Wednesday, May 04, 2016

AIDS

A 25 year old man who has never seen a doctor presents with a year's worth of symptoms. He's had weight loss, diarrhea, fatigue, and shortness of breath. This last symptom was what finally convinced his sister to force him to the emergency room. Over the last month, his shortness of breath has been progressing rapidly. He has fever, night sweats, and a nonproductive cough. On evaluation in the emergency department, he is noted to be in severe respiratory distress. His oxygen saturation is 89%, and on minimal movement, it drops down to the 70s. Although he is quickly put on oxygen, his need escalates and he is eventually intubated. He is transferred to the intensive care unit. His chest X-ray shows widespread bilateral infiltrates in the lungs.

I had a suspicion, as I had seen this presentation as a medical student. I sent off an HIV test, and it came back positive. His T-cell count was 20. I was convinced this was Pneumocystis jiroveci pneumonia (when I was a medical student, this was called Pneumocystis carinii pneumonia). The presentation, chest X-ray, and clinical picture all pointed to it. I sent off the appropriate tests, supported him clinically, and consulted our infectious disease specialist.

How surprised we were when we found it was not Pneumocystis pneumonia! But the diagnosis wasn't any better; the cultures grew back three separate bugs: Klebsiella from the lungs, and both Staphylococcus and Salmonella from the blood. He was in full-blown septic shock and acute respiratory distress syndrome.

For the next two weeks, he was the sickest patient on the service. Each day, I met with the sister, knowing that could be the day he might die. He was the first patient I saw when coming in and the last patient I checked before leaving. He was being oxygenated with 100% oxygen and a PEEP of 15, and his oxygen saturations were barely adequate. We even had to give paralytics for a few days. There has been extensive research on acute respiratory distress syndrome, but unfortunately, very few things work. I tried everything I could think of; we even considered prone positioning, but by that time, he was on continual dialysis, and it wasn't possible. Finally, I put him on inhaled nitric oxide, a rescue therapy used mainly in right sided heart failure, but I hoped it might match pulmonary blood flow and oxygenation better. Over a period of weeks, his lungs finally recovered; he eventually had a tracheostomy because by that time, he was quite debilitated.

His other organs took a hit, but made it through. As you might expect with an immunocompromised septic patient, he needed three pressors, pushes of bicarbonate, continuous dialysis, artificial nutrition, transfusions (for bone marrow suppression leading to pancytopenia), and a lot of antibiotics. But in the end, his heart, kidneys, and liver recovered. He suffered no cognitive impairment; he was headed to rehabilitation.

This patient was a real save. I never expected to see full-blown AIDS with three opportunistic infections in a community ICU. But I also felt ready to handle such a challenging case. This is why I went into critical care.

Friday, April 29, 2016

Hospitals and Bankruptcy

How does a hospital go bankrupt?

When I was interviewing for jobs, I actually visited a hospital that was in dire financial straits. The hospital and staff were great, but I kept wondering, what happens if it is financially insolvent? How do we spend such tremendous sums of money on healthcare in this country, yet have hospitals shutting down or scrambling for buyers because they can't make ends meet? How can we have such drastic disparities even within the Bay Area?

I don't know much about hospital administration, finances, or organization but I imagine a lot of different factors are at play. This hospital cared for many who were uninsured, provided a lot of charity care, yet it was not a county hospital so it didn't get buoyed by public funds. Perhaps hospital management needed to focus more on optimizing efficiency, attracting and retaining high quality practitioners, and developing a strong reputation. We vilify hospitals for trying to extract as much money as they can from insurers or patients, but a hospital that doesn't focus on finances cannot keep operating. Even nonprofits need to meet the bottom line.

Eventually, hospitals may need to find other parties to buy them out, or they risk closing down. Such turmoil has lasting effects on the community. There are few alternatives to these "safety net" hospitals, which care for the poor. If the hospital changes management, it may be uncertain whether that mission will remain; if the hospital closes, nearby facilities will have to step up. Physicians worry that they need to move their practices elsewhere, and when they start moving their business, the hospital starts losing more money, creating a vicious cycle. Doctors may not want to work with the new management buying the hospital. Prospective physicians like me won't take the job simply because of its uncertainty, even if we otherwise like the underserved populations, the dedicated colleagues. Labor unions at the hospital scramble and protest. The volatility can have so many downstream effects.

Ultimately, it seems drastic to shut down a hospital, and we almost think that it would never happen, as if hospitals were "too big to fail." Unfortunately, unlike Wall Street, there aren't a lot of ways to bail a hospital out of this situation.

