Friday, December 31, 2010
Wednesday, December 29, 2010
Sunday, December 26, 2010
But it gives me a fascinating and critical insight into the lives of patients. They, too, would rather not be in the hospital. No one wants to be sick, but to be sick over the holidays is so much worse. And although family and friends may visit, it is simply not the same. So around this time of year, I try to spend a little more time chatting to patients about things that aren't medical - about where they grew up or their family or (at the VA) their stories of the military. That bond we create goes beyond the patient-doctor relationship to an understanding among people bound to the hospital when we'd rather be home.
Friday, December 24, 2010
Calls are interesting as well. Right before the holidays, when we were on call on December 23, we accepted a lot of transfers. Everyone - clinics, other services, other hospitals - tries to decrease their services for the holidays and a lot of them come to medicine. For example, patients who require infusions (such as chemotherapy) that can normally be given as an outpatient come into the hospital simply because the infusion center is not open. Clinics who would normally follow their patient up in a week admit them because they aren't open. Other teams try to transfer their patients to medicine. As a result, we got hit hard last call with tons of transfers, some which I did not think were fully justified. But it is the way of things around the holidays. Hopefully on Christmas Eve and Christmas, the patient loads will decrease as patients shy away from the hospital, and transfers decrease in volume. We might expect after the major holidays for things to pick up again as those patients who had dietary indiscretions or minor illnesses that avoided the hospital start to trickle in.
Wednesday, December 22, 2010
The Delivery of Modern Medicine
starts with a number, eight digits and a band,
a looping, a manacle, a room and a curtain
budding into a nurse, a cuff, another looping,
numbers, more numbers, numbers divided by
other numbers, into a poke and whisper
of the arm, into poles and bags and foot-manacles
to stop the clots that bloom from being bound.
The Delivery of Modern Medicine
echoes with the repetition of story, and again
to each wayward passenger on this medical train
the same prodding fingers, bounding stethoscopes
reverberating into routine alarms,
the voice of the phlebotomist, and then the intern
and then the resident, and then the attending.
Oh, the Delivery of Modern Medicine
quakes with the steps of social work
the power behind the throne, the one
who moves patients, rocks, mountains.
The Delivery of Modern Medicine
trades in pills, tablets, capsules, caplets,
barters in knives and lasers
a commerce in drugs of Janus,
two faces, two names, a dozen colors.
The Delivery of Modern Medicine
ought to start with a touch, with a warmth
with a hand on a shoulder, a grasping
of the willows and oaks, a burgeoning
of sense, a blossoming of age, recapitulation
of that we know, deep within us.
Monday, December 20, 2010
Saturday, December 18, 2010
Thursday, December 16, 2010
Wednesday, December 15, 2010
Otherwise, geriatrics clinic also focuses us on medical problems we see less commonly in the inpatient setting. I spend my time doing mini-mental status exams to characterize dementia, assessing fall risk, and thinking about health screening. There are special clinics as well for patients who are especially complicated and high-risk; they are seen by a team of social workers, psychologists, and nurses for a comprehensive approach to aging. It's a good experience for us as interns to care for older patients in the clinic setting.
Tuesday, December 14, 2010
In any case, this attending at the end of the rotation told me why he does this. He thinks that attendings need to push interns and residents. Sure, we do a good job, and we take good care of patients, but to really propel ourselves forward, we need to challenge ourselves to learn more, think harder, never be complacent. It is easy, he says, after 24 hours of call to make assumptions, rely on other people's interpretations, and neglect to make our own clinical decisions, but we should resist that urge. I thought this was a very true point. When we are students, our incentive is to do well, get a good grade. But this incentive drops out when we are residents. Our main motivation is simply integrity: to do more than get through residency without hurting anyone; to learn, challenge ourselves, achieve excellence.
Sunday, December 12, 2010
Sometimes I wish I could be evil,
black as flint and glass-sleek,
my hair chopped off and heinous-looking.
You would have been a good henchman
and I, a connoisseur of evil.
I wish we didn't have to be so good all day,
what's in it for me anyway?
Other people will save lives in my absence
and even if they didn't, it'd be fine--
we're being bad today, remember?
We would make true our promises,
get crayons the size of lampposts and terrorize Atherton,
sing sea shanties waving cider
and plop our feet on the arms of couches
without removing our shoes.
We hold peculiarity hostage,
build a fort of pillows, our sanctuary of villainy,
communicating in code,
making our rapscallion reputations
and staying up much, much later than we should.
