except this patient was a bit different. Because of some special conditions with his surgery, he had a drain sewn into the wound, one which was important to check. So this morning, on rounds, my chief asked "how much did the drain put out?" My only answer could be "I don't know, but I'll check." So the intern and I dropped a few notches in the estimation of our team. The problem is, we hadn't known to look for a drain, because there had been no mention of it in the operative note. Not an excuse, but it showed how mistakes get propagated up the chain. Fortunately, the patient was fine.

So, this afternoon I was asked to do another pre-op check. And to ward off any reminding corrections, I said "sure, I'll do it. And this time, I'm stripping the patient naked before I write the note."

This guy didn't have a drain. But I won't make that mistake again.

I hope.

This is Neurosurgery

2007-01-24T18:01:00.000-05:00

I walked into an operating room shortly after 8am this morning, to a case which was already in progress. And when I left the hospital, thirteen and one half hours after arriving, only after the insistent "seriously Nathan, you'll have plenty of long hours later, go home and get some sleep" from my resident, the case was still in progress.

This patient, Mrs. Walker, has an acoustic neuroma, an overgrowth of the protective layer of Schwann cells around her eighth cranial nerve. The nervous system is much like any electrical system, and it needs insulation. So, just as the average copper wire has a coating of plastic around it, our nerves have coatings, made of fat. And around the eighth cranial nerve, CN VIII, the vestibulocochlear nerve, this coating is made of cells called Schwann cells.

Mrs. Walker's Schwann cells have been growing more than they need to for a long time. And as they have grown, since CN VIII is inside the skull, they have run out of room and started to squeeze the nerve, and the rest of the brain. Obviously, this is not good. It also happens to be the job of neurosurgeons to fix.

The initial portion of the case involved starting anesthesia and then laying the patient on her stomach, with her head tilted to one side. Then, through an incision behind the ear, a section of the skull was removed. Then, in one of the best demonstrations I've yet seen of the delicacy and absolutely steady hands necessary to be this kind of surgeon, a microscope was moved into position and the cerebellum was gently retracted out of the way about a centimeter or two. Through the space created, the chief resident and a staff neurosurgeon began gently separating the tumor from its surrounding arteries, nerves, and bone. Though it takes only a paragraph to describe, by this point it was 1PM. The tumor was carefully resected from its surroundings, preserving the nerve running right down its middle.

Then things got complicated. Another surgical team, from otolaryngology, came in to ensure there was no tumor involved with the facial nerve, and to do so, they needed to shift the position of the retractors holding things open. And as they did that, some of the petrosal veins tore. These are tiny, tiny vessels that run from the superior surface of the cerebellum to the superior petrosal sinus. That sinus is labelled at about the 7 o'clock position in the image to the right. There are two problems right away with this. One, veins do not clot off as easily as arteries, so while you bleed faster from an artery, the body will do its best to stop that bleeding. Not so the veins. (at least to some extent) The second is that, with the incision where it was, these veins are behind the edge of the petrous temporal bone from where we were looking. Imagine using tweezers in a hole 3 inches deep, looking through a microscope to see the nerves you are dissecting, and suddenly, a minor emergency occurs around a blind turn at the end of that hole, forcing you to work quickly and accurately on microscopic vessels you can't see around that turn. The next approximately nine hours were consumed with attempting to fix that bleeding. The bleeding was eventually stopped by clotting it with Gelfoam. Then it was time to put everything back, close the incision, and head home. The surgeons were there in the OR until 11PM.

It was thrilling in a way, to see most of this operation and the deliberate haste with which the surgeons worked. At the same time, I realized that, despite how late they were working, all of these guys would be back in the hospital at 5am the next day to start all over again. I could never do this job. I don't mind long hours once in a while, and I defintely signed up to do medicine knowing I would work more hours for less monetary compensation than almost any other educated profession, but I'd like to have a life, someday. And I think, to have a life outside the hospital and be a neurosurgeon, you need to redefine "life."

And now, a moment of Zen

2007-01-21T21:30:00.000-05:00

I was going to say, "shamelessly lifted from someplace I can't remember," but there's the email address for you. Send the guy some kudos.