Sunday, April 24, 2016

Book Review: Nonviolent Communication


Nonviolent Communication by Marshall Rosenberg is probably the most important book I've read recently. Although it is short, it is quite dense, a mix of a workbook, textbook, and nonfiction primer. Most of us don't think about how we communicate. We talk to our friends, coworkers, bosses, spouses, family. Sometimes we have arguments. Sometimes we have deep brilliant conversations. Sometimes we have fights. Sometimes we persuade each other. But we rarely reflect on how we talk.

This book challenges us to do that. It proposes a way of communicating that encourages openness, empathy, honesty, and engagement. Although it might seem simple at first, I have found good communication surprisingly difficult. I've also realized how much I have to improve. If I am not careful, I assume; I demand; I don't listen; I don't ask for what I want; I don't hear what the other person wants. The last two points are so, so important and they get missed so often.

We talk about this in medicine a little, that clinicians interrupt patients in half a minute or speak in technical jargon when they shouldn't, but everyone can improve. Furthermore, we don't talk about how to talk in our personal lives, how we communicate with our spouse or parents or kids. Yet communication is the core of all our interactions. It shapes our relationships and creates the backbone for our shared happiness or frustration.

I recommend this book to everyone; I wish I had read it earlier in my life, like in college. Marshall Rosenberg explains things clearly and simply, and the concepts are not hard. Yet as I try to implement what I learn, I realize putting this into action requires a lot of attention and care. I hope that moving forward, I communicate with more kindness, empathy, and heart.

Image shown under Fair Use, from amazon.

Tuesday, April 19, 2016

Integrative Medicine

Being in Northern California, I think I'm in one of the most receptive places towards integrative medicine. I am not an expert, but my understanding of integrative medicine is that it emphasizes treating the whole person using a wide range of techniques, from Western medicine to complementary and alternative approaches. The approach attends to a patient's biologic, social, psychological, and spiritual sides, and seeks to maintain the patient's wellness in all these areas. An integrative healer may utilize evidence based medicine, acupuncture, meditation, counseling, massage therapy, supplements, etc. Like anything, integrative medicine has its proponents and critics, but after listening to a number of medical students and physicians talk about it, I wanted to write a post about it.

I think integrative medicine will become important and catch on in the future. One aspect is the patient side - this is what patients want. They want to be seen and treated as whole people. They (at least in California) want to talk about hypnotherapy and traditional Chinese medicine and Ayurveda. They expect their doctors to know about these alternative schools of thought. In addition, I think in the next few decades, more data will come out on what works outside of mainstay Western medicine. We will gain more tools for combating chronic disease. We will have more ways of maintaining health. We ought to use all the modalities that work, even if it doesn't come from a pharmaceutical company or cost an exorbitant amount. Especially with diseases like fibromyalgia, chronic fatigue syndrome, and mood disorders, we need everything we can get.

It makes me a little uncomfortable, like I imagine it makes most physicians. But, deep down, it also makes me excited. Who is to say that the scientific method, the multi-million dollar clinical trials, and the ridiculous lobbying power of the pharmaceutical industry is any better or less biased than centuries of wisdom passed through traditional Chinese medicine? How can we be so closed-minded as to dismiss everything else as "snake oil" simply because it's not what we learned in school? Of course, we all know these patients aren't the easiest to deal with. But these issues aren't going away. We should embrace anything that makes our patients healthier, better.

Ultimately, I remind myself of one immutable principle: no matter all the hype or excitement around integrative medicine, we must do no harm. If a patient wants neck manipulation for his cervical spine stenosis or mega-doses of St. John's wort while being on antiretrovirals, I will say no. If he believes cognitive-behavioral therapy will trump surgery and antibiotics in appendicitis, I will say I disagree. There are complementary and alternative treatments that harm patients, and all physicians have seen this. But aside from that, it is time to open our minds to other ideas that could potentially benefit our patients with little harm.

Friday, April 15, 2016

Q&A

I love getting comments on my posts, and I read all of them. Depending on how busy things are, though, I'm sometimes pretty late in replying. Here is a question posed by Ethan (thanks for the comment!). I'm posting it as a new post in case it helps any other readers.