Saturday, December 11, 2010
Friday, December 10, 2010
The uncertainty of it makes it the worst thing. I don't mind taking call or doing extra work, but the fact that I could be activated at any time is awful. I carry my pager around with me 24/7. It is on my nightstand. I check it compulsively at restaurants. I wonder whether I should go farther than a 30 minute radius in case I get called to come back immediately.
Of course it happened. I was jeopardized to the emergency department for the graveyard overnight shift. It was a little tough since there are only two residents in the emergency department overnight, and I had not had been in the ED before. But the resident and attendings eased me in, and at least in the ED, I did not need extensive signout and could cover another intern's shift pretty easily. The ED (I am sure I will write about this in February when I have that rotation) is a fascinating place. It is all about efficiency, multitasking, and figuring out where patients will go (observation, inpatient admission, home) as soon as possible. Unlike what is often depicted in TV shows, the majority of things I saw were not serious and not emergencies. Most of what I saw were sore throats, pain management, musculoskeletal injury, COPD exacerbations. In any case, it's never fun to cover extra shifts, but I do not mind helping my cointerns out. It is simply the uncertainty - that our lives aren't our control and that the hospital can call us in on a whim - that makes jeopardy so hard.
Monday, December 06, 2010
One of the main activities for this rotation is skilled nursing facility (SNF) rounds. We often discharge our patients to SNFs for rehabilitation or hospice. These patients have nursing requirements, but don't need to be in an acute care hospital. But I never thought of what happens when patients go there. Making rounds on SNF patients is really enlightening as it allows us as interns see what issues arise for patients after leaving the hospital. We see the long road to recovery, we begin to understand the physical, emotional, mental, and psychological issues of transitioning to independence. Oddly enough, we get a flavor of how insurance companies and Medicare fit into the scheme of approving or denying care. We get a really important sense of how discharge summaries for SNFs differ from those for patients going straight home; the SNF physician needs to know what rehabilitation or skilled nursing needs a patient has. For those reasons, even though it's not a high yield rotation in terms of learning medical knowledge, it's essential to understanding how the medical system as a whole operates. We also take home call for the SNF to be available for questions or concerns. The issues that come up are similar to cross-cover but require us to understand how to triage complaints over the phone.
Sunday, December 05, 2010
A pot ages on the stove, effervesces in a film of brine.
A tap with a spoon on its crust, as if creme brulee
and a flame coaxing the soup from its stupor
into a welling of lemongrass and coconut
steaming my glasses as I stir.
Each circle of the ladle draws in new colors,
the fire of a carrot, the silk of tofu,
the lucency of onions, the curry spice.
Do you think it's still good, she asks.
We made it on her birthday, and ever since, she's resented time,
that winged chariot, that muse of poetry.
It rumbles past outside, in the cold.
What is it for our pasts to slough off,
why are we so recalcitrant,
why must we dig in our heels to slow the earth's revolution
or else hide in an hourglass' wake?
What could we want or imagine or have
if we could leash time to our bending, if we cage it
or well it into dams? Unleash it during boredom,
savor it in joy, curl it as a madman or sorceror?
If I could bottle time, I would cork it, hide it,
keep it in the cabinet next to the cinnamon and nutmeg.
I'd add a dash or two every time I make lemongrass soup.
Saturday, December 04, 2010
Image shown under Fair Use, from www.greenapplebooks.com.
Thursday, December 02, 2010
Wednesday, December 01, 2010
Cardiology was also a really good rotation to learn about devices. There are more devices for the heart than for any other organ system. Although we generally gain an understanding of device indications and what they do in medical school, the nuances escaped me until this rotation. What is the difference between a pacemaker and an implantable defibrillator-cardioverter? When pacemakers are set to "DDD", what does that really mean? How can I tell which device a patient has from an X-ray? Because we admitted patients who needed pacemakers and ICDs, I also got a sense of the common complications of device placement and the arrhythmias and indications that lead to their placement. Furthermore, we got to discuss cardiac assist devices such as LVAD and the Impella pump. Overall, it was a really good review and overview of the amazing biotechnological advances for cardiac care.
First image of Guidant pacemaker and second image of St. Jude's pacemaker are shown under GNU Free Documentation License. Third image of ICD is shown under Creative Commons Attribution Generic License. All images from Wikipedia.
