Cardiology

My month on cardiology was very educational. I am much more comfortable with both EKGs and echocardiograms, staples in medicine and anesthesia. Bread and butter consults included chest pain, atrial fibrillation and flutter, and pre-operative evaluation. Interesting consults were mostly strange arrhythmias, both bradycardic and tachycardic. I became more familiar with the wide selection of rapidly evolving cardiac drugs. The rotation was also highly evidence-based, as much of cardiology is, and I really appreciated that. We were able to see the cath lab, transesophageal echocardiograms, and other procedures. We acted pretty much as interns, with a good scope of responsibility and sufficient oversight.

Ever since I did research on beta-adrenergic receptors in the heart, I have loved cardiovascular physiology and pharmacology. The medicine of cardiology will always have a place in my heart (okay, I admit I intended that one). But after this rotation, I have become very excited about cardiac anesthesia, using real-time echocardiography and managing patients with complex comorbidities. If I had instead decided to go into medicine and then cardiology, I think electrocardiography is where I'd end up because I never get tired of the EKG. Cardiology has a lot of analytic problem solving which caters well to my way of thinking.

The Doctor

I find this 1891 painting so powerful because it captures the emotions of the family and the bedside physician. Image of "The Doctor" by Luke Fildes is in the public domain, from Wikipedia.

Poem: The Thirteenth Labour of Hercules

The Thirteenth Labour of Hercules

They tell of beasts of legend
as if they were dominions of the past
from an age of deity and fire,
whose monsters tremble with earthquake
and faces that turn tides
whose pets command oral tradition
passed down from one smoky fire
to another, shadows upon the wall
acting out prisoner and prison,
both captivating narrative and
a narrative of captivity.
Plato told us so much, at least
to those of us who dug.
Those of us, lonely and forgotten
who never knew Popularity
who developed gout and arthritis
as we waited to become kings,
lying on our backs, our necks craned
to the next page, a Republic unfolding.
Hydra, Bull, Stable, Cerberus,
fictions that beg time and again
a little ignorance, dowsing for moral
spent shackles in shadow.

Narrative Medicine

I am taking an elective this quarter called Narrative Medicine which seeks to use short stories from and about underserved and "underheard" communities to understand narrative approaches to health, illness, and medical practice. The first story we read was not directly health-related but a wonderful story called "The First Day" by Edward P. Jones. One question that came up about this story is context. Knowing background on the author changed people's perception of the story. Some found that the story was less genuine because the author was male and the perspective in the story is from a female. This was fascinating to me. Should stories be evaluated solely on their own merit? How much should external context affect our reading of a story? In my experience, academics like to critically analyze stories in relation to their author, the historic setting, and the cultural backdrop of the time. How can you teach or read "Everything That Rises Must Converge" or "Parker's Back" without knowing Flannery O'Connor's Southern, Roman Catholic background? How can you interpret Joyce without referencing Dublin? Nevertheless, when I read stories, I never look up the author or the sociocultural context. I am sure subconsciously, I am aware of the author's name and perhaps other works, but I enjoy stories and find them noteworthy solely based on the text.

I find this interesting in medicine because we always see patients in a context. Whether I am seeing a patient in the emergency department, at a homeless clinic, as a consult in a tertiary care center, or in a home visit, the location makes a difference. I almost always have some pre-existing information about the patient. In clinic or the emergency department, it may be nothing more than a name and age. On the other hand, volumes of records may accompany patients, and even if I don't read a single word, the fact that volumes of records exist influences me. If I get a "one-liner," that can change everything. "A 25 year old intravenous drug user who is a frequent flier in the emergency department" is different than "an 80 year old recent immigrant" which is different than "a 40 year old businessman." Even before I get the story from the patient's mouth, I think I know a lot about them, and I may already have a list of diagnoses in my head. Is this fair? Is this right? Am I typecasting people before I have even met them? I think context will always be important in patient care, but like stories, I must evaluate the story based on what the patient tells me because after all, he or she is the person I am treating.

Online Professionalism

A recent article in the Journal of the American Medical Association commented on a surprising incidence of unprofessional online behavior by medical students. With technologies like Blogger and Facebook that allow users to interface with the public, there is an unexplored territory of ethics, professionalism, and legality. There is little explicit guidance to what is and is not allowed with rapidly evolving Internet applications. A recent study surveying medical school deans found that students have indeed been cited for unprofessional behaviors online. As this has direct relevance to this blog, I figured I should comment on it.

