Nostalgia

"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.

Volume Overload

Congestive heart failure is one of the core concepts learned in medical school. When the heart is unable to push fluid forward, it backs up into the lungs and the rest of the body, as demonstrated by the chest X-ray shown above.

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.

Book Review: Superfreakonomics

Reading during residency is hard, but I picked up this book a while ago. I really enjoyed its predecessor Freakonomics, but to be honest, the sequel fell short of expectations. Although most of its topics are superficially interesting, it did not carry that interest through for me. Other than the chapter 0n global warming, I found the writing, research, and revelations to be lukewarm at best. They make a big deal over not having a "unifying theme" but I think that's what killed the book; the writing tried too hard and the train of thought wasn't all too coherent. Unfortunately, I would not recommend this book.

Image shown under Fair Use, from freakonomicsbook.com.

Gatekeeper

I once played a game in which there was this boss called the Gatekeeper who was extremely hard to defeat. Nobody could get past him, but if you got a group together, you could sneak someone by. (You would think there was a paradise beyond that bridge, but unfortunately, it was a dead end. Why we were so fixated on beating him I never figured out).

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.

q3

I have a quick stretch of "q3" meaning that I am on call three nights after my last call. This is because we just switched rotations. Thus, I was on call Sunday, post call Monday, and I'm on call tomorrow. The problem is that it only leaves me one day for my blogs. So today's will be short and unfortunately it'll only make sense to those in medicine.

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."