An obstetrical memory

2007-01-20T21:30:00.000-05:00

I don't know when I first recognized it, but I like jargon, the peculiar set of words that grow up to shroud or nourish a particular field. Hence, in college, I would laugh along with the engineers' obscure cracks about heat transfer, and the hackers making obscure puns on the distinctions between grep and grok, peppering their conversation with quotes from the immortal tomes of Douglas Adams, all the while meandering towards my own degree in an unrelated field.

Perhaps this explains why I find blogs about the humor in child raising funny, though I have no children of my own. (Not likely to soon either, but that's another story, boiling down to "got to find the girl." I digress.) I also found this article in Slate hilarious and intriguing, despite only ever having been on the other side of it. I'd like to think the hilarity is just the author's style, but the intrigue is in the point of view I didn't get in my time on OB/Gyn.

He discusses the doctor-doctor interaction, handing off the patient who is his wife with this wonderful passage:"Tabitha's doctor collected information from the doctor on call, in the way doctors do. They spoke for maybe two minutes, in English as intelligible as their handwriting."

And then, in a paragraph I like because it reflects a lot of my own feelings on medicine:

Tabitha's doctor is maybe the least likely obstetrician in Berkeley, Calif. He doesn't believe, for example, in the sanctity of his patients' whims. He has no time for superstition; he is unapologetic about his belief in the power of modern science; he believes that the best way to endure childbirth is not out in the woods surrounded by hooting midwives but in a hospital bed, numb from the waist down. He is, in short, my kind of guy.

As a resident of mine on my obstetrics rotation put it, "there's nothing wonderful about 'natural childbirth.' People died in natural childbirth, that's why there are doctors." I do know more than a few people who are fans of natural childbirth, but while (being bound for internal medicine) I'm a little more understanding of the sometimes inscrutable whims of patients, this is one I don't think I endorse. Life is painful enough sometimes.

The passage I quoted above reminded me of a patient I saw on my obstetrics rotation, who is the reason I don't like doulas. She was pregnant with twins, and had a history of several prior births that had not gone well. Her children had all been born drastically prematurely, and as a result suffered from a variety of congenital ailments. Because of her history, she had a cerclage placed, though when I first saw her, she had finally reached term, and had that particular apparatus taken out. Here is where it got complicated. She had been discussing her situation with a doula, and this non-medically trained individual convinced her it would be a good idea to give birth at home, despite her history of tragic pregnancies, and the fact that she was carrying twins. And to complicate the matter further, the final ultrasound I saw her get showed the twin closest to the cervix was smaller, and the second was breech.

When a woman gives birth to twins of different sizes, the order in which they come out has a powerful influence on the ease of the birth. If the larger twin comes out first, the second delivery is relatively easy, as the cervix and canal have stretched already. If the smaller one comes out first, the second will involve more laboring, and chances for things to go wrong, such as prolapse of the umbilical cord with concomitant asphyxiation of the newborn. This patient was set up for failure.

The next weeks were tense, as every night the patient's story was related, "just in case" she changed her mind, or showed up on the ER door with a kid halfway out of her and in extremis. And about a week and a half later, she did show up, doula in tow.

She had tried to give birth at home, and finally her screaming had gotten to be too much for everyone involved, who dragged her onto the labor and delivery deck at about 2am, probably waking the entire population of the hospital. As I went into the triage room, I was genuinely concerned someone was dying, because of all the noise. My resident was right behind me and it took a total of about 2 seconds to decide to take her to the OR.

We did manage, in the OR, to start an epidural, and then we tried to deliver the kids vaginally while waiting for the staff doc. He arrived minutes later, and began to prep for a C-section, just in case. Through the whole delivery, I heard absolutely the most foul language imaginable coming from the doula and her charge, our patient. Evidently the epidural didn't have time to kick in before the kids were coming. It was positively distracting, and my resident reflected later that it was a pity the first word the kids heard was a vulgar reference to their conception. The second child had to be delivered with forceps, and that wasn't pretty either.

The whole team came out of the delivery pretty exhausted. The doula had disappeared. My attending turned slowly to me and intoned "well I hope you've learned why natural childbirth is overrated."