This blog is not only accessible to the public, it is linked from the UCSF Synapse (student-run newspaper) website. I openly welcome readers from the community and have enjoyed comments and discussion from readers worldwide. Although this is a non-official interface between the University and the public, I am not at all censored and have never had any problems with freedom of speech.

It is difficult to walk the line between sharing something personal and important and violating privacy laws. I make a sincere effort on this blog to avoid any kind of legal, and more importantly, moral violations. I cite any images that I show, and do not show images of patients. I make an attempt to find images that are in the public domain. I purposely do not place ads on this blog. I do recount stories of patient interactions but I omit any patient identifiers and purposely change patient descriptors including gender and age. I avoid libel when discussing colleagues and the University. I am happy to discuss my personal interests, opinions, and ideas, but keep this blog professional. If there is anything on this blog that seems inconsistent, please do let me know and I will remove, amend, or comment on it.

Frequently Asked Questions

Those who've been around the wards know that there are a few questions that attendings and residents like to ask students. Before doing a radial arterial line, you will get asked about the Allen's test; when taking care of a patient in diabetic ketoacidosis, you will get asked about treatment of hyperkalemia; when a surgical patient has a fever after an operation, you will get asked how many days post-op he is. But one question that I've been asked twice so far has to do with the origin of the word warfarin, and so here is its fascinating history.

A strange disease struck Cows of Canada in the 1920s. Cows undergoing minor procedures like dehorning and castration were dying from hemorrhage unexpectedly. A Canadian veterinarian investigated these untimely deaths and found that cattle who ate moldy sweet clover were bleeding to death. He determined that the moldy sweet clover had an anticoagulant property. Twenty years later, Karl Link at the University of Wisconsin decided to isolate this compound and after several years and several graduate students, he was successful in extracting the compound. Their characterization of dicoumarol led to development of the anticoagulant warfarin, named after the Wisconsin Alumni Research Foundation which became rich off the patent. Warfarin was widely used as rat poison. In 1951, a U.S. army recruit attempted suicide by ingesting the compound. He was unsuccessful and recovered fully; as a result, warfarin was studied as an anticoagulant in humans. When Dwight Eisenhower had a heart attack in 1955, he was prescribed the drug. Now it is widely used to prevent strokes in patients with atrial fibrillation, artificial heart valves, and other risk factors for clots.

Image of warfarin tablets from Wikipedia, in the public domain.

First Class vs. Economy

With the issue of health care reform looming over us, I wonder what we can do to change the system. I'd like to mention an idea I had, even though I am not really satisfied with it. I thought of it in the context of the airline industry. Everyone who buys a plane ticket gets a basic level of service: a safe trip from one location to another. Yet a passenger can pay more to get more perks; business class might net some more leg room and first class may come with a gourmet meal. Yet the basic service is the same, travel from one place to another. In the case of an emergency, there's no preference given to passengers of one class over another.

In the same way, everyone deserves a basic level of health care. Under President Obama's plan, this may require everyone to carry some sort of insurance. This minimal level of insurance needs to encompass things like primary care visits, management of chronic diseases, preventative care like vaccinations, obstetric and gynecologic care, psychiatric services, hospital services during acute illness, etc. However, in order to promote competition between insurance companies, plans may offer perks above and beyond the basics. Of course, insurance plans already do this: they come with or without dental or eye care or prescription medications.

But what if this was extended to a hospital stay. Importantly - and this is most important in my eyes - the medical services do not differ. A doctor should not know whether a patient has an economy insurance plan or a first class one. Any physician or nursing services offered to one patient must be offered to another. But there can still be perks - perhaps the patient with "better" insurance has higher priority for single rooms or larger TVs with more channels or valet parking for visitors or flowers on admission. Perhaps they can get childcare or make long distance phone calls or have another bed in the room for the spouse or partner. Even though the medical care cannot differ, there might be a lot of other variables that "VIPs" could qualify for.

