Poem: Sequel

Sequel

Before writing the sequel to my life this afternoon
I close the shutters, take off my wristwatch,
and draw up fresh ink into my fountain pen.
There will be a girl named Japonica
and a castle named Elsinore
and I find myself a different era
with the heft of crossbows and the ring of chainmail,
imagining the rumbling gallop and tossing manes
of Destiny or Legend or Lore, some farfetched abstract
so different than Mortgage or Benefits or Tuition.
I will wield a Sword of Virtue or Lance of Purity,
not this Checkbook of Numbers
or these Car Keys of Convenience.
Bereft of daydream, this world will have more
flavors of tea, more dances, more colors of roses.

Surgery

I am currently on an eight week surgery rotation at Community Regional Medical Center in Fresno. The hospital is the only Level 1 Trauma Center between Los Angeles and the Bay Area, and it has a huge catchment area. It's busy and it's brutal. We spend four weeks on the elective surgery service which treats hernias, gallbladder diseases, and colorectal diseases; two weeks on trauma; and two weeks on burns and plastic surgery. The patient population here is diverse; Fresno has one of the largest Hmong populations in the U.S.

Orientation was ridiculous. We had a full day of lecture and anatomy lab (8-5pm) after which we had to drive 200 miles from San Francisco to Fresno so that we could arrive here ready for orientation at 8am the following morning. I realized how much I have forgotten about the abdomen and anatomy. It will be a daunting rotation.

Image is in the public domain. "A thoracic surgeon performs a mitral valve replacement at the Fitzsimmons Army Medical Center," taken from Wikipedia, originally from the Department of Defense.

Specialties

In the past, I had never put much thought into neurology and its related specialties. This rotation was good for me to think about whether I want to be a neurologist. I really like the brain; it's a fascinating organ, we're breaching the frontier of neuroscience, new therapies are being developed, the impact of brain-related diseases is tremendous, and the symmetry (mostly) of the brain satisfies my OCD tendencies. There's an overlap with psychiatry as well as medicine; some drugs work for both neuro and psych conditions (yet I don't think we can explain on a molecular level how epilepsy is similar to bipolar disorder) and there's a tight relationship between cardiovascular parameters and neurologic function. As a specialty, I don't think I'm heavily considering neurology at this point; I don't see myself in the resident's shoes, and I don't get as excited about managing common neurologic problems as the rare ones. While outpatient complaints interest me now, I think they will eventually become routine. And even though inpatient neurology has great pathophysiology, I simply don't like comatose patients. None of the crazy sub-sub specialties interest me (epilepsy, neurovascular, oncology, neuromuscular) except maybe neuro infectious disease. Outcomes for many neurologic diseases are devastating and rehab is the only treatment we have at this time. I think I might be interested in doing another rotation in neurology (consult at Moffitt), but to learn rather than for a future career.

I also got exposure to neurosurgery and neuroradiology, neither of which makes my list of future fields. Neurosurgery is impressive; of all the organs to do surgery on, nothing beats the brain. But I don't think I am built for the stress and pressure of it. Being a neurosurgeon is equivalent to being a movie star. Also, the pathology, while interesting, is limited mostly to mass lesions such as tumor and bleeds, craniotomies for increased pressure, and insertion of devices such as ventricular drains and brain monitors. Neuroradiology, too, is simply not for me. I'm just not into brain anatomy and MRI. Interventional would be very cool but I'd probably go the route of neurology to interventional neurology if I chose to do that.

Neurology 110

To be honest, I was miserable in neurology at first; I was not used to the schedule or the residents and I had trouble adjusting from family medicine and consult psychiatry where I interacted directly with attendings and had nice hours. It also took a while to remember neurology and get comfortable with the examination. Tough parts in the clerkship included my first coma exam, my first ICU patient, my first call, my first death.