Oh I have. I most definitely have.

5 things you don't know about me

2007-01-20T15:20:00.000-05:00

I've been tagged by Zwerver with this "5 things you don't know about me" thing, and I'll admit, it is tough. The reason for this is that, being a bit of a private person, I usually reveal on this blog just about everything I'm comfortable with telling the world. And I've been trying recently to keep more closely to the subject of medicine. However, I'll attempt to foster the congenial spirit of the blogging community and come up with five things. Hey, it's my day off, and the apartment is almost clean. To help, I'll assume the target "you" is someone like Zwerver, whom I've never met.

1) The greatest struggle I face in maintaining an attitude of Christian charity is when I'm behind the wheel of a car. Seriously people, drive like you mean it.
2) I never said a "bad word" and meant it until I took physical chemistry from the one devout Christian professor I ever had.
3) I'm excited about finishing medical school in large part because it will be the only difficult thing I've stuck with long enough to accomplish.
4) I want to build a ship in a bottle.
5) I took five years to return a book once. I had to FedEx it nearly two thousand miles. Sorry, Steve.

Role reversal

2007-01-19T19:21:00.000-05:00

In 119 days, I will be Dr. Nathan. At that point, I'll have to start teaching med students and passing on what little knowledge I already have. As Dr. Lest said a few days ago, if we don't teach those behind us, there will be no doctors eventually.

So today I had an opportunity to warm up to this, and I may have learned more than he did. There's a third year med student on my team, and today I delegated two patients from my load to him, to examine and write notes on. And being a third year, he did some pretty bad exams, and wrote some pretty bad notes. Here's where I made my mistake. As the next guy up the chain, it really is my responsibilty to make sure his work is as good as I can make it before I pass it up the chain. But I didn't. I let his notes get passed on to the intern without correction. And later, when the third year was off doing something else, the intern started telling me what he thought of his notes.

In a scientific profession, a great deal of your collegue's opinion of you is formed by your writing, and muddy reasoning doesn't win you friends. Not here anyway. And once you get off on that track, any quirk or slip becomes fodder to form a progressively worse opinion. So after the notes fiasco, I'm afraid my third year has a long uphill fight to get a good grade. The plan, according to my intern, is to "ream some sense into him. The way you learn is by getting chewed out, so you don't make the same mistake twice. If that guy doesn't hate me by the end of this rotation, I haven't done my job."

See you run into this type of person a lot in medicine, at least (and especially) in surgery residencies. They aren't bad people, per se, they just have a very hostile attitude and a firm belief in the wisdom of imparting wisdom through beatings. I'm not one of them, but I should have seen that coming.

But on the other hand there is some wisdom to what he said. By this point, he should be able to write a good note. And in residency, you have to be able to put up with a lot of drudgery and thankless work to take care of patients. Though it is often minutiae, the minutiae matter in medicine. Even the easy going guys know this. Another, much more chill intern, when discussing his plans for teaching next year when he is a resident, said "really, your interns should be terrified of you for six months. Otherwise they won't be conscientious enough."

I guess in the long term, the most important thing is that the med student/intern/resident takes care of their patients without hurting them. But I think a close second goal is preserving peace between us all. The universe is a big enough enemy most days in the hospital, without creating more.

I think I'm a tolerable teacher, but now I have a twofold motivation to be better. One, making good doctors out of those behind me, and two, equipping them them to avoid the pain of getting chewed out by others with more punitive styles.

So, third year, let me show you how to write a note...

Coffee Thoughts

2007-01-18T20:48:00.000-05:00

The morning cup of coffee has an exhiliration about it which the cheering influence of the afternoon or evening cup of tea cannot be expected to reproduce.
- Oliver Wendell Holmes, Sr.

Wise words from a physician gone before.

Faking It

2007-01-17T20:17:00.000-05:00

Neurology grand rounds today discussed a patient who is experiencing pseudoseizures. In other words, he's faking epilepsy. But it was absolutely the most informative and interesting learning I've done yet on this rotation.

This patient has obviously done some reading on epilepsy, as he starts out his pseudoseizures correctly, but as he progresses he makes mistakes. He was being monitored in his room with a video EEG, which, as the name suggests, films the patient while recording his brain's electrical activity. This is later reviewed, either by his physician, or a roomful of them, like this morning.