Will patients or companies pay more for "deluxe" treatment at hospitals? Will insurance companies use this as a means of enticing different customers or differentiating themselves? I don't know. I'm not sure I even like this idea since medicine ought to be a form of social justice. But given President Obama's desire for an affordable marketplace for health care, perhaps throwing more options into the mix will stimulate the market.

Cardiac Cath

Cardiac catheterization involves injecting dye into the coronary arteries - the blood vessels that supply the heart - to see if there are any blockages. This is the best test for coronary artery disease which can help clinicians determine if a patient is at risk for a heart attack. I hadn't seen a cardiac cath until this rotation, so it was new and fun for me. The difficulty is learning the coronary anatomy; depending on where the camera is positioned, recognizing the vessels can be tricky. But the pictures are quite beautiful and given my interest in procedures, I really enjoy being in the cath lab.

Cardiology has two faces. On the one hand, cardiologists master the physical exam; listening to the heart and assessing a patient's volume status are the two hardest things I do, and every day, I work on sharpening those skills. When confronted with chest pain, the most powerful tool is the history, and in this way, cardiology really rests on the fundamentals of patient care. On the other hand, cardiology has blossomed with technology. Procedures like cardiac catheterization which allows visualization and repair of tiny blood vessels are quite incredible. The heart can be examined by CT, MR, and ultrasound. Stress tests involve nuclear medicine. Cardiology technology really runs the gamut.

Poem: Clemency

Clemency

Hunched along the gum-flecked sidewalks
that shine like mica, they smell like tobacco
and exhaust from municipal buses,
faces haggard for a little clemency
turned away, whether in shame or loss
of faith as men and women walk by.
Almost a part of the graffiti behind them
melted into the wall, curious and implacable;
only children turn heads. Larger hands
and feet shuffle them away. When
they get here, their most overt possession
is their dignity; they know what sandwich
they want, won't settle for another,
and request the corner pocket bed in the back
where they can draw curtains and sleep.

Echos

This is my first formal introduction to echocardiograms and it is really fun. Previously I didn't understand enough to get anything out of looking at the images. But on this rotation, we have formal from-the-basics instruction about how to read a transthoracic echocardiogram. Now I find echos really satisfying to read because they're so rich with information. A lot of it is visual pattern recognition of various views and how valves move, but there is a fairly systematic methodology of looking at images. It also takes practice; when I started, I couldn't see valvular regurgitation, but now I'm beginning to notice the details of Doppler. It's really fun to see pathology, whether it is segmental wall motion abnormalities or a mechanical valve or aortic insufficiency or a thrombus. Learning about echocardiograms really makes me realize how visualizing the physiology or pathophysiology of a process can be key in understanding the clinical syndrome.

Image of the four chamber apical view transthoracic echocardiogram is from Wikipedia, in the public domain.

ERAS

ERAS is that dreaded residency application that divides my classmates into two camps: those beading with sweat, furiously working into the late hours of the night and those who with relief have sent their fate off, awaiting replies with apprehension. Gratefully, I have stepped from the prior camp to the latter. The process has been harrowing. Though it is perhaps a touch easier than the medical school application ordeal, it is still reasonably nerve-racking. Unfortunately, things are less transparent as each specialty has its own quirks, and there are a lot of rumors and hearsay out there. But after wading through the process and reflecting on my past four years and motivations for the future, I'm glad to be done with the first pass metabolism. This process has also reaffirmed my decision for anesthesia and perioperative medicine; the next four years are going to be fantastic. Now that my applications are in, I am simply waiting for replies. If any program directors arrive at this website, welcome!

Belief

A while ago, I wrote a post about a 75 year old woman who was hit by a truck, suffering overwhelming orthopedic, gynecologic, and urologic trauma. She went through abdominal compartment syndrome, several septic episodes, and pleural effusions. She had a grueling ICU course over several months and to be completely honest, I wasn't sure she would make it. At that age suffering that many insults, her prognosis is poor. We held many family discussions, but although they revised her code status, they wanted aggressive care.