But at the end of the rotation, I felt pretty good about neuro. Our residents for the last three weeks were great, I love ambulatory clinic neurology (headache and vertigo are great medical student cases), and I saw interesting (and scary) pathology on the ward service. I became comfortable with the management of stroke, seizure, and comatose patients. I developed a good rhythm and pace for doing the neurologic exam. We got good teaching, oversight, and feedback from residents and attendings. I felt that I was able to contribute to the team and to patient care. I enjoyed ICU pathophysiology. I'm sad I didn't get to do an LP, but I think compared to what I hear from other classmates, I got to see more patients, do more, and have more responsibility at SFGH.

On a side note, on my very last day of my neurology rotation, I saw one of my psych consult patients who had previously been bedbound and depressed out walking with PT and with a smile on his face.

Diagnostic Challenges

One aspect of neurology I really enjoyed was the diagnostic challenge. We had several people on our service over the month that defied diagnosis despite impressive attempts at tracking down the cause of dementia or coma or other clinical presentations. Most recently, we had a man in his 40s come in with a month history of headache and dizziness. On CT scan, he had a rim-enhancing mass in his cerebellum suggestive of tumor or infection. But a chest X-ray showed an impressive reticular opacification (ground-glass) of bilateral lungs, mostly in the periphery. This became the topic of discussion among neurology, pulmonology, and radiology. Occam's (Ockham's) razor dictates that one cause must be causing both conditions. The patient only had mild dyspnea and cough; he otherwise looked pretty healthy. It was fun seeing how excited everyone got with this diagnostic mystery and the responses of the audience at neuroradiology conference. In the end, the pulmonary consult team guessed that this was a rare manifestation of an atypical infection in an immunocompetent host: Nocardia spreading to the brain.

SFGH

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tossed to me,
I lift my lamp beside the golden door!"

This phrase seems apt when thinking about San Francisco General Hospital.

Poem: Dying

Dying

Her hair was cut short in the style of a Japanese pop star,
a prevenient wild, calculated to pull one’s attention
from the brewing storm, the nurses securing a line,
the frantic whispers, the wallflower medical student.
Assigned the name Giraffe as she rolled into the ER,
I wondered about her real identity, what TV shows
this eight year old liked, who her friends were,
whether she would want to be called Giraffe.
An anime face, her pupils were wide and doll-like,
comforting to those who knew the least,
holding her hand, whispering release,
rolling orange polka-dot socks onto her feet.

Eulogy

I've written and re-written this post multiple times, attempting to "get it right." It is written in honor of a family I met at 9pm on my last call night for neurology, coincidentally the same day I wrote the previous post on brain death.

The technical details aren't important. We were called to consult on a case of an 8 year old girl with Rett Syndrome (a severe disorder of developmental delay) who presented with cardiac arrest. Like the woman of the previous post, her heart was beating spontaneously after resuscitation, but she showed no brain stem activity. Most likely, she will have withdrawal of care today.

What struck me most about this was the feeling I got deep down in my gut, that stereotyped heart wrenching upon seeing the parents who had struggled eight years to keep their very sick daughter alive and comfortable, now confronting her brain death without a significant chance of recovery. What must it be like to experience the most horrible thing imaginable: a parent seeing their child die prematurely? How does one find reconciliation in this world, how does one deal with guilt or blame or if-onlys? How does one say good bye? There was nothing good about this situation: the balled up tissues, the welling of tears, the cold sweats, the helplessness.

Tragedy has many faces and she shows herself at the most unpredictable of times without remorse, without apology. No matter how hard we try to navigate our crafts, no matter our courage or experience or ideals, we cannot control how mercilessly we're tossed in this sea churned by fate. I cannot really describe how I feel. I'm not sure I know how I feel. But part of medicine is tiding people through the worst of times, seeing how people cope and respond to the extremes of circumstance, and learning how best to conduct such etudes. Watching someone die is hard but within my scope of ability. Watching a parent watch her child die, that's infinitesimally harder and something that demands explanation or apology but finds any response wanting.

The Celestial Discharge

We have a patient in the ICU with an unfortunate new onset atrial fibrillation that has caused a basilar artery clot and brain death. She is unresponsive off of sedatives, has no brainstem function, does not clearly initiate breaths, and is not going to recover from this state. She meets brain death criteria, a theoretical and intellectual checklist. But actually dealing with this patient has taught me the nuances of end-of-life care.