When I first watched the video, I thought I was seeing a real seizure, but as the discussion continued, and the tape was rewound and watched over and over, the points in question came out. This patient attempted to simulate decorticate posturing, but he probably read a definition like the one I linked to there, which doesn't say how the arms are twisted. He was supinating his forearms, while pronation is more common. Also, he made thrusting motions with his extensor spinae muscles, rather than the usual fixedly rigid posturing. Ten or fifteen other tiny details were discussed and analyzed. He was moving rhythmicaaly when he shouldn't be, and was fixed when he shouldn't be. The EEG didn't match epilepsy either, and displayed only motor activity. There were no rhythmic cycles in it, and some leads showed almost no activity.

So the staff started asking the residents questions about management. The funniest proposition was from a first year who said he would announce in a loud voice "if this doesn't stop, we're going to have to use rectal diazepam." After the laughter died down, he was gently reproved to use more compassionate techniques. Several different ideas were discussed, and I found it thrilling, in a way, to sit down in a room full of super intelligent people and discuss, essentially, ways to trip up someone who is lying to you, without letting them know you know he is lying.

The staff concluded with a remarkable set of points. First, he said, we have to remember that this patient does indeed have a disease, it's just not epilepsy. And second, we can't let on that we think the patient is faking it, because it won't help his behavior. On the contrary, he'll just try harder to convince us. And in the end, our goal is not to flaunt our intelligence over this poor guy, it's to help him get better and go home.

Time to consult psychiatry.

Peds Neurosurgery

2007-01-16T20:32:00.000-05:00

Roughly a month ago, a boy named Jay was born with a prosencephalic defect. (I couldn't get a straight answer from the neurosurgeons, one telling me it was something between prosencephaly and holoprosencephaly, and another that it was sort of like holoprosecephaly. I could try and figure it out, but I'm lazy, and I have to study more neurology. Anyway, to return.) After an insult to his development very early in gestation, his brain stopped developing in the way it is expected to, and began to force his brain outside the confines of his skull, so that, at term, his CT scan looked something like the picture to the right.

Enter Dr. Lest. Aside from being one of the nicest people I've ever met, and remarkably personable and witty, he specializes in pediatric neurosurgery. He combines the personality of a pediatrician with the skills of a surgeon. Enheartening to watch. Exempli gratia, today he was speaking with Jay's family, and one of them expressed surprise that, except for the defect, he looked and acted like a normal newborn. The good doctor's reply: "I know, he's cute as a button, isn't he?"

So today was this child's surgery. If you look at that CT scan from the first paragraph, you can see that the brain is quite thin along the top of the skull. With Jay, the thin part protruded much farther from the skull, and there was actually no bone over the defect. It was essentially a fontanelle about 4cm across. So the plan was to remove some of the skin, drain the excess fluid off the child's brain, and reconstruct the skull to allow more normal development.

The surgery took 5 hours. First the chief resident and Dr. Lest removed a strip of skin over the hole, then they incised the dura over the area, sparking a tiny fountain of CSF for a few seconds. Then they peeled back the dura and looked inside. There, inside a living, breathing body, was visible both right and left thalamus, all the way forward to the optic chiasm. This was only possible because Jay doesn't have a corpus callosum and then, of course, the hole here in the middle of his brain is a bit larger than it should be.

Seeing this ranks as one of the few near-mystical experiences I've had in med school. All of them have involved this closeness to life, this first hand knowledge of these beautiful structures, these elegant machines we struggle to understand, which keep our biological lives in motion. The first was nearly three years ago, in neuroanatomy lab, when I removed and then held in my hand the brain from my cadaver for the first time. Chilling and inspiring and sad and exalting and humiliating all at once. I felt a bit like a stage Hamlet pondering Yorick's skull, only I was wearing scrubs, and I reeked of formaldehyde. I guess satori is independent of the scent of carcinogenic preservatives.