Tuesday, November 30, 2010
On cardiology, we are very good with certain issues. We manage blood pressure, cholesterol, thyroid problems, and diabetes closely because those are such pertinent factors in the management of heart disease. But we often gloss over chronic medical problems like arthritis or COPD. As I gain more independence and insight as an intern, I begin to address other medical problems even if they are not the primary problem. On one of my patients, I noticed a chronic anemia. It'd be easy enough to ignore this and defer to outpatient work up - after all, it's been going on for a long time and unrelated to the chief complaint. But I went ahead and sent an iron panel which lead to a diagnosis of iron deficiency anemia.
Should cardiology attendings worry about general medical issues? Of course they should; we must provide comprehensive care for our patients. But the reality is that they are much more interested and skilled at resolving issues of the heart. That is why these patients go to a cardiology service rather than admitting them to the general medicine wards with a cardiology consult. But one of the wonderful things I can do as an intern is to make sure small issues do not fall through the cracks.
Monday, November 29, 2010
Saturday, November 27, 2010
However, these rules create an even more fundamental change in the structure of residency programs, especially in pediatrics and medicine. While other specialties such as anesthesia and ob/gyn are more amenable to shift work structures, medicine and pediatrics have traditionally been structured with overnight call cycles. The new work hour regulations decrease the flexibility of residency programs a lot, in essence mandating a shift work structure.
Whether this is right or not is a moot point; residency programs must comply with it. Thus, this is effectively a forced paradigm shift in the education of medical residents. The call cycle that has persisted for decades must be replaced by shift work. However, this provides an opportunity for those interested in medical education to do a complete rehaul of the system. Similar to Descartes' thought process in Meditations on First Philosophy, it is time to undermine the foundation of everything existing and decide what things ought to be rebuilt.
Indeed, this is the attitude Stanford has with regard to the residency program. In determining the structure of rotations next year, the only guidelines are the program's philosophy and the ACGME regulations. Of course, many elements will stay the same, but I think this will be a great opportunity to prune those activities that aren't educational and to emphasize the importance of resident well-being.
Thursday, November 25, 2010
Wednesday, November 24, 2010
I don't have his exact EKG but I found one that is similar and it is shown above. The ED sees this EKG and calls a STEMI code - they read this as an acute heart attack. His troponin is 0.3 (creatinine is 2). The interventional cardiology fellow comes and is about to whisk the patient away to the cath lab when the family says perhaps angiography and stent is not consistent with the patient's goals of care. They decide to medically manage this STEMI without aggressive intervention. We are called to admit this patient to the general cardiology floor.
The EKG above is not the patient's EKG, but when I looked at the patient's EKG, I also noted some ST elevation in the inferior leads and no reciprocal changes. As a result, I started worrying that this was not a STEMI as advertised but possibly percarditis. It is odd, however, that the patient had no chest pain whatsoever.
When the attending reviewed the EKG and the story the next day, however, he became suspicious that this was neither a STEMI nor pericarditis. Although those are the two most common causes for ST elevation on an EKG, a much rarer diagnosis can do it as well. It turns out that this patient had an LV aneurysm; he likely had an old MI a week or two ago with persistent troponins due to his chronic kidney disease. During the interim, he developed a large LV aneurysm which lead to the false STEMI activation.
This case was a fascinating lesson in EKG interpretation; context is so, so important to diagnosis.
EKG is from wikidoc.org, shown under Fair Use.
Tuesday, November 23, 2010
Monday, November 22, 2010
Image is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.
Sunday, November 21, 2010
For nineteen years I danced.
I danced to forget, unknowing, ill-caring.
There were no faces, eyes sanded away
leaving only the frame of things, the rock and sway
of blues, the kiss and linger of waltz.
Masks of glitter, masks of gold,
masks of clay and wood.
The sprung floor ached rhythms
and we wrung tears from the paneling.
A face painted black and white lead me blindly.
Eyes were painted over eyelids,
they fixed me upon my axis,
I could only spot on white pupils with each turn.
A woman with feathers leapt with pas de basque,
skirmishing the others until hearts subsided.
I found a mask on the ground, trampled, formless,
and yet we need not heed the warning.
We danced month after month, year after year
until drumming and fire flickered in ritual,
our madness conjuring motion from dust.
He came for us in the end, how could he not,
and he sent us awry, ascatter.
His mask was white, bloodless, rent and bloodrung.
I knew then he came for me.
