Sunday, May 22, 2016

Book Review: The Water Knife

I guess I really do like books about dystopian post-apocalyptic futures. I was talking to an old college friend of mine the other day, and we realized how much we've changed with what we do during our free time. Before medical school, I would read books like House of God, pursue philosophy treatises, try to understand the movies critics liked. Now, I read and watch a lot more fantasy. Escape is an important form of well-being, of decompression. There was a time when I thought I ought to fill up the entirety of my day with productive work, and sometimes I wish I had that kind of commitment. But then I realize how necessary it is for me to simply retreat into something I enjoy, something apart from the emotional tenacity of patient care. It's not that I need something mindless - I don't own a TV - but I need something that sparks the other faculties I enjoy: creativity, art, movement, wonder, imagination.

In The Water Knife, Paolo Bacigalupi paints a vivid picture of a world without water. This hits close to home as California weathers drought after drought. The world is a cutthroat every-man-for-himself situation where each state and city vies for rights to water. It touches on environmentalism, culture and society, espionage, and technology, but ultimately the story is about a journalist, a spy, and a refugee, all struggling to survive. It's beautifully written and tantalizingly addicting, though the world created is harsh and violent. It's not a must-read, but I did thoroughly enjoy it.

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Friday, May 20, 2016

Book Review: The Heart Goes Last

I'm becoming a real fan of Margaret Atwood. What an amazing writer! Like many novels I've been enjoying, The Heart Goes Last describes a dystopian future where limited resources and economic crises cause tremendous social turmoil. One community devises a solution where citizens take turns being prisoners. It reminds me a lot of the Stanford Prison Experiment. The novel probes provocative questions of free will, conformity, infidelity, happiness, psychology, euthanasia, sexual drive, and technology. What would you give up to have three meals a day and a bed to sleep in? Would that make you happy? The book was written in serial form online and has a Charles Dickens-esque nature to it where it can be a little uneven, but for me, I enjoyed the rollercoaster ride. Her writing is exquisitely beautiful; even the title is a hauntingly beautiful phrase. I can't wait to see what she comes up with next.

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Tuesday, May 17, 2016

Procedural Efficiency

In private practice, efficiency makes a big difference. On one exhausting night in labor and delivery, I ended up putting in four epidurals in the span of an hour. Consenting for, placing, and setting up an epidural in fifteen minutes is not that challenging, but doing it consistently for four epidurals was tough for me. When you're the only anesthesiologist around and there's a queue of procedures, you learn to optimize everything. It reminded me a lot of how I taught procedures to residents when I was a fellow. I think that developing a routine is the most important thing. By doing each procedure the same way, I don't forget details and I avoid wasted movements. I teach this to senior residents placing central lines: each motion matters, plan ahead, anticipate the next step. I learned from doing nerve blocks that positioning makes all the difference; adjusting the height of the bed and helping the patient get into the fetal position can make the impossible epidural easy. And I also learned from having challenging procedures how to recognize when something's not going to be easy. Sometimes the patient is morbidly obese; sometimes she moves with each contraction; sometimes the anatomy just feels off. When this happens, it's important not to simply proceed by rote; this is when clinical judgment is important to recognize the situation and change the routine to accommodate it. Just like anything, even after the initial learning curve to become proficient with a procedure, there's still a lot to improve in order to master it.

Sunday, May 15, 2016


A forty year old woman with cocaine addiction unfortunately presents with a massive stroke from drug use. She is clinically brain dead; although her heart, lungs, kidneys, liver, intestines, and other organs are uninjured, she has no neurologic function. She is homeless, but our social worker (sometimes I think of them as miracle workers) discovers that she had a son who she gave up for adoption. The son had turned 18 a month before, and he had left his foster home and was living on his own. We contacted him and he came in to see a woman he had never met, his biological mother, and to tell him that she was going to die (technically, she was already dead because brain death is equivalent to death).

