Wednesday, August 24, 2016

The Block

Samuel Shem's iconic House of God describes the block with hyperbole. When the emergency department calls for an admission, you try to block the patient and turf him to a different service. If you're an orthopedic surgeon and the patient has a hip fracture, maybe she also has chest pain so she would be safer on a medicine service with an orthopedic consultation. If you're an intensive care physician and the patient is dying of septic shock, perhaps you can dig up an advance directive and POLST saying the patient wouldn't want aggressive medical treatment in this situation.

This is not healthy behavior, but House of God describes why it proliferates; every service is trying to block patients, and if a physician accepts patients indiscriminately, her service will blow up in size. When we are residents and fellows, our clinical volume has no relationship to our salary so there's little incentive to take a lot of patients. Most specialty consultants master the art of the block, and as a result, patients get dumped onto the general medicine or intensive care services. We are the catch-all for any medical problem, so if no one else will admit them to the hospital, medicine will (or the medical intensive care unit if they are sick enough). In general, I was okay with that because the patients got better care, but the idea of blocking always bothered me.

Private practice is the exact opposite. For many of us (but not myself), clinical volume determines our revenue. I was surprised to learn consultants were eager to take on extra work and that there was no push-back when I asked other services to accept patients. A patient's disposition (the medical term of who takes care of them and where in the hospital they go) is determined entirely by medical factors. This is the way the system should be; physicians shouldn't block patients; we should care for them, treat them. Perhaps its not wrong to link this to financial incentives. The goal is to have a collegial and smooth-running system that focuses on the needs of the patient.

Monday, August 22, 2016

Statistics

As I get farther out from school, I start thinking of disciplines I wished I studied more. Some, like English literature or computer science, I think one day I might pick up again. But there's one discipline that I should have studied yet never will, and that is statistics. In the last few years, I've been learning from perusing medical journals (rather than textbooks and lectures which comprise most learning for medical students and early residents). The more I read, the more I realize that statistics matter so much. A study's design is its foundation, and without a solvent knowledge of statistics, I feel like I'm often evaluating the facade of a study rather than its real integrity. Nevertheless, for whatever reason, statistics classes just never engaged me. The one I took in college just passed me by. For me, it is like music theory; growing up, I enjoyed playing an instrument, but never cared for music theory. I guess there will always be a few things where we recognize the importance but just can't make ourselves endure. That being said, I think if we were to rethink the premedical curriculum, statistics is far more relevant than subjects like physics.

Image is in the public domain, from Wikipedia.

Saturday, August 20, 2016

Technology and the Cardiac Exam

The stethoscope is the iconic symbol of medicine. There so much I love about it: how it was conceived, the panoply of obscure sounds that indicate specific pathologies, the synecdoche of listening to a patient's heart for the patient-doctor relationship. But I also imagine a time where the stethoscope is relegated to history. Why do we still use an instrument invented in the early 19th century? Physicians are notoriously slow to adopt new technologies, but I can think of two inventions that should replace the stethoscope.

If listening to heart sounds is crucial to medicine, why don't we develop a microphone that we can place on a patient's chest that will record the patient's heart and lung sounds? We have the electronic ability to filter extraneous noises and amplify relevant sounds. Computers can analyze the sounds to dissect out what fledgling medical students struggle to discern. In the same way that the computer reads EKGs, programs can be developed to detect an extra S3 or S4, the type of murmur, or the presence of a rub. Recordings can be saved and compared to prior captures; wouldn't it be fantastic if we could compare today's lung crackles to yesterday's?

And this may be anathema, but I'm not sure listening to the heart offers that much diagnostic value. I definitely think it's important for the patient-doctor relationship and has interpersonal, even therapeutic, value. But it's pretty rare that what I hear on heart or lung exam changes my decision making. This is definitely because of my clinical specialty; in the intensive care unit, I'll often order chest X-rays and echocardiograms, and in the operating room, few heart sounds will cause me to cancel a case. But still, there's less medical utility in the stethoscope than we might wish.

This leads me to wonder when bedside echocardiograms will replace the stethoscope. Handheld echo probes are starting to drop into the affordable range. There's certainly a learning curve, but once bedside echo is mastered, it gives a lot more information than listening to the heart. One day, I think this will become the cardiac exam.

Image is in the public domain, from Wikipedia.

Monday, August 15, 2016

One More ICU Story

It is Saturday midnight, and I'm called by the emergency department to admit a patient who was intoxicated at a party with unknown substances. I ask the nurse if we know anything more about the patient - his identity, other medical problems, etc. She replies, "We don't know too much but we searched his pockets and found a little plastic bag with what looked like crystal meth. But when we gave it to the police, the police replied, 'That's not crystal meth.' I asked, 'What is it?' And he replied, 'That's just crystals. Like decorative crystals.'" That made my night.