The stamping became more furious,
the drums would not hush. I fled.
The mask I wear is the one I destroyed nineteen years ago,
the one my wife, my daughter, my family knew.
The cult-summons gleaned confession from me,
sweat escaped the sides of my face's tomb.
I tore it off, stripped a layer of skin,
recoiled in apprehension. The webs and spiders of the room
flooded me, harnessing, and when in years past,
I would let the rebound catch, this time, I pushed through.
The room was humming in ghosts and macabre.
Out in the river, I emptied my pockets,
the rope, the gun, the razors.
The water caught my glance, then hurled it back.
I touched my face; unconcealed, wet,
the first time I had touched it
since I had last seen myself.
Friday, November 19, 2010
We got an autopsy on this patient. I blogged a long time ago on autopsies; the last I attended was two years ago. I think they are an invaluable resource. We didn't know the diagnosis; we didn't know why his heart went bad at the start and our theory of pulmonary embolus was hypothetical. But going down to examine the organs was incredibly enlightening. We were able to see the wedge infarcts and visualize the clot burden. We were able to hold the heart in our hands and feel it. We were able to confirm our diagnosis of why the patient coded, and as soon as the pathologists complete their microscopic analysis, we'll have a better sense of why he had cardiogenic shock in the first place.
Thursday, November 18, 2010
The truth is, I have only been at a handful of codes and none that have been incredibly acute. Recently though, in the CCU, one of our patients coded and we were there from the very start. In fact, it happened on rounds; the resident was first called away, then he pulled the fellow in, and then a minute later they poked their heads out and asked for more help. The attending strode in and started directing the code. Although running a code tends to be the job of a senior resident or fellow, it was entirely appropriate in this case and I immediately saw why. The patient had an uncertain diagnosis and the attending's mind worked so quickly. He not only went through ACLS by rote - another round of epinephrine, continue chest compressions, charge to 100 Joules - but talked aloud, allowing us some insight into his rapid and complex thought process. He immediately laid out the differential diagnosis, described the rhythm he saw on telemetry, and proceeded to complex therapies way beyond ACLS (we even tried inhaled nitrous oxide). He remained coolheaded throughout, asking for ideas, maintaining absolute control of this situation. A CCU patient crashing is terrifying because these patients have no reserve; there's no higher level of care; there's no room before they die. But at least in the CCU, the staff is trained for this level of complexity, the patient had abundant access, and he was already on drips we could titrate. He didn't make it, but that's something for the next post.
Tuesday, November 16, 2010
Monday, November 15, 2010
But the two most central aspects of depression are a depressed mood or loss of interest or pleasure. How often do residents meet that criterion? Hopefully, most of us went into medicine because we enjoy it; we love seeing patients, we feel privileged in caring for people, we get a sense of satisfaction from the relationships and interactions that form. But to some extent, residency grinds a little of that out. I go into each call night hoping I don't cap on admissions. I don't necessarily go in hoping I'll admit zero (I feel like then that'd be a waste of time), but I'm not such a work-o-phile as to ache for more patients. When we realize we wake up before it's light out and leave the hospital after it gets dark, it's hard not to have a depressed mood. We see our friends outside medicine making more money, working fewer hours, having less stress, starting families, and cannot help but wonder did we make the right choice?
That being said, I don't think I really ever met the DSM criteria for depression. Despite days here and there where work really affects me, for the majority of time, I love what I do. I don't mind being in the hospital and I cultivate those things outside the hospital which make me happy. The friends I've made in the residency program are so wonderful and supportive. We help one another get through those long call nights, remind each other to take care of ourselves after work.
Image of Vincent van Gogh's "On the Threshold of Eternity" (1980) is in the public domain, from Wikipedia.
Sunday, November 14, 2010
Saturday, November 13, 2010
PTLD is a lymphoma-like picture seen in the post-transplant patient population. Unfortunately, it meant we had to cut back on the patient's immunosuppressants, risking a higher chance that she'd reject her new heart. My post-call morning was a-flurry. Oncology felt that the neurologic involvement made this a near-emergency; they wanted a stat biopsy by interventional radiology, neurosurgery, or ENT as well as an emergent consultation by radiation oncology. This was all complicated by the fact that she concomitantly had an acute surgical emergency, but surgery wanted to hold off on operating because it would set her chemoradiation back. I realized how complicated it was juggling recommendations from differing services. In the end, we managed to treat the surgical emergency with aggressive medical care, got a stat biopsy, and began chemotherapy to decrease the disease burden of PTLD.