I could not imagine what must have been happening in his mind or heart. How hard it must be to grow up for 18 years without a mother, having those emotions brew and churn, struggling to find closure. How earth-shattering it must be to have that world change. What a shock and scare it must be to finally meet one's mother in an intensive care unit, unresponsive, on a ventilator, at death's door. It is hard enough for any family member to see a loved one in the ICU, but to have a teenager wrestle with death for an estranged parent - that was something else. Although I did my best to support him, I leaned heavily on our social workers and chaplain to guide him through this terrible ordeal.

Thursday, May 12, 2016

Societal Values

What does society value and what do you do when those values are contrary to your own?

A long time ago, when I was in high school, I volunteered with a group that mentored elementary school kids. For part of our curriculum, we looked at the media, how it portrayed our heroes and villains, and what this reflected about our society. I came to understand how media and culture shapes our values. These elementary school kids, ages 8 to 11, would watch wrestling and trashy tabloid talk-shows and violent movies. These made such profound impressions on them; they had terrible preconceived notions of sex, violence, race, drugs, education, and even success in our society. We had a lot of work to help these children.

I don't pay much attention to the media these days; I have no TV or Netflix, just the Hamilton soundtrack on repeat. But the primaries have triggered this question for me again. What are our society's values? Are they the values I have? Our potential presidential candidates reflect a scary set of values and character. On the one hand, we have a candidate characterized by outlandish comments, bravado, arrogance, and racist and sexist statements. As the delightfully snarky Economist describes him, his "beliefs lack coherence or much attachment to reality." But on the other hand, we have someone who seems above reproach and immune to punishment for having classified documents on a personal email account. If I had patient information in my email, I'd be fined and jailed.

I don't want to blog about politics or policies, but simply want to ask why our society puts up with bullying, selfishness, and hate-mongering. Why our society puts up with someone who is not accountable, beyond reproach, able to do anything without being punished? Maybe these traits are lesser evils compared to the other qualities they bring, but these candidates don't reflect my values.

I chose a profession that tends to the sick; that turns a blind eye to disease, age, race, gender, sexual orientation, socio-economic status; that is bound by a code of ethics; that seeks to be humble. I am not a businessman, entrepreneur, political insider, media mogul, or great leader. I try not to be selfish. I try to give more than I take. The policies I care about most are those that affect my patients. I hope these values, my values, are not lost to our society.

Sunday, May 08, 2016

Never Seen a Doctor

Anesthesiologists like to have all the information available. We can get a little obsessive over when an echo was done or the last time an alcoholic drank or which medications the patient took this morning because it can make all the difference between a smooth well-prepared anesthetic plan and a scramble to keep things under control. The worst, though, is the situation where we know nothing about the patient. A victim of a car accident is brought in by ambulance with an open fracture needing reduction and fixation. I'm on edge because maybe the patient is on methamphetamines or maybe she has a heart condition or maybe she is allergic to an antibiotic I'm about to give or maybe she's on dialysis and nobody thought to check for a fistula. This is one of the reasons why I don't like trauma.

But even outside of trauma, these situations happen. An older woman is brought in for an acute abdomen. She's never seen a physician. Her blood pressure in the emergency department is 200/100. She is audibly wheezing. All I know is that she smokes. She's never been to a hospital, doesn't take any medications, has never had surgery. While sometimes a patient who's never been to a hospital is lauded for keeping good health, I had a hunch this wouldn't be the case. Her dentition suggested she'd never been to a dentist. Her scleral icterus suggested she might have liver problems. Her wheezing could be heard without a stethoscope. She had a hacking cough that brought up thick yellow sputum.

This is why emergency cases are riskier and more challenging that scheduled elective surgeries. After I intubated her, I noticed that her capnogram suggested severe chronic obstructive pulmonary disease. I struggled to keep her blood pressure from bouncing too high or too low. She could have heart disease no one has diagnosed. Her abdominal pathology could be causing her to go into sepsis. The endotracheal tube kept getting flooded with secretions from her 50 years of smoking. In cases like these, I have to have constant vigilance and high standards for care. At the end of the case, I waited a long time to make sure she was able to manage her breathing before extubating her. I stayed in the recovery unit getting her blood pressure into an appropriate range. These are things we should do for all our cases, but for someone whose diseases are uncontrolled, it requires constant attention and intervention.

Wednesday, May 04, 2016


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.

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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.