Q: ...Looking ahead, I am very intrigued by the possibility of completing a critical care fellowship and practicing as a critical care anesthesiologist...If you ever have some time, I would be really curious to learn about your schedule on a monthly basis. Do you split time between the ICU and OR or do you work strictly in the ICU? Do your colleagues in critical care anesthesia have similar set-ups or is there some variation depending on the hospital system/institution? Any advice going forward would be appreciated.

Great question, but it's not really straightforward to answer. My advice is to talk to as many critical care intensivists as you can. In the U.S., most critical care units are staffed by pulmonologists (as opposed to Europe where last I checked, the ratio actually favored anesthesiologists). Particularly in private or community hospitals, a large proportion of departments are solely run by pulmonologists. I'm in a rare community hospital that actually has both anesthesiologists and pulmonologists in the ICU (and we are greatly outnumbered). Most places that have intensivists from different backgrounds (internal medicine, pulmonology, anesthesia, surgery, neurology) are large academic institutions or the VA. Keep this in mind if you choose the field; it's not easy to go into private practice and find a job that balances both specialties.

There are a number of reasons for this. Aside from historical or conventional reasons, money plays a big factor. Anesthesiologists can make more relative value units in the operating room than the intensive care unit. Private anesthesia groups don't have a large incentive for getting into the ICU. Most groups run lean in order to maximize revenue, and it's hard to organize scheduling between OR call and the ICU.

Nevertheless, I think it is important for anesthesiologists to be in the ICU (as well as those from all other backgrounds). The intensive care unit really requires a multispecialty approach, and we bring a lot of skills and knowledge to the table. Most community ICUs are mixed medical-surgical units, and we know the surgeons well. We understand the perioperative period best. We have special expertise in the airway, resuscitation, cardiopulmonary evaluation, and crisis management. But we also recognize our limitations; my medicine colleagues have more experience with other organ systems, interacting with other consultants, holding family meetings, etc. I strongly believe a multidisciplinary unit where all the attendings collaborate, especially in difficult cases, improves patient care, quality, and satisfaction.

In any case, the reality of it is that most anesthesia-trained intensivists who continue to practice critical care do so in academic or VA settings. However, I do know of some private practice anesthesia groups that are expanding their boundaries to cover the ICU. This is something strongly pushed by the American Society of Anesthesiologists, that we become physicians of the perioperative period, including covering critical care and pain management (the so called "surgical home" idea). It also integrates a private practice group with the hospital so that hospital administration recognizes what they bring to the table.

So regarding the specifics of your question - I spend the bulk of my time in the operating room. I spend about 20% in the intensive care unit, a 21 bed mixed medical-surgical-cardiothoracic unit. We cover a week of days at a time (Monday-Friday) during which I have no operating room responsibilities. We cover random night and weekend calls; if I'm on call for the ICU at night, I still have a day of cases in the OR (but it's usually light). We share this schedule with a group of pulmonologists who we have great relationships with. The schedule is made between the two departments so that my ICU and OR schedules don't conflict. I love my ICU time, and it reminds me of a lot of why I went into medicine, but it exhausts me. I enjoy my OR time as it tends to be a little less tiring.

Most critical care units have similar types of schedules. At my residency, for example, the ratio of anesthesia and non-anesthesia critical care faculty is about 50/50 so between two teams, there is almost always an anesthesiologist. They are on for a week at a time, and all the other weeks, they work in the OR, in teaching, or in administration. Nights and weekends are covered by random attendings who do work the daytime (but of course, nights and weekends are easier with residents).

Regardless of what you choose, when you finish, you'll get emails with locums tenens or per diem jobs, and the ICU ones are all quite similar: day or night shifts, usually a week at a time. Some look specifically for pulmonologists (to take pulm consults), others are open to any critical care trained physician.

I hope that helps! Please let me know what else I can answer. Thanks again for the comment.

Monday, April 11, 2016

Self Care

It is easy to wear adversity as a badge of honor. "Back in my day, I was on call every other night, taking 36 hour shifts for months at a time." And, if I'm to be completely honest, it's kind of fun to make a statement like that with a bit of swagger. But this is not healthy. I spent part of this weekend learning from a group of medical students and physicians who reflected on the importance of self-care (among many other things). What is the humanism that brought us into medicine? What does it mean to be a healer? How does the harsh reality of medical training alienate us from the heart within us? How do we build resistance to persevere in the face of residency? How do we find ourselves after we make it through to the other side?