The patient's heart still beats. With ventilator support and aggressive management, we can keep her in this comatose state indefinitely. Yet she has practically no chance of recovery or change. She's stopped thinking and feeling, and those qualities that we associate with "being human" are irreversibly damaged. On a technical note, I got to observe cold caloric testing of brainstem function, transcranial doppler, and an apnea challenge.

The ethically correct thing to do is to withdraw support. People may believe that so long the heart beats, the person is "living" but I am inclined to say that which made her the person her family loved is now gone. Reconciliation is difficult, but now is the time for closure. At the family meeting, family members were on their knees begging. Her youngest child is 13. They cannot understand why our abilities are so limited, why anything we do now is futile, how we can say there is no chance for improvement and turn away.

There are so many ways to approach this problem. Would you like to be in a comatose state with no chance of recovery? Would you think about organ donation? If you were the organ recipient, a person with longstanding kidney failure with dialysis beginning to fail, how would you approach this situation? As a taxpayer, it is costing thousands of dollars a day to maintain her in an intensive care setting; is it worth it? Yet what if you were her family member and sanctioning withdrawal of care feels akin to murder?

I have a particular stance on this issue. I believe the intensive care unit is not a place for people with no hope of recovery; ICU is intended to support those patients with a reasonable chance of leaving the unit. I am sympathetic to the costs to society and to the limitations of medical ability. Though I believe in supporting someone until all the family members can reach the bedside, I don't think it is prudent to support someone indefinitely to appease a family, dissuade medico-legal action, or avoid the feeling of guilt and failure. It is time to say goodbye.

Longitudinal Clinical Experience

As part of the third year, we have a Longitudinal Clinical Experience or outpatient continuity clinic. This spans the entire year and consists of 22 half-day sessions with an outpatient preceptor. I actually had a few logistical problems; the first two assignments I had did not work out even though they were with a cardiologist and a pediatric cardiologist, my top choices (along with emergency medicine). Finally, after 3 months into rotations, I got assigned to a hematologist-oncologist who works at California Pacific Medical Center. Today, I'm going to blog on the patient population.

California Pacific Medical Center is an interesting place; it is made up of several large private hospitals and caters to a higher socioeconomic population. I find it striking coming three miles from San Francisco General to CPMC. At the General, a substantial number of patients are poorly clothed if they are clothed at all; they may be covered in bodily fluids; they are emaciated, homeless, jobless. It's a remarkable difference compared to those who come to clinic at CPMC dressed in a suit and a tie, reading The New Yorker, talking about buying a new BMW. I've met the CEO of a big steel company, a local film director, a retired pathologist. Patients talk about sailing on a boat in the Mediterranean, carry an Apple iBook to their appointment, make recommendations on wines.

It's a good experience seeing different patient populations, but I honestly have mixed feelings. There will always be someone to take care of the rich; there's no doubt about that. But it takes considerable dedication to devote one's life to helping those who can't help themselves, the drug users, the poor, the homeless, the jobless. There is a big sacrifice in that. The middle to upper class patients show up on time, they are respectful, rational, educated, they bring gifts, they ask about your kids. They get sick too, and certainly if you're good at what you do, you can make a good living by catering to this population. The facilities are nicer, you can get the tests you want, your patients get their medications, you have technology at your disposal, they have a place to go when they leave the hospital. So I don't know. I feel strongly for serving the underserved, and I feel that it would be hypocritical to get one's training from the poor socioeconomic class and then reaping the benefits serving the rich. Yet I can see the appeal of putting yourself in a position with financial and emotional resources long term.

Jail Ward

I finally got a patient in the jail ward. It's been described as an "extension of the prison" and to some extent that's what it feels like. A police officer has to buzz you in through multiple security doors that look like an airlock. All the rooms have multiple windows for guards to watch; there are no bathrooms, just a toilet and sink in an alcove. We are not supposed to tell inmates when they will be discharged. But otherwise, medicine is the same; I examine my patient (careful not to close the door, otherwise I'd be locked in) and write my notes and put in orders. It's actually less exciting than it sounds.