Throughout the course, I was awed by this patient's self-sufficiency. She went through hardship after hardship with nothing but perseverance and the hope to achieve a quasi-normal life. It really is a privilege for me to meet and work with and treat these patients, and I have a lot to learn from them.
Thursday, November 11, 2010
Wednesday, November 10, 2010
Tuesday, November 09, 2010
Monday, November 08, 2010
Finally, the twilight of my five month call marathon. After inpatient wards at Stanford (which ended a while ago, but blogs always lag), I moved onto the cardiology service. Unfortunately, I am feeling burned out, which is sad because if I had boundless energy, I would really love this rotation. It has a good mix of ICU and quick-turnover ward cases, simple bread-and-butter and complex patients. The attendings have been some of the best in intern year so far. The experience is high-powered, demanding, and rich. I feel like I'm just chugging along, but I try to get as much out of it as I can.
We begin each morning in the coronary care unit, the cardiac ICU. I love the ICU. It feels oddly reassuring to me. We discuss all the new overnight ICU admissions in a Socratic method style. The CCU attendings I've had have been phenomenal, weaving in education with the evolving stories of each patient. From acute heart attacks to frightening cardiac rhythms to dramatic heart failure, the cases illustrate some of the best physiology I've seen in a while. We pore over EKGs, analyze Swan-Ganz tracings, labor over chest X-rays. CCU rounds can be fairly exhausting, but they are always thoroughly educational.
Image is from Wikpiedia, in the public domain.
Sunday, November 07, 2010
But rather than wax philosphical, I wanted to write about two sickle cell patients. Sickle cell crises are intensely painful, and I recently admitted two sicklers in the midst of excruciating pain. They kept on demanding more and more narcotics, to the point that I felt uncomfortable; one who was allergic to half a dozen conventional agents wanted meperidine (demerol). It is an opioid with dangerous drug reactions - it may have lead to the death of Libby Zion, a college student whose death gave rise to the work hour restrictions we have today. Furthermore, exceeding the FDA-approved dose increases the risk of seizure dramatically. This patient demanded more and more demerol, past the maximum dose of the drug.
So what is pain? Of course these patients are in pain; sickle cell is a painful disease. But on the other hand, continued escalation of pain medications has its risks. I worried about exceeding maximum doses, causing tolerance, even feeding drug-seeking behavior. Yet all I had objectively was the word of the patient, his vital signs, and how he looked in bed. I wanted to treat this patient's pain; it's unethical not to. But the patient demanded more and more until he was so somnolent we could hardly wake him. What do we do in these cases? How do we approach them?
Friday, November 05, 2010
Image of a chordoma in the brain from Wikipedia, shown under Creative Commons Attribution Share-Alike License.
Wednesday, November 03, 2010
Sun-baked cinnamon, mulled senses and flame,
November's whisper dances circles across the floor.
We cannot be but horizontal,
eating to the sky, our tongues lavishing
stewed tart apple, our cheeks brushed with brown sugar
ice cream droplets scatter the pillows framing our heads.
We lap up cider, aroma like tea, lemons bobbing,
the flicker of shadows as a draft caresses candle.
Amber, woody, auburn, fall,
basking in the luxury of sense, texture of smell.
Tuesday, November 02, 2010
Sunday, October 31, 2010
You'll often find residents gasp at such statements for the fear that we might jinx a pleasant call night. This is quite amusing to me. Physicians are some of the most rational, logical people I know - we call upon data and science and reason to justify our decisions and statements - and yet, almost every resident has this superstitious belief that we can jinx our call night if we say the wrong thing ("gosh, it's slow today"). I actually don't worry too much about what I say (you may notice this in the blog) but if five chest pains roll into the ED at midnight, I guess I might change my feelings about it all.
In other news, it makes me happy that the radiology techs today are dressed up in costumes (a pirate, a knight, a cowgirl).
