Almost coded

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.

And so it ends

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.

More from the ER

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?

The truth is out there

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

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

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.

Every accidental crack

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.

Development

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

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.

Another day

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

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

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

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.

Shaka and Surgeons

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.

Oops

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

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."

An obstetrical memory

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.

Faking It

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

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)

Evening Rounds

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.