I heard a ridiculous story though. Apparently, it's not uncommon to have a prison inmate who has some severe medical condition leaving them paralyzed or unconscious. Yet even in those circumstances, they handcuff him to the bed and place a guard outside the door.

Poem: The Dead

The Dead

The Dead are not here
not reading the new yorker, propped in bed
unshaven uncouth grin when I come knocking

The Dead are not down there with the writhing bodies
the pain, the wolfing down of mashed potatoes
once I clear the drooped face for swallow

Nor are the Dead hiding in the machines, the octopus
rammed down the throat or the collar
of the high vicar like the spine of a book

The books don’t contain The Dead
I’ve looked a dozen times between De Quervain
thyroiditis and deep vein thrombosis

Jokingly, I search for The Dead in the cafeteria
among the saltless foods, the mystery sauce
the misery sauce that makes us do what we do

The Dead aren’t what we do, but haunt us
like phantoms, thunderclouds, armies of widows
who wring their hands and say, what now
and the best answer we have is to follow suit

Problems with Healthcare

I can't write an overarching big picture argument so I am just going to focus on things I have noticed. We have a gentleman on our service who has suffered several strokes. All the diagnostic workup and treatment is done; what he needs now is rehabilitation. His insurance (Medi-Cal) won't pay for him to go to an acute rehab facility so he stays in the hospital. The hospital costs a lot more than an acute rehab facility would and it will lead to poorer outcomes for the patient (since rehabilitation is more effective early and hospital acquired infections are common). There's nothing we can do so he is indefinitely on our service without a significant hope of recovery even though a cheaper and more effective alternative exists.

The clinic is overbooked so that multiple patients are scheduled for the same 15 minute slot. Patients wait hours after their appointment time in order to be seen by a doctor.

A "stat" CT is ordered for a patient with a life-threatening stroke as a result of domestic violence. It takes four days for her to get the scan even with medical students harassing the radiology techs.

The emergency department overflowing such that I found my patient not in a room, but in "Hallway C, Bed 2."

Brain Drain

I'm a little over half way done with the neurology rotation. Things have gotten better; even though the hours are pretty bad, at least now I have time to blog. The attendings on this service are fantastic. Our new attending is ridiculously smart; he can pull out obscure Latinate descriptions of diseases when discussing any sort of case. He's really enthusiastic about teaching and his differentials have an obscene number of zebras (acute intermittent porphyria, inclusion body myositis). But it's fun, I'm sort of adapting to the q4 call schedule and the pace of things here.

We recently had a "mini clinical performance exam" where we did an observed history and physical of a standardized patient. It seems kind of silly since that's what we do every day, but I guess they like to make sure everyone is on track with things. I'm almost done with my outpatient psychiatry clinic and I've really enjoyed it; the patients are fascinating and motivated to change, the preceptors give us a lot of responsibility, and I'm making a difference in an underserved population.

A Day in Neurology

A 90 year old Holocaust survivor with a history of a stroke was assaulted in an elevator, his wallet stolen. He was admitted to our service for an expressive aphasia. He could understand everything we said and follow complex commands, but he couldn't repeat or say anything. When shown a tie, he could not name it but if given a list, he could point at the correct word.

A man who suffered multiple brainstem strokes, now "locked in" so that he can only move his eyes.

An older Cantonese gentleman who is active, conversant, wandering around the hallways but does not understand that his cognition has been destroyed by neurosyphilis.

A Filipino woman who had rapidly progressing dementia with language problems, gait instability, and personality changes. She puzzled the service for months; we ran every test would could think of and yet couldn't diagnose her. In the end, we had to do a brain biopsy, which unfortunately showed primary central nervous system lymphoma.

A young African American woman who presented with a severe right brain stroke. Her left arm and leg are completely paralyzed. On further history, we found that her boyfriend had hit her in the jaw, causing a tear in her carotid artery which sent a clot to her brain. We contacted social work and the police because of domestic violence.

An older man who says he "suffered a massive stroke" and laments that he is "completely paralyzed on his left side." Meanwhile, he is seen eating with both hands, adjusting the TV with his left hand, and eventually sauntering down the hallway with the help of physical therapy. Yet all the while, he said he was completely paralyzed and could not be convinced otherwise. He is now in psychiatry.