Sometimes we eat our words. She was recently transferred from the acute care hospital to a rehabilitation facility. After months of battling injury after injury, she made it out of the ICU and began working with therapists on the floor (not even the step-down unit). At time of transfer, she could talk with her tracheostomy, expressing that she "wanted her food hot." Although she was not at her baseline mental status, I was floored. I thought this woman would not make it, and here she was, learning to get into and out of a chair. True, this is just the beginning of a long, tough road, but I was thoroughly impressed by the miracles of modern medicine. Her transfer summary had 29 diagnoses. She had at least 30 procedures in the operating room. And the eventual discharge plan anticipates that she will go home with family.

Blood/Tear

I took this picture at the Olympic Sculpture Park in Seattle a couple weekends ago. I love the concept.

September 11

Where were you? Where were you eight years ago when plumes like hands sent skyward a warning beacon, a misery unfettered, a poison mistaken for a draught. What were you doing, what images are imprinted upon your neurons, what emotions upon your myocytes? I imagine the electrical impulses cascading from sulcus to gyrus, scaling cliffs of the brain and rappelling down, telegraphs marching out shock and grief. I remember that day. I had not heard until I got to school. Fingers numb, I thought it was the wind. Passing by the windows of a coordinated science classroom, the silhouette of Mr Knight held me. Standing under the TV, his head crooked up at the screen, as if hung by murder. What a piece of work is man! How noble in reason, how infinite in faculty. If only we had known, if only we had read the cards or thrown the dice or followed the lifeline, divination by desperation, thaumaturgy in retrospect. If only, if only. Where would you have been if you had known? If by premonition or askance, you suspected such miscarriage, what would you have chosen? I don't know where I'd want to be. Perhaps I'd take some great sacrifice and stand another's place or be at the front, clearing rubble. But perhaps I'd rather the sanctuary of home or perhaps I'd still choose to be where I was, outside Mr Knight's classroom, breath steaming the window, time paused for no man. This indecisiveness, this parity of possibility, the lack of commitment to the hypothetical - that is why I sometimes leave free will behind. Sometimes, I find it easier to float current-rushed rather than paddle. Sometimes, I pick fruit off the ground rather than climb the decision tree. But in annual renewal, I remind myself that passive routes, though they may seem better lit, are hardly express and admirable, in action hardly an angel, in apprehension hardly a God. We must act on any injustice, lest a witness become carrion. No whisper is left unheard. 09.11.09.

RBRVS

In the 1980s, William Hsiao, a Harvard researcher, put together a committee of doctors, statisticians, economists, and other specialists to figure out how much doctors should be paid for what they do. Prior to that, there was little standardization; physicians charged whatever they wanted and surprisingly, insurance companies would often pay that sum. However, the Resource-Based Relative Value Scale was created so that there would be some uniformity to Medicare reimbursement. The committee looked at every possible procedure that a physician could do, from a heart transplant to a psychiatric evaluation to delivering a baby, and determined a price that a provider should charge for that service. This price is based on physician work (52%), practice expense (44%), and malpractice expense (4%). Physician work includes the time required to perform the service, the technical skill and physical effort, the mental effort and judgment, and stress.

One problem with RBRVS is that in an era when medicine is driven by evidence based outcomes, outcomes don't play a role in RBRVS. Although outcomes are starting to become important (Medicare no longer reimburses for hospital catheter-associated infections, decubitus ulcers, etc.), RBRVS is the change that needs to happen. The problem is there's no easy way to incorporate outcomes. Only a few interventions have shown definite mortality benefit in large-scale randomized trials, but perhaps these interventions should have an additional multiplier by the RBRVS scale. The scale is relative such that an increased value in a procedure leads to decreased value in the other procedures. I realize this change would be unfair to certain specialties (for example, pathologists don't make patient interventions that have a mortality benefit), but I also think it'll align what is best for a patient with what is best for a doctor's pocketbook. It is sad that economic incentives need to be in place to improve health outcomes, but perhaps that is just what we need.

Health Care Reform

I apologize about the two day pause; I've been busy trying to send off my residency application. I'm deferring a 9/11 post to Sunday.

"What we face is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country." - Ted Kennedy.

President Obama's 9/9/09 Remarks on Health Care can be found here:
http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care/

Change must happen, and the nation is now placed in a position that may make implementation feasible. What the best approach is, how the details fall in place, who irons out the nitty-gritty points, I don't know, but I found President Obama's speech to be, though general and idealistic, motivating and inspiring. The changes he's proposing - consumer protections for those with insurance, an exchange for individuals and small businesses to purchase affordable coverage, and a mandate that those who can afford insurance carry it - are just a start. They will not solve everything; rather, they will raise more issues about the massive problem of health care in this country.