These are questions I have poked and prodded, but it was amazing to encounter students and physicians who have immersed themselves into pondering and reflecting on this. One lesson for me was the importance of self-care and wellness. Residency will transform us, and the harshness of it - the lost sleep, the endless hours, the menial tasks, the burdens of responsibility, the stark emotions - will change us. There may be more built-in support than there was a decade ago, but it is still inadequate. We must find support among our family and friends to weather this experience. We find strength within ourselves. We build community to buoy us up.

On the spectrum, I am probably more on the stoic side. I endure well. But the challenges of residency - even if they are necessary (which I am not sure they are) - are not healthy. It is not healthy to go through a day and only eat saltines and juice. It is not healthy to avoid going to the dentist for years. It is not healthy to switch back and forth from day and night schedules. It is not healthy to counsel patients on a healthy diet but resort to fast food because there's no time for anything else. There is no doubt in my mind that we were all much healthier before residency. Now, I am learning ways in which I can recapture that health.

Take care of yourself. Cultivate friendships. Spend time with family. Empathize with others. Communicate. Build a community. Meditate. Walk, cook, exercise. Bask in the sun sometimes. I am learning these things.

Tuesday, April 05, 2016

Hospitals vs Hotels

Although the previous post was a little tongue-in-cheek, it's not that far from the truth. In the last decade, there has been a huge shift to focus on customer satisfaction. Even going from medical school to residency, I noticed a lot of changes. Flat screen TVs, loaner iPads, and menus became popular. Even though it's a tiny thing, this last detail really surprised me. In the hospital, physicians determine a patient's diet; we write an order for a low salt or diabetic or renal (kidney) diet. We (along with our speech and swallow therapists) decide whether a patient can have a regular diet, puree foods, liquids only, or some other strange consistency. That a hospital can still come up with menus that adhere to the medical requirements but give patients choice is really impressive. There were many times when I thought that patients ate better than residents (but only if the patients didn't have congestive heart failure, kidney disease, or liver disease).

Why has this been the case? In the last few years, hospitals have become obsessed with customer experience. Physicians are encouraged to care about and improve their Press-Ganey customer satisfaction surveys. For some of us, reimbursement is tied to how many "excellents" we get. Insurance companies are starting to pay attention to what their customers want. Businesses pick HMOs that their employees like. Physicians start worrying about their online reviews. In a society and world where everything else - hotels, restaurants, museums, babysitters - are reviewed, physicians and hospitals now have to start thinking about the customer experience.

So all of a sudden, we have valet parking, artwork in the hallways, gadgets for patients, consultants to help us dazzle up the experience. These things improve our surveys. But unfortunately, the quality of medical care matters less. Patients really aren't aware of most of the medical decision making. How do they know if the antibiotic prescribed was appropriate or if the X-rays they got were actually necessary? Poor outcomes may occur despite appropriate care, and good outcomes may happen even if care was egregiously wrong. For the most part, I think patients cannot easily assess the quality of their care. Even if that's probably the most appropriate metric to rate a hospital, patient satisfaction happens to be easier to survey and validate. Hence the recent rise of hotel-like hospitals.

Friday, April 01, 2016

Choose Your Own Anesthetic

The trend in the Bay Area is to allow patrons to customize everything. We have make-your-own burgers, sundaes, pizzas, salads, even lattes. And what could be more empowering than being able to put locally foraged hipster quinoa into that green smoothie? One of my patients last week was an engineer entrepreneur who expects everything to be customizable in the near future. Already, you can build your own computer, choose the features of your Tesla, and build a trampoline room in your multimillion dollar home. We had a long conversation and concluded that this will soon move into medicine. Especially in the Bay Area with highly educated Type A personalities, patients want to take control of their health. Empowering patients is an important role for physicians, and we envision a role where doctors are patient advocates and patient consultants, guiding them through choosing their own treatments.

Here's a rough draft of the anesthetic protocol for a straightforward general anesthetic.

1. Pre-anesthesia consultation. Choose one:
[  ] Phone call the night before from my anesthesiologist.
[  ] Pre-operative clinic visit one week before surgery (extra charge may apply)
[  ] None