Saturday, October 30, 2010
Friday, October 29, 2010
One patient I had at Stanford had loving family members who knew him very well. They micromanaged each little condition. They called around to multiple doctors and would meet us in rounds each day with a list of suggestions. Some were clearly inappropriate and some were clearly indicated. But much of medicine is gray, and this is the problem. The patient was mildly anemic and actively bleeding; his hemoglobin was not at a level that transfusion was clearly indicated, and it was not at a level in which transfusion was absurd. I felt that I did not want to transfuse this patient at the time. But the family requested that I do. This was not an unreasonable request and in consultation with the resident and attending, we did transfuse. It is important not to confound correlation and causation but I felt the transfusion marked the transition between him getting better and him getting worse. There are actually a lot of medical reasons why the transfusion could have harmed him (and medical reasons why the transfusion could have helped). We will not know which happened. But I have since been haunted by this incident not necessarily because I think I harmed this patient, but because I was persuaded to do something I was not inclined to do, and because it ended up correlating with a poor outcome.
Thursday, October 28, 2010
Monday, October 25, 2010
Sunday, October 24, 2010
And when I smother myself in poison,
find clumps, hills in the shower,
negotiate nausea, pain, itch
I wonder how Prometheus did it,
letting vulture consume that which he did not want
hoping to regenerate the purveyor of iron --
oh, I know of the Prometheus support groups
pre-transplant, post-transplant kumbayas --
but I defy absolution! I bathe in your
widowed, your winowed -- I roar
against cages, cells, cancers --
I am not so sure we are not Titans,
that we aren’t chained some precipice
to have our organs devoured.
Burn me, hold me, let scars radiant
beam down that valley, shadow, light.
Friday, October 22, 2010
Thursday, October 21, 2010
Wednesday, October 20, 2010
The patients admitted to the general medicine wards are generally of two types. The typical emergency department admits include little old ladies with failure to thrive, run-of-the-mill pneumonias, patients at nursing facilities who aspirate, patients with liver disease. But at Stanford, we also accept transfers from outside hospitals (like the case described previously) that can be nightmarish. Those patients can be exceedingly complicated. Other types of complex patients are those with rare diseases or congenital malformations. In fact, one patient on my service was 20 years old and had 45 surgeries in the past. Though it is a good educational mix, it is also so overwhelming to a newly minted intern.
Tuesday, October 19, 2010
(This is a continuation of the case below).
Astute readers, of course, recognize this as the dreaded mucormycosis. This fungal sinus infection progresses rapidly toward fulminant death. The mortality rate of rhinocerebral mucormycosis is extremely high. When we called ENT for this patient, they wanted a stat MRI scan which showed fungal invasion into the brain. ENT placed the mortality at 100% even with all aggressive treatments. Infectious disease also looked at the case and put the mortality at >95%. Mucormycosis - a disease so rare that I had only thought I'd see it in textbooks - is truly a sobering diagnosis.
With the concern of almost-certain fatality, we held multiple family meetings to try to understand what the patient would have wanted. She would not have wanted her face disfigured, and indeed, the marginal benefit of such a heroic intervention was not worth the cost. Eventually, the patient was made comfort care and with the aid of the palliative care service, we let her go peacefully and quietly.
The real question that came up was whether this was an appropriate transfer and whether there was delay in diagnosis. I felt that the patient was not necessarily stable for transfer; she carried with her a definite surgical indication, and she came from a hospital that had an ENT physician. Then again, I wonder whether the accepting physician at Stanford knew how dire this condition was; when we were told about the patient, we had simply thought she was here for a workup of the brain lesions. Lastly, and closest to my heart, I wonder whether I could have made the diagnosis quicker. When I examined the patient, the worry of necrosis and mucor rhinosinusitis did come up like a nagging thought, but I was loathe to call it and call the surgeons for an emergent evaluation. Did the couple hours I waited before calling ENT make a difference? Most likely it did not as the disease was quite progressed when the patient arrived, but sometimes I worry that I did not do enough.
Monday, October 18, 2010
Image is in the public domain, from the CDC.
Monday, October 11, 2010
I'm always running behind on my blogs, and there is so much to write about but so little time. In looking at my schedule, I think I will have to take a week-long break from blogging. Alas, residency comes first. I'll be back next Monday.
Image is in the public domain, from Wikipedia.
Saturday, October 09, 2010
Medicine at the Valley is also a great experience because we do everything. There is no primary neurology service, and so I admitted and managed stroke patients, racking my brain to remember how to localize the lesion. I was able to do several paracenteses on patients with liver disease. I saw overdoses of the widest array of medications. It was a really good bread-and-butter experience and a reminder of how wonderful it is to take care of county patients.
Thursday, October 07, 2010
Wednesday, October 06, 2010
Each morning, I wake to a new window.