I think the first is that while many more people will get insurance, we won't have enough doctors to take care of them. Already, we don't have enough primary care doctors; those with insurance currently wait months for an appointment if they can even find a doctor. The already-strained primary care network will crumble as people with new-found insurance seek to enter the system. Somehow we must mobilize more primary care resources, whether by nurse practitioners or physician assistants or incentives to physicians to avoid specializing. Beyond getting everyone health insurance, we need to get everyone a doctor, and that may prove an equally hard hurdle. Though this will be incredibly difficult, it seems all things having to do with health care reform are incredibly difficult.

The second issue is that of cost. Health care simply costs too much in this country. Things that are cheap and effective - smoking cessation, a Mediterranean diet, daily exercise - are supplanted by marginally beneficial interventions, expensive medications, fancy tests. The culture of extravagance at the expense of proven utility must change. The costs of health care must be reined in for an affordable market to emerge. And I believe costs can be contained without a decline in outcomes if there is a compensatory emphasis on those lifestyle changes that are simple, effective, and currently overlooked. This is why primary care needs to happen.

Lastly, I realize I am not going into a primary care field, and saying such things may reflect a sort of hypocrisy. But I don't think that is true. I've always felt that primary care is the core of modern medicine, that its effects are far more reaching than those of subspecialists, and I admire those with the courage to enter such a daunting field. To me, it is equally important that subspecialists recognize the fundamental need, importance, and contribution of primary care, that these front-line doctors who chose to train less are nevertheless the backbone without which health care would be ineffective, fragmented, and grossly transfigured. Indeed, that's what's happened to our nation, and it's time to fix it.

EKGs

I love EKGs. They're so much fun, and that's one of the reasons why cardiology was always on my list of specialties. EKGs are amazing because they're an easy, cheap, non-invasive test and they can reveal an enormous amount of information about the heart. But even more than that, I think they're wonderful because the amount of information in an EKG varies by one's experience. As a first year medical student, I could decipher basics of a rhythm strip and perhaps make a stab at axis. By third year, I was able to identify some rudimentary arrhythmias and take a shot at signs of ischemia. Now on my cardiology rotation, I return to the same EKGs but notice atrial or ventricular enlargement, bundle branch blocks, and some common patterns like pulmonary embolus. A resident and then attending reading the EKGs can tease out even more subtleties. I like that about electrocardiograms. Anyone can take a shot and get something useful from an EKG, but as one's refinement increases, she can mine more information and do it more efficiently. This is in contrast (no pun intended) to say, an MRI of the brain where non-radiologists and non-neurologists can glean very little or a lab value where there is no puzzle to be deciphered.

We have EKG reading three times a week with a community cardiologist and it's very fun. I've realized each preceptor has a different approach to the EKG and much can be learned from all of them. I really like the systematic aspect of the EKG, and it feels like learning a new language. The EKGs we read are real EKGs rather than a learning set and though that can be frustrating (there are artifacts, leads are switched, multiple pathologies may be going on at once), it's starting to become very rewarding.

Image is shown under GNU Free Documentation License, from Wikipedia.

Poem: Generation Gap

Generation Gap

A generation ago, the Hyatt was a house.
Instead of twenty feet of surrounding glass
I could have touched the ceiling without jumping;
no hormone-charged roses here, no bowers
of gold, no waterfalls, not even a petal-lined carpet;
I imagine popping the plastic canister of film open
with my thumb, sliding it into the slot of the camera
and seeing this shot: the vows, words like wisps
like magic, the light of the eyes, the intensity
of gaze, the brush of finger on finger,
the freedom and dissolution of reservation
that penetrates the pulsations of time,
and would have, even if in the moment,
my fingers numb, I never took that photograph.

Cardiology Clinic

We have clinic 1-2 half-days a week which is pretty fun. Clinic is where I see all the great physical exam findings; I've seen several patients who had rheumatic heart disease in the past and have easily audible murmurs or mechanical heart valves. The patients are generally elderly and cute, who are fun to talk to and treat medical students wonderfully. They usually don't have a chief complaint, but are just getting routine follow-up of their heart disease. The pace in clinic is usually pretty time-pressured as we're always over-booked and behind. But I think compared to other clinics, the heart stuff is pretty fun.