Saturday, August 13, 2016

Five Days in ICU

Monday

A young man is picked up by emergency medical services unresponsive and hypotensive. He is intubated but despite liters of fluid, his blood pressure remains barely measurable. On exam, his belly is rock hard; I think it's filled with blood. After we start a massive transfusion, we're able to get him to the CT scan, and we find a massive retroperitoneal bleed. He is whisked off to the operating room. On return, his drains pour out liters and liters of blood. The color of the blood coming from the drains is the same as blood drawn from the arterial line. Of course, he returns the operating room and then to interventional radiology for an emergency TIPSS because he has severe cirrhosis. All in all, over a 12 hour period, he gets 25 units of blood, 25 units of plasma, 4 six-packs of platelets, and 2 units of cryoglobulin. Over the week, he goes into acute respiratory distress syndrome with impressive oxygenation requirements (FiO2 100%, PEEP 18), cardiovascular collapse needing pressors, renal failure requiring continuous renal replacement therapy, alcohol withdrawal, continued transfusions, and a return trip to the operating room.

Tuesday

I sign out to the night-time intensivist at 6PM. I finish my notes over the next two hours, clean up pending items, and get ready to go home. On my way out, the nurses flag me down because a surgical patient who was doing fine and planning to leave the ICU had an acute aspiration. After intubating and stabilizing the patient, I sit down to finish those notes as well. I get home well past 9.

Wednesday

I am called by the emergency department to help with an intubation for a cardiac arrest. When I rush down, I see the nurses doing compressions on a child. A three year old previously healthy girl presented with ventricular fibrillation and seizure. Other than accidental overdose of medications, I'm not even sure what causes cardiac arrest in a child. I intubate her, but an hour later when I am admitting a separate patient from the ER, I see that they call time of death. The family is in hysterics. I go home to wrestle with family crises of my own.

Thursday

I see twenty two patients today. We only have 21 beds, but we started with 17 patients and despite sending a bunch to the floor, I get 5 new admits. I'm not even sure if clinic physicians see 21 patients in a day. I make myself a spreadsheet to keep track of notes, orders, and to-do items. The most interesting patient is a person who comes in with torasdes de pointes (shown below). We all learn about torsades in medical school, but this may be the first time I've actually seen a case. It is caused by medications she takes. That first afternoon, she kept having scary episodes of polymorphic ventricular tachycardia, but they finally subside as the medications metabolize off her system.


Friday

I get my most interesting patient on my last day on service. A young woman is intubated in the emergency department because of "bizarre behavior." When I get the call, I wonder how bizarre her behavior was to necessitate intubation and sedation. Apparently, she hasn't been herself for two months. She works at a cafe in the daytime, but according to her boyfriend, she started going out every night to four or five in the morning. She'd sleep for three hours, then go back to work. He wasn't sure what she did at night, but wonders if she was smoking, drinking, and doing drugs. The day before admission, she parked her car on the shoulder of a freeway and ran across the highway. Fortunately, she was picked up before getting hurt and brought to our emergency department. Initially she was admitted to psychiatry, but over the course of the day, she became more combative, even hitting a nurse and harassing another patient. She got 25mg of haldol, an impressive amount, as well as atypical antipsychotics and benzodiazpines. Finally, the ER decided she simply needed to be sedated so they intubated her to get a lumbar puncture and head imaging. She was negative for meningitis, encephalitis, or structural abnormalities. Her toxicology showed benzos and marijuana. I really don't know what was happening with her, but I suspect either intoxication or withdrawal of drugs or a new psychiatric diagnosis with a manic or psychotic episode.

I haven't worked this many hours since fellowship. Along with these cases, I also had the usual old person presenting with sepsis from a nursing home, cirrhotics with low blood pressure, slow ventilator weans, chronically ill patients who had been hospitalized for over a month, gastrointestinal bleeds, and postoperative patients. What a week.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Wednesday, August 10, 2016

The Originally Celebrated Curiously Strong


In an attempt to understand how acetaminophen might help some musculoskeletal pain I have, I tried to conduct a blinded placebo-controlled trial on myself. It wasn't very successful, which might have been for several reasons. First, I'm pretty sure I could tell when I got an altoid rather than the trial medication. Second, the acetaminophen I was using is expired. I'm pretty sure nonsteroidal anti-inflammatories would have been a better intervention. Oh well, this is why I never made it as a research scientist.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Sunday, August 07, 2016

Expectations and Medical Decision Making

A pregnant woman at term comes in with active labor. However, she is adamant she does not want her vital signs to be checked, an IV to be placed, or labs to be drawn. She insists on having none of it despite understanding the risks. There's no compelling reason; it's simply her birth plan and preference. It's not clear why she decided to deliver in a hospital rather than at home or a birth center. Nevertheless, she is declining hospital standards of care by refusing an IV and vital signs.