An inmate from San Quentin, allegedly in for selling oxycodone, presents with transient changes in vision. He was handcuffed and shackled, accompanied by a police officer.

A woman with a massive bleed into the brain due to a ruptured aneurysm. Neurosurgery took her into the operating room at 8am to clip the aneurysm. She did not return to the intensive care unit until 5am the following day; it was a 21 hour surgery.

Mapping the Mind

Yes, I am actually writing a book review. I read Mapping the Mind by Rita Carter, an interesting nonfiction book that explores the fascinating story of the brain. Written for laypeople, it goes into considerable scientific depth about how the brain works, what we know about neurologic and psychiatric diseases, and the amount we have yet to learn. The content surveys a broad range of material that would appear in an introductory psychology course from memory (HM) to executive function (Phineas Gage) to emotions to language. It's a good read if you have spare time, but it would be something to peruse for interest rather than knowledge because it is only covers topics in cursory detail.

Image from www.ritacarter.co.uk.

Poem: Locked In

Locked In

Dreamed of chasing the sun across the British Empire,
a cartographer of ancient imperialism,
but I failed history and took up road-tripping
California to Illinois until I was waysided by Reno.
Slowly the world enclosed on me, victim of debt, harried by lawyers.
If only I could pay enough to find a better job,
leave this state without calling the parole officer
without the restraining order
without thinking of the kids or the money or where I would start
without the failures, the mother on dialysis, the heroin,
just to see a coast again, a seagull, a fish, an untamed ocean
before a series of strokes takes my right side,
and my left, my eating, my face, my words,
leaving only eyes which cannot even close properly.
Every morning, the student comes,
I see his eyes a pity, a misunderstanding,
a question of how I escape these walls
how imagination persists and sustains.

Team Dynamics

Team dynamics make an incredible impact on the experience as a medical student. I've had "bad" residents who are really inefficient, impolite, and poor role models. They might make students do more scut work (busywork) than we really should; I've been asked to do excessive non-emergent stuff for patients I wasn't following, and I thought that was unnecessary. I've seen residents have poor attitudes and interpersonal relationships with staff. And I can tell when residents don't feel that teaching is their responsibility. On the other hand, I've had really excellent residents who set aside time for teaching even on their post-call days. They will give us constructive feedback about how to "look good" for the attending, show us how to do a good physical exam, and thoroughly read our notes. These residents don't use students merely as ways of expediting their own work; they instead encourage us to identify and pursue what we think would be valuable.

Power in the Hospital

We have a patient on our service who had a stroke and needed a PEG (percutaneous endoscopic gastrostomy), a feeding tube placed directly into the stomach. This was the only thing she needed before she could go to a rehabilitation nursing facility. We put in the order to interventional radiology on Monday, but they said that they were too busy and would not get around to it until the following week. They wouldn't budge.

We decided to expedite the process by calling utilization review, the group that analyzes costs and expenditures in the hospital, telling them that this PEG procedure was keeping this otherwise medically cleared patient in the hospital. The PEG was done on Wednesday. It's scary how the bottom line can make immovable things happen.

Clock

Only one of my call nights so far has been particularly eventful, but it was intense. I was working up a consult (vertigo vs. syncope) when we got paged at around 5:30pm. The woman was found unconscious at a bus stop at 2:30 and brought to the emergency room. She was worked up for coma which most often suggests a metabolic abnormality or intoxication. To get coma, a lesion has to hit bilateral cerebral cortices, bilateral thalami, or the brainstem. Usually, only a global cause (infection, electrolyte problems, drugs, hypoxia) can do that damage.

However, the ICU team receives normal labs and begins thinking about other causes of coma. They call us to evaluate for stroke. The call resident sees the patient and rushes back reporting that she thinks it may be a basilar artery stroke - nearly the only place that an embolic stroke can cause coma by hitting bilateral vertebral arteries.