Today it is the window of an officer's glasses
eyes magnified, serpent-like
in an expression encountering halitosis alighting
that breath of rum and vodka,
and the next window is the torch:
look at my nose, the prodding voice commands
and I dodge into the next room
the images swim up, portals of access and descent
until another window consumes, a window
with a blackberry vine, a meander across
the splintered barn, my shoulders aching
from the beat and welt of days.
You are too serious, I tell the bars
and like you, their insistence is silent.
Oh, the windows say the same thing every day
shelter among shelter, and believe me,
if I could climb through, I would have long ago.
Tuesday, October 05, 2010
Sunday, October 03, 2010
Whether this is good or not, I am not sure. As a medical student, notes are of paramount importance, but as a resident, they are a nuisance and necessity. Notes have an important documentation and legal value. Good notes also convey thought processes and communicate. But in the overall scheme of things, my priorities are focused on patient time and orders, not documentation. I found that having to write less at the Valley gave me more time to think about the "doctory" stuff - thinking about a patient and deciding what to do rather than writing about it.
Saturday, October 02, 2010
The end of medical school and the start of residency is a wonderful time for some of my friends. My friends and classmates are starting to hit that stage of life when they are thinking of starting their own families and committing to their loved ones. Indeed, this summer was a blossoming of weddings, and just today, I walked from Stanford Hospital to Memorial Church to attend one of my friends' weddings. Congratulations to all the newly-weds. And to those in the midst of their residencies or med school or first jobs, I am so incredibly impressed by your sustenance through such a stressful time.
Image is in the public domain, from Wikipedia.
Friday, October 01, 2010
Wednesday, September 29, 2010
"Every day's so caffeinated, I wish they were Golden Gated / Fillmore couldn't feel more miles away / So wrap me up return to sender, let's forget this 5 year bender / Take me to my city by the Bay" - Train, "Save Me, San Francisco."
Though it is wonderful being back down in the Peninsula, I do miss San Francisco. Every time I return to visit friends, I am astonished by how beautiful and striking the city is.
Image from Wikipedia, in the public domain.
Monday, September 27, 2010
The principle was clearly illustrated this last call when my team was on "Super Sunday" (when we cross-cover all the medicine patients in the hospital). On Saturday night, the hospital was bolused with a huge number of patients; 17 patients were admitted overnight. Normally on Sunday, the "on call" team takes 12 total and no other teams pick up patients. But given this extraordinary number of admits, the chief residents had to activate the short call and pre-call teams, giving them patients when they normally would not get any. The pump - the admitting team - simply could not move things along. The entire hospital was volume overloaded and patients were backing up into services that should have been free. It was somewhat of a nightmare since if we did not try to break the cycle, it would get worse and worse.
We ended up taking 13 patients total (one more than we usually do and three more than we do at the valley). It was fairly painful but we had to relieve the pressure on the system and allow services to diurese patients. I've never seen something like this happen before, and when it does, the system can barely handle it.
Image from Wikipedia, shown under Creative Commons Attribution Share-Alike License.
Saturday, September 25, 2010
Image shown under Fair Use, from freakonomicsbook.com.
Friday, September 24, 2010
In any case, the emergency department often acts as a gatekeeper to the hospital. Most patients pass through the ED to become inpatients. Thus, ED physicians have a huge responsibility and burden to triage patients correctly. With defensive medicine, increasing complexity of problems, overwhelming patient burden, and decreased time, ED physicians are starting to get conservative on who they admit. I've found on the medicine wards that we often get "soft" admits: patients who we don't think need to be in the hospital. They stay for a day, we get a few tests, and we send them out the next day.
This is a quandry. On the one hand, hospitalized patients are the most expensive patients, and inappropriate admissions cost the system a great deal of money. We have a shortage of hospitals and hospital beds, and even physicians are becoming an increasingly rare commodity. Filling hospital beds with healthy patients takes away from those who need our attention the most. Even "easy" and straightforward patients come with a mountain of paperwork (oh, discharge summaries) and pages.
On the other hand, I completely sympathize with the emergency department. They are overflowing with patients and they must make snap judgments without being able to go through all the past medical records. The medico-legal climate does favor conservative decisions such as admitting to the hospital even just for observation. It is not easy being an emergency medicine doctor.
I have no good solutions. But I feel that if we do not nudge the pendulum the other way, we will be spending resources on patients who do not need them. The emergency department is the gatekeeper to the hospital, and they have that extraordinarily difficult job of wading through the patients flooding the gates and determining who needs that precious hospital bed.