Back in Jay's surgery, several pictures were taken, as this is a "once in a career surgery, for some" in Dr. Lest's words. I certainly won't see it again. Then he and the chief were able to close the hole and reconstruct the bones to partway cover it, and start the kid on the road to recovery.

I was curious, as was the family, what this kid's chances for recovery are. And apparently, no one knows. Only time will tell. But Dr. Lest has "several dozen" former patients who've had this procedure done who are now doing just fine in school, apppropriate to their grade level. And the only way you can tell is, in his words, that they wear glasses. Anything is possible. There's a card taped to Jay's warmer that says "God is with you." Certainly, this is true, and therein lies his greatest hope.

First picture from enotes
Second two from Gray's Anatomy (not the weird medical-ish soap opera, the real one)

Holistic thinking

2007-01-12T18:29:00.000-05:00

I've been wanting to write a more substantive comment on the recent discussion ranging from here to ibid's and S. Lee's blog and back on neuroscience. Unfortunately, every time I try to string something coherent together, I am unable to express what I'm thinking. I keep returning to what one of the commenters said on ibid's post, "neuroscience is the frosting on the cake...analyze while you eat." Which, at first reading, was unsatisfactory. I thought the poster was ignoring the the issue at hand. But when I thought about it some more, I realized that's precisely the point. It is easy, I think, to become so wrapped up in details that the picture fades. As with a Magic Eye poster, you have to step back, and use the right filter, and suddenly the picture makes sense. Reality, similarly, is best appreciated holistically, and though the details are important, they are not the picture. To use another poster-metaphor, it is possible to make a photo mosaic of almost anything, using smaller, more detailed, but incomplete versions of the whole.

Returning from the world of metaphor, though the details are important to understanding, what is more important is the reality of which they are a small part. Even though the details, in this case neuroscience, may seem to give contradictory information, I am confident that the balance of reality will prevail, and that over a long enough time course, the scientists will find themselves saying, with Eliot:

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

Every piece of the whole, eventually, leads us to a greater understanding of it. Einstein's famous theory may have changed the way we understand the orbit of Mercury, but it does not change the singular experience of watching that beautiful planet arrive over a ridge line just before the sunrise. Bernoulli's famous principle may have allowed us to fly, but it does not alter the wonder with which we watch a flock of geese winging south.

Though on the balance, I dislike the man, Walt Whitman reached a similar conclusion, and summarized it better than I can, when he wrote the following:

When I heard the learn’d astronomer;
When the proofs, the figures, were ranged in columns before me;
When I was shown the charts and the diagrams, to add, divide, and measure them;
When I, sitting, heard the astronomer, where he lectured with much applause in the lecture-room,
How soon, unaccountable, I became tired and sick;
Till rising and gliding out, I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.

We can do little less. I may know progressively more about the way my patients think, and the fact that they are crying before a procedure may tell me their amygdala is working overtime, but it doesn't change the reality that they are scared, and it doesn't change my responsibility to hold their hand and talk them through it. The reality of our perceptions is where each of us must live, and as a Christian, I must interpret that reality through the lens of Christ, who asks each of us to act as if we had free will, whether or not we truly do. He asks each of us to have compassion, whether or not that can be reduced to a set of electrochemical principles. Doing less, on the basis of conjecture, would be irresponsible and wrong. And those are two things for which we cannot write an equation. We must simply know their reality.

Evening Rounds

2007-01-11T19:18:00.000-05:00

It will come as no news to anyone who reads this blog that there are differences between surgeons and physicians. (Ha, low blow already, obviously I've picked a side) Anyway, that difference was made starkly apparent this evening on rounds.

Rounds, for anyone who doesn't know, is what docs call our going around as a treatment team to call on each patient we are taking care of. On a medicine service, this usually involves going into the patient's room, saying hi, chatting a bit, doing a quick (for medicine) exam and discussing findings and options, usually about fifteen minutes per patient if we are moving lighting (again, for medicine) speed.

Today I witnessed absolutely the quickest patient rounds I've ever seen. We saw the first patient, who is about to be transferred out of the SICU, and the chief resident literally looked in the door, pointed, and said in an earnest and friendly voice: "you okay pal?" Recieving an affirmative answer, we went to the next room.