Upon hearing of an evolving acute stroke, the residents sprang into action. It was dramatic. The patient was about 3.5 hours out from baseline. Treatments for acute strokes are highly time-dependent. Intravenous tissue plasminogen activator (tPA, a "clot-buster") can only be given within 3 hours. Intra-arterial tPA is given within 6 hours, but a basilar embolus of this size was not a good candidate. The last alternative is embolectomy, sending the patient into surgery where an interventional radiologist pulls out the clot. This is limited to 8 hours (but often extended in basilar clots because they are so serious).

The one person who can do this intervention at San Francisco General Hospital is out of town. We begin putting into motion everything needed to get her over to the main UCSF hospital. We call the admitting neurology team there, get an interventional neuroradiologist, fire up the operating room, assemble the anesthesiologists, identify the nurses, prepare a critical care ambulance, contact the durable power of attorney, hold a family meeting, fill out the paperwork.

We need to get this woman into the operating room as soon as possible. Every minute is brain tissue lost. She went from a perfectly functional woman taking public transportation to a completely unresponsive unconscious person likely going to die from brain edema and herniation.

Unfortunately, what eventually happened was the durable power of attorney declined the intervention. We felt this was an appropriate interpretation of the patient's wishes and an ethically and legally valid decision. We put in a ton of work and in the end, we withdrew life support care from the patient the next afternoon. But our job as the medical team is to give patients (and their legal decision makers) the ability to make decisions about their care. This is just the way life and death go.

Teaching

During attending rounds, the teaching style is interesting. We discuss a patient that was admitted the night before, but the attending really probes our thinking. For example, given a certain history, what are we looking for on physical exam? And given that, which lab tests will be normal or abnormal? It sounds simple, but is quite difficult to think in this fashion. While I'm taking a history, I start formulating an idea of what's wrong. But I haven't learned to translate that into tailoring my exam to proving or disproving my hypotheses. I almost always do a standard exam, record the abnormalities, and ponder afterwards whether those make sense. I suppose this takes time to learn.

We also go over paper neuro cases in a small group discussion format once a week. This shores up any deficiencies in our learning. I like these sessions because they are a familiar style of learning and have high efficiency in covering material. Once a week, a neurosurgeon comes to discuss a case with us, expanding our learning to issues such as craniotomy, ventricular drains, stereotactic biopsies, lobectomy, etc. Once a week, we also have neuroradiology rounds when we go through MRIs and CTs of the brain, interpreting scans.

Neurology

The goal for the neurology rotation is to learn a good neuro exam. All of neurology involves "localizing the lesion" and apart from expensive imaging studies, the exam is the best way to solve these puzzles. Is the weakness peripheral in a proximal distribution (myopathy) or central in a pyramidal distribution (stroke)? Where would a stroke have to be to mimic this set of symptoms? Neurology is highly intellectual and requires a lot of critical reasoning. Over the past week, I've become better at remembering, performing, and reporting the clinical exam but it's still very difficult to figure out how the findings fit together.

Our inpatient service is busy and involves a number of strokes as well as a few "zebras" such as neurosyphilis and primary CNS lymphoma. It's a little disappointing and depressing that recovery is unlikely for many of our patients. One is nearly locked in and can only move his eyes; a few may be good rehab candidates. Neurology is a field in which the therapeutics are limited.

Clinic occurs twice a week and I really enjoy it. Students see only one patient but we do a pretty thorough history and physical. The complaints are outpatient based such as vertigo, headache, medication management, seizure, and movement disorders. It reminds me of family medicine. On the last clinic, I saw my first inmate patient, complete with handcuffs and shackles in an orange jumpsuit followed by an officer. He was complaining of amaurosis fugax, an eye finding in possible stroke. Surprisingly, it was a very normal interaction and I felt no conscious difference between seeing him and any other patient.

Poem: Sunday

Haiku is a good form for busy weekends.
-
Sunday

elevators on time
carrying white coats like ghosts
through the silence

Surgery Pun

With regards to the wii surgery game "Trauma Center," one of my friends commented:
"If we play the two-player mode, it'll be co-operation."

Cupcakes

Image from Flickr (jdesmeules) which a friend found for me.