Tuesday, September 21, 2010
My attending said, "back when I was in medical school, we had a gastroenterology professor who was extremely boring. He liked to pace from side to side in the classroom. We called him shifting dullness."
Monday, September 20, 2010
(as such may be)
flitter me away
to that edge, sky to sea where
cloud burns to seaspray
and scientists goggle
at The Beginnings of Things
and I simply want to leave
to bury my head
where I love it so much
and I give it all away
to The Beginnings of Things
(that refrain we sing)
as if we were not always here
as if becoming safe in our skin
makes us statuesque
and rumbling tide turns
rock into sand all the way until
(you know where we return)
Saturday, September 18, 2010
We see this all the time; the uninsured and underinsured cost the health care system way more because of that. In a time when there are not enough doctors, not enough hospital beds, not enough nurses, we need to triage patients to the places that are most suitable for them. I hope that requiring universal health coverage may ameliorate this situation, but the truth is that it may not; people may still be underinsured if skilled nursing facilities cherry-pick the patients with the best insurance. This situation reminds me that medicine is entirely a social affair and doctors must be advocates for social justice.
Friday, September 17, 2010
Resources at the county hospital sometimes seem limited. Santa Clara Valley Medical Center actually has pretty much anything you'd want, but I find that beds are often limited. Each morning, we get a routine page - now a joke almost - to transfer and discharge our patients because there's a host more in the ED waiting for inpatient beds.
But I think the thing that bugs most people - and will probably be a separate post - is that county hospitals are a repository for people who have no discharge plan. I have at least two patients who have no medical indication to be in an acute care hospital, but will probably never leave. The social reasons that keep people in the hospital, using up resources, time, money, can be ever so frustrating.
Thursday, September 16, 2010
Tuesday, September 14, 2010
Medical students hate the idea that a patient needs a "guaiac." The stool guaiac test is as important as it is unpleasant. It is designed to detect to presence of occult blood in stool. The duty often falls upon the medical student to do the rectal exam and check for blood. Almost all patients who present to the emergency department get guaiac'd, simply to make sure they aren't bleeding.
One of my co-interns looked into the origin of this test, and it was fascinating. The word "guaiac" comes from guaiacum, a genus of flowering plants that has a host of crazy uses. The genus supplies some of the hardest wood; gum made from the wood was once used to treat syphilis; wood chips make a tea; a derivative is a common medication for cough called guaifenesin; sometimes you see ornamental plants from this family. And I had thought it was only a fecal occult blood test.
First image of the stool guaiac test shown under Creative Commons Attribution Share-Alike License, from Wikipedia. Second image of the flower from Wikipedia, in the public domain.
Monday, September 13, 2010
Friday, September 10, 2010
Usually, these patients are quick: put in a long term access PICC line, then find a nursing facility to take them. But this patient kept getting sicker; he would spike fevers, and then his labs started becoming inexplicably bizarre. He began showing an indirect bilirubinemia without evidence of hemolysis. Not only that, but with a bilirubin of 8 or 9, I did not find any icterus or jaundice on exam. If I looked in the right light, there might be a yellow tinge, but I really had to squint to get that. None of his other liver function enzymes budged.
Then, his INR - a sign of synthetic liver function - started shooting up dramatically. Within 3 days, it went from INR of 1.5 to 7. I've never seen something like that happen. Sometimes for patients with clots or atrial fibrillation, we purposely want to raise the INR. But invariably in those circumstances, the INR waffles excruciatingly slowly; it might take a week to get from INR 1 to 2.5. What's even more bizarre, we gave the patient a touch of vitamin K and his INR dropped from 7 back to 2 within 2 days. Strange, strange.
In the end, a CT abdomen/pelvis identified lesions in the liver concerning for abscess. We needed interventional radiology to drain it, but I had so much trouble getting him down for the procedure because he was hemodynamically tenuous. Despite being hypertensive on his first ICU admission, he was now hypotensive to the 100s/50s and tachycardic to the 120s (my EKG read was atrial flutter with variable block). He was definitely showing SIRS physiology which was concerning because he could have been septic - severely infected. A repeat CT showed more abscesses despite the antibiotics he was getting for his endocarditis. To my chagrin, he eventually bought himself an ICU bed again, but I have not been able to follow up to see how he has been doing.