As a future internist, I was a bit surprised. I mean, the guy is getting better, but he's still in the ICU. But, like I said, there's a difference between our styles of thinking.

A lot of it, I guess, is in the nature of the problems we face. For a surgeon, the patient's big problems are behind them once they get out of the OR. (And heck, if a neurosurgery patient is aware and talking, things are going fantastically well.) For an internist, they are probably only beginning. And while I respect the surgeon's drive and intensity, I possess more of the thoroughness and patience of an internist. Residency choice confirmation #203.

And as a short commentary on yesterday's post, two things. (I love numbered lists. For some reason, I think that fits with the topic at hand...) One, you know you're tired when you put the honey for your tea on the coaster, rather than in the cup. But two, with warm food and a job that is fun, lack of sleep fades in significance.

But I'm still headed to bed.

What time is it?

2007-01-10T19:06:00.000-05:00

My alarm went off at 4am today. This was intentional. It is also insane. I just returned home, a little more than 17 hours later. I'm trying to wrap my mind around the idea that this will be my life for the next year, at least. I'm also quite thankful I didn't select surgery, where this would be my life for the forseeable future.

Only three and one half weeks of neurosurgery left.

Neurosurgery begins

2007-01-09T18:55:00.000-05:00

Today I spent most of my time in clinic, usually regarded as a painful experience by most surgeons. It's easy to see why, as one of the staff docs saw thirty patients between 730 and noon. But thankfully, I have an out from some of the craziness. One, the surgeons know I'm likely to slow them down with some of the patients, so I'm not expected to see follow-ups or patients I'm not going to learn from. And two, I signed up earlier this year to teach the first year students about medical interviewing, which will take me away from this madhouse at least one afternoon a week.

Still, there is a charm all its own to this clinic. The surgeons themselves are much more laid back than might be expected from the reputation of neurosurgery. One of the senior staff members has a wonderful sense of humor as well. Today, I was presenting a patient to him, who had come in solely to get Dr. Lest's opinion on another doctor's advice. When, as part of my presentation, I mentioned that this patient "respects your opinion, in his words" Dr. Lest shot back "that's the narcotics talking." When, later in the day, he was describing a procedure he will be performing shortly, he said "Not a big deal. I'll just make an sagittal incision, expose the cerebellum and occipital lobe, and do the resection around the tentorium. It's not brain surgery." He smiled and paused. "No, wait..."

And I got the word that, this being a surgical service, I am welcome to wear scrubs, even in clinic. Wonderful.

Notes on another day in hospital

2007-01-08T21:34:00.000-05:00

First, a bit of advice. If you are going to be pretentious and cool, and order your meal in the cafeteria in Spanish from Julio (who is a really nice guy speaking perfect English), you are absolutely not allowed to complain that he got your order wrong. I already could tell your Spanish isn't the greatest, you had to ask one of the words you used, your accent is worse than mine and I've been told by Spanish speakers that I sound like a Russian when I try to speak their language. (And channelling Trotsky is definitely passe. Even Christopher Hitchens is backing away from it now.) Anyway, complaining about your order after your own linguistic debacle is not classy, and it holds up the line. Plus, friend, this is a hospital. Probably a fourth of the docs in here can not only order in Spanish, they can discourse on G-protein signalling in it. You aren't impressing anybody.

Ok, that was uncharitable. Sorry.

Second, ahhhhhhhhhhhhhhhhh. I know I am probably deeply disturbed for feeling and saying this, but it was so refreshing to walk back into a hospital. Though I don't want to become a hospital junkie, I can see the appeal. And three weeks of vacation seems overlong for some reason. Work is good, and I like it.

No patients yet, as it was orientation time, but I'm sure they will start coming tomorrow.

Thinking about neuroscience

2007-01-07T01:05:00.000-05:00

Everybody's
talking
about
it.

To set the stage for those of my readers who do not read the blogs of the commenters here, I'll explain that of the four above links, the first two are blogs discussing the second two, which are articles. The essential question is, what are the implications for faith of neuroscience, which to hear Tom Wolfe tell it (third article), is rapidly approaching a point at which everything can be proved to be determined by our genes.