Image is in the public domain, from Wikipedia.

Cardiology Consult

For the next month, I am on the cardiology consult service at San Francisco General Hospital. Again, as a consult team, it is generally less work than being a primary cardiology service, but we get to see a variety of cases when other teams call us about potential cardiac issues. The team consists of a fellow, intern, and two medical students, and we see about one new patient a day, rounding in the afternoon. Consults commonly come from the surgery services, including surgical ICU, and so far, seem to involve either a question of chest pain or arrhythmia management. Most of the chest pain, it seems, is not cardiac in nature, but of course, patients are taken very seriously so they cycle troponins, get an EKG, and call cardiology. The most common arrhythmia question so far has involved atrial fibrillation and flutter. It's good for me to review these bread and butter topics.

Cardiology is one of the few fields that still champions the physical exam, and I hope that on this rotation, I get better with seeing jugular venous pulsations, feeling the heart, and listening to murmurs. The older attendings spend an inordinate and inspiring amount of time examining, listening, and taking care of the patient. Tests like EKGs and echocardiograms have also become staples of hospital medicine, and I hope to increase my familiarity with them in the next few weeks.

Image by Heikenwaelder Hugo, shown under Creative Commons Attribution ShareAlike 2.5, from Wikipedia.

How Science Publishing Works

You might have to click to enlarge. This is from SMBC, "Saturday Morning Breakfast Cereal" by Zach Weiner, sent to me by my classmate Stephanie, shown under fair use.

Infectious Disease

I had a great time on my ID rotation. The teaching was outstanding; the fellow, attending, or pharmacist would give us daily lectures, and I really got a good grasp of antibiotics, common hospital infections, and HIV. The flexibility of a consult service allowed me to read and learn independently. I was able to see a diverse set of patients with both diagnostic and therapeutic problems. Furthermore, as consults, patients were generally very interesting and complex, from the orthopedic to gynecology to surgery to medicine services.

Infectious disease is very interesting to me; there's a lot of good bread and butter, and then there's all the trivia (birds associated with psittacosis, vibrio vulnificans associated with oysters) that aren't too practical but fun to know. That fits my personality pretty well. You aren't restricted to one organ system, and you have to know a lot of medicine. But really, the key is knowing the antibiotics; I found the ID pharmacist to be invaluable. I'm glad I did the month long rotation; I really enjoyed it.

AIDS

Another aspect of infectious disease is the management of HIV/AIDS patients; it makes up a bulk of outpatient infectious disease. Interestingly, I learned that when the AIDS epidemic swept San Francisco in the 1980s, all sorts of physicians got involved, from dermatologists (noticing new unusual skin diseases like Kaposi sarcoma) to oncologists (who were knowledgeable about immunocompromised states) to immunologists and infectious disease doctors. But it is on my ID rotation at SFGH that I really focused on learning HIV. Of course almost all practitioners at the general hospital have an interest in HIV, but the primary care doctors and infectious disease specialists are so passionate about it, it's inspiring.

The last patient I consulted on was a middle aged gentleman who had long-standing HIV, CD4 count of 30, viral load of 80,000, off antiretroviral therapy. He was admitted for an anemia of unclear etiology and when he was being transfused, he had a temperature of 38.5. Although this was most likely a transfusion reaction, blood cultures were drawn that grew 1/2 gram negative rods. Right before antibiotics were started, more blood cultures were drawn that also grew 2/2 GNRs. These speciated as Salmonella, non-typhi, non-paratyphi. Thus, ID was consulted.

Salmonella bacteremia is interesting; it was much more common prior to the era of antiretrovirals, and although it is much more common in HIV with a low CD4 count, people rarely think of it when listing opportunistic infections. Furthermore, Salmonella bacteremia in AIDS often acts like typhoid (Salmonella typhi) with a subclinical course, worsening over time, sometimes with a fever and a rash but not much else. Although Salmonella is exquisitely sensitive to antibiotics, the disease often recurs after the course of treatment. Hopefully this gentleman can be plugged back into care and start receiving antiretrovirals.