2. Day of Surgery: pre-operative orders.
[  ] Nothing to eat or drink after midnight. If an earlier surgical slot opens, we may be able to accommodate you.
[  ] Allowed to drink black coffee, clear tea, or fruit juices up until 2 hours before surgery. You cannot have your surgery earlier than your scheduled time.
[  ] Offered black coffee, clear tea, or fruit juices on check-in. ($5 donation suggested.)
[  ] Regular parking     [  ] Valet parking
[  ] Cloth gown: Mark size here: _____
[  ] Paper gown that allows attachment of heating system.
[  ] IV placement by RN
[  ] IV placement by nursing student. You will receive a thank-you note in the mail.
[  ] IV placement by anesthesiologist with lidocaine 1% (extra charge may apply)
[  ] IV perfered location: ____
[  ] iPad while waiting for your surgery.
[  ] Cable channels while waiting for your surgery.
[  ] Video game system while waiting for your surgery.
[  ] Wifi (24 hour access)
[  ] Operating room heated up before you are brought in.
[  ] Extra pillows
[  ] Extra blankets
[  ] Tempurpedic mattress
[  ] Compostable oxygen mask or nasal cannula requested

3. Anesthetic Choices
[  ] Anxiety treated with midazolam before you enter the operating room.
[  ] Volunteer to hold your hand as you are falling asleep
[  ] Oxygen mask can be scented: [  ] Bubble gum  [  ] Cherry  [  ] Watermelon  [  ] Mint
[  ] Awake intubation with a recorded video of your vocal cords (extra charge may apply)
[  ] Asleep intubation with a recorded video of your vocal cords (extra charge may apply)
[  ] Induction of anesthesia with ketamine to experience dissociative state (may have nightmares)
[  ] Smaller endotracheal tube (may decrease sore throat)
[  ] Lidocaine sprayed into trachea prior to intubation (may decrease sore throat)
[  ] Minimize opiates
[  ] Extra opiates please
[  ] Non-steroidal anti-inflammatory mediations (ie. ketorolac) (extra charge may apply).
[  ] Please use nitrous oxide
All our patients get complementary ondansetron to prevent nausea. Please check if you would in addition like [  ] metoclopramide  [  ] scopolamine
Please list music requests for the operating room (genre, songs, or artists): _______

4. Recovery Room
[  ] Window slot requested
[  ] Aisle slot requested
[  ] Soothing music played
Please give me [  ] ice chips, [  ] water, [  ] apple juice, [  ] cranberry juice, [  ] organic Blue Bottle coffee (extra charge may apply).
[  ] 35 minute massage (extra charge may apply)
All our patients get complementary sequential compression devices. Please check if you would also like a [  ] 15 minute foot rub (extra charge may apply)
All our patients get a complementary photograph. Please check if you would like [  ] High resolution emailed picture, [  ] Framed photo, [  ] Framed photo signed by your anesthesiologist.

Happy April 1!
Craig

Wednesday, March 30, 2016

There's a Day for Everyone

I found out today was Doctor's Day. I guess there's a day for everyone. On some level, it bothers me as it fuels the "everyone is special" message in our society ("Let's celebrate our graduating second graders!"). I have to say, though, I appreciated our luncheon; the private community hospital I'm at goes all out. So the particularly cool thing about National Doctor's Day is that it celebrates the first use of ether anesthesia for surgery at Massachusetts General Hospital. There aren't a lot of public proclamations about anesthesia, and to celebrate all physicians on the day general anesthesia was first used is a big deal. It makes me feel a little tingly inside to be recognized as such. Now, if only we had a Google doodle celebrating this...

Tuesday, March 29, 2016

Arrogance

The contradiction is this: in our society, in medicine, in relationships, at work, at home, and even at play, we must be confident. We need to have self-assurance in our skills, our abilities, our knowledge, and ourselves. But I think the biggest downfall is arrogance. An anesthesiologist who is arrogant will plunge into a case unprepared when he could have been. A surgeon who is arrogant will promise outcomes that he may not always deliver. A friend who is arrogant grates on the relationship. A spouse who is arrogant cannot see your perspective. When someone is arrogant, they think they own more than they do; a physician owns a disease and controls its progression, a suitor owns the man she chases, a teenager "pwns" his opponents at a game.

Perhaps there is a thin line between pride and arrogance, but I have a subconscious reaction almost immediately. I stand proud with someone who is proud: a friend who just took his boards, a new set of parents, a surprise winner of a board game. But arrogance almost immediately rubs me the wrong way. There are many other faults I accept so much more easily; even incompetence is tolerable as long as the person admits their failings. But a doctor who is arrogant does his patients a disservice just as a friend who is arrogant will find himself without, a politician who is arrogant will create chasms, a self who is arrogant will want for happiness.

I don't usually write such prescriptive blogs about personality, but a convergence of a lot of things - what is happening in the primaries, encounters with friends, thoughts about who I am and who I'd like to be - lead me to scribble this down.