I want to write something on the topic, but S. Lee has gone and provoked a whole round of new musings, so that wil have to wait. I recommend checking out what he has to say, meanwhile.

Internship? I must be dreaming?!

2007-01-05T11:27:00.000-05:00

So I can tell I'm starting to worry about internship. Last night, I had a dream in which I reenacted a conversation I've had about 50 times over the holiday break, which usually begins with Distant Family Member X saying something like "So, what exactly is internal medicine?"

My stock answer is "if you're over 18, not pregnant, and don't need surgery, you come to me." Which isn't exactly true, but it is close, and of course every correct medical answer begins with "it depends." (Thank you Dr. Harvard)

Anyway, so, I'm having this dream, and all of a sudden, the random person I'm talking to about my chosen field starts getting hives, falls over, and codes. (I swear I'm not making this up.) And I look around, see someone else, and yell at them to bring the code cart as I start CPR. (Code cart? I don't remember this conversation being in a hospital.) And then I start trying, in my dream, to remember doses of epinephrine and atropine. I woke myself up after getting frustrated trying to start an IV, and not being able to find my ACLS handbook. In my sleep.

Maybe this is a good thing. More likely it is a sign of things to come, and that's not entirely pleasant. I know in college I thought it was a positive sign when I started dreaming in Russian, but now I'm not so sure.

Flashback: General Surgery

2007-01-02T11:43:00.000-05:00

I started this blog after I had finished my general surgery rotation, so for the two fold purpose of preserving another story, and providing entertainment whilst waiting for my next rotation to start, I offer: my first day on general surgery.

I knew I was probably in trouble on this rotation. The middle four weeks of my surgery experience were to be spent on a general surgery team, the non-laproscopic surgical oncology one. Later on, the one shining light of a resident in the whole malignant program would call our team the "kings of maximally invasive surgery" but that was still waiting. But I knew I was in trouble because I had been at a large hospital staff meeting at which some awards had been given out, and the surgeon who was to be my chief had gotten one of the big ones. He never smiled, through the whole process. What kind of a guy is lauded in front of most of his peers and never smiles? A surgeon, I guess. I counted myself lucky that I had four weeks of surgery already, and knew the basics of scrubbing in and such.

Day one of general surgery then, worried me. When I came in the first day, I knew we had two thyroidectomies scheduled, because I had checked the schedule before leaving the previous day. (I wasn't usually that OCD on surgery. That showed my nervousness) And I was a little relieved that my best friend from my class was on the same team. As we came in to the scrubstation, Dr. Neversmile looked at us, asked our names, and said to my classmate "You. You're the med student on this case." Then he told the chief resident to page him when the patient was ready, and left the OR. During that first surgery, I became more and more concerned. Surgeons (and some other docs) like to "pimp" medical students, by asking them harder and harder questions about the surgery they are performing (if they are nice) or whatever comes into their head (if they are mean), usually with the intent of belittling the medical student. Supposedly, pimping is meant to be educational, but usually it just scares the med student into reading in his off time. Anyway, Dr. Neversmile was asking some ridiculously difficult questions, and my classmate was not doing well. Once or twice, when he didn't merely shrug and ask another question, he would look over at me and ask the question my friend had missed. Both of us came out of that surgery shaken. I was more worried because I had to bear the brunt of the questions for round two.

The second surgery began much like the first, technique-wise. In a thyroid surgery, the medical student stands at the head of the patient, reaching around the head on both sides to hold retractors to expose the gland. It is difficult to see anything unless you lean partways over the patient's head, and this gets dangerously close to invading the surgeon's space. My classmate had been told repeatedly to move his head back, which demand would invariably be followed by a completely unfair question like "which artery is this?" And "I can't see it" is not an acceptable answer. So the good doctor started his incision, and as he was placing the retractors, took the time to look at me and ask "who was Charles Martel?"

At this point, I was nervous enough not to think that this question might have anything to do with surgery. Having had more than a little history in my education, I quickly answered "he was Charlemagne's grandfather, steward of the royal house of France, and commander of the army that held the Muslim invaders back at Tours in, I think, 723 AD."

Dr. Neversmile, who had looked back at his work, stopped. Looking up at me, he said "do you know what that was?"