For generations, decision-making was entirely up to the physician. Medicine was paternal; a doctor would tell a patient the plan. In the last few decades, we've recognized the ethics of patient autonomy and shared decision-making. We do our best to inform and educate a patient about the nature of their condition and the risks, benefits, and alternatives of diagnostic or therapeutic interventions. We may give our recommendation but we would never force a patient to undergo something he or she did not want.

I wonder sometimes whether we've reached the other extreme, allowing a patient to dictate everything. One reason to deliver at a hospital over home or a birthing center is the insurance against an emergency. The vast majority of patients do fine, but a few need interventions like an urgent C-section. By declining vital signs, IV access, ultrasound examination, and other tests, that benefit is negated. This patient did not receive prenatal care so we had no idea whether the placenta was normally implanted, whether she had pre-eclampsia, even whether the baby was breech (other than by physical exam). The patient was of "advanced maternal age" and there was a real possibility of needing a Cesarean (fortunately, she did not).

While one could argue that with adequate counseling, a patient can understand that risk and decline those interventions, I think that is ultimately unfair to the providers. In a case like this, unacceptable risk is transferred to me. I am not comfortable in a situation where someone may need emergent surgery but does not have an IV. Even if that's what a patient demands, do I have to acquiesce? (Ultimately I did, but these issues are real conundrums).

Like every relationship, the one between patient and provider cannot be controlled entirely by one party. Biomedical ethics is much more than simply reciting "autonomy, beneficience, nonmaleficence, and justice" (what they teach in medical school). We have to learn and approach real-life ethical dilemmas with care, nuance, and compassion.

Friday, August 05, 2016

Satisfying


In nearly every hospital I've been, when there is a patient who is a difficult IV and everyone else has failed, the anesthesiologist gets called. Usually when I arrive, everyone feels relieved, including the patient who often has two armfuls of bruises. I always get (and still get) a little knot in the pit of my stomach because I'm the last resort, and often these patients absolutely need IV access.

There are a few tricks I've picked up over residency. Most nurses won't try the ventral (inner) part of the wrist (the veins are fragile and tortuous and it is painful). In adults, there are usually visible veins on the fingers (including the thumb). I'll look at the ankles and feet. I'll consider the external jugular in the neck. IV drug users who have scarred every other vein usually miss the back of the elbow. And there's always ultrasound and the central line as a last resort.

It's most satisfying though, when I manage to get an IV with a single attempt after the patient is exasperated, exhausted, and at wit's end. A 7 year old boy comes in with appendicitis. Four nurses have each tried once, and finally I am called. I sit down and we chat about Finding Dory, second grade, and swimming. I make out a bluish tinge along the wrist which we sometimes call the "intern vein" and he doesn't even flinch when I get it.

It's strange how anesthesiology involves so much, so many procedures, so much cerebral decision making, but on some days, the most satisfying thing is a simple IV.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Tuesday, August 02, 2016

Types of Anesthesia

I was recently asked by a patient, "How many types of anesthesia are there?" It's an interesting yet odd question because I wasn't sure how to answer it. One interpretation might be that anesthesia can be delivered as a general anesthetic, through a neuraxial technique (like an epidural or spinal), through a regional nerve block, through local anesthetic, or as IV sedation. But I'm not sure that's how I think about it. In my mind, anesthesia is a sophisticated art and science where the nuances, details, and decisions matter, and that is what distinguishes each individual anesthetic.

Although the vast majority of anesthetics are performed with a limited number of medications and agents, the tailoring of an anesthetic to a patient, surgeon, and procedure is rarely "cook-book." I was talking to an anesthesiologist at a different institution and we were surprised how differently we do our anesthetics. Most of it is institution-specific; the culture of a place affects the medical decision making. At this hospital in New York, for example, anesthesiologists use a lot more laryngeal mask airways and rarely use long-acting opiates like hydromorphone. When I moved from an academic hospital to private practice, I adjusted my anesthetic techniques to the medications that were available. It's a good reminder that there's no "one right way" to anesthetize a patient, and that a lot of different factors influence our decision making.

Sunday, July 31, 2016

Therapy and Socioeconomic Status

One thing about therapy and counseling that troubles me is the cost. I've always been surprised by how expensive it can be, and not all therapists accept insurance. What they do is amazing and certainly worth the price, but the expense means there are be barriers to access. Mental illness is certainly more prevalent in populations that are poorer, though this is correlative and not causative. But even aside from psychiatric disease, many people simply need counseling for itself; we go through hurt, loss, and tragedy, and most of us don't have extraordinary coping skills. 

How can we lower the barriers to counseling? Like medical or dental insurance, I think mental health and personal well-being resources should be available to anyone. Depression, grief, anger, and addiction can be just as life-altering as cavities or a broken bone or a heart attack. No one should have to pay hundreds of dollars out of pocket to address these issues. And I think ultimately, society will benefit. With good counseling, patients may need fewer medications, be more productive, and be less likely to get involved with gangs, drugs, and violence. We need to increase the number of providers, lower the cost of getting help, and expand access to this critical resource.