"No sir."

"That, Nathan, was an afflatus. Do you know what an afflatus is?"

"No sir."

"It is a flash of divine communication of knowledge, as if the person was breathed upon by an angel. Do you know any angels?"

"No sir."

"Anyway, that was brilliant, but not the answer I wanted. Charles Martel was actually a sea captain who was the first person to have his thyroid removed, and who died because his parathyroids were removed as well. Here, let me show you something..."

And that was it. From that point on, Dr. Neversmile was nice to me, in his own way. He still made me hold a retractor on a liver case for 4 solid hours, he still asked ridiculously difficult questions, and he still never smiled, but he actually taught me from that point on, and when we did thyroid cases, he let me peer over the patient's head and see what was going on. I actually came out of the rotation having learned something besides the fact that I never wanted to see the inside of an OR again. Thank God for that afflatus.

*As a side note, I was actually wrong about the date of Martel's victory. It was in 732 AD. It didn't seem to matter. Also, the picture of Martel the sea captain is from American Journal of Surgical Pathology. 20(9):1123-1144, September 1996.

Happy New Year

2007-01-01T13:42:00.000-05:00

Nothing much to say, but I did get to see some snow, finally. Of course, I had to fly three fourths of the way across the country to do it, but you do what you have to do, right?

On the work front, I'm busy reading my Neurology Primer and a few other books I've picked up in the desperate attempt to not look like an idiot over the next four weeks. I know next to nothing about neurology. It truly is a black box, as far as I'm concerned, despite having a good friend who is getting his Ph.D. in the subject.

But nevertheless, it is important, and learning important things is ostensibly why I'm in medical school. 137 days to go...

2006-12-20T20:11:00.000-05:00

If you're a close reader of the comments here, you'll have noticed that the tests turned out as I hoped, not as I feared. And another scary chapter of my life is finished. But the pessimist in me mutters as I write that "the book is not yet finished." The good thing, I guess, is that I'm fairly aware of the different ways you can get a needlestick.

And as I noted yesterday, I am away from the hospital until the new year. Probably the last break I'll have before internship, so I intend to enjoy it. Posting will probably be light over that time, but I'll be starting up with neurosurgery in January, and that should be fairly story-rich. No, this is not out of a new-found desire to be a neurosurgeon, it is simply a relic of the fact that my school assigns lottery numbers to students as we pick our required neurology rotations, and, as is already evident, I'm not particularly lucky.

An oddly bright moment today was opening my mail. On my last ward medicine month, I had really clicked with a patient, who then proceeded to offer me a week at his beachhouse out of thanks. I never took him up on that, but I did get a Christmas card from him, addressed to "Dr."

Almost, almost. And it is wonderful to know he's still doing well.

Choosing a doctor, finding patients

2006-12-19T11:40:00.000-05:00

I'm on my winter break, hence the dearth of posting lately. But yesterday, I was in a music store, asking for a specific and (I guess) rarely requested piece of music for my guitar, Spencer Doige's Fingerpicking Joplin. Check it out here, but give the guy 22 seconds to start the real piece. And here. I digress.

Anyway, the woman helping me find this piece said "I assume you're a professional then, getting this book," which started a bit of a discussion about my job and what I'm going to do. And as we ranged over my theories on accupunture and osteopathic manipulations (I'm an allopath), she was evidently impressed. She stated finally that "when you get out of your residency, come back by, because I need a new doctor, and it's so hard to find good ones."

Which got me thinking down the road. I don't really know much of how someone in private practice goes about getting a panel of patients. We aren't taught a whole lot of that in school, and as an internist, most of my time for the immediate future will be in the hospital, out of clinic. But eventually, I'll be out in private practice, and I'm not sure I want to be a hospitalist, so I'll be doing clinic and needing patients. So I guess I'll start with the guitar stores to drum up business, eh?

Blogger Beta

2006-12-13T23:06:00.000-05:00

I upgraded to the new version, and the first thing I noticed that changed was that it deleted all the authors to the comments, replacing them with "annonymous." Not an auspicious beginning. Anyway, I can't go back now, spilt milk and all, so I'll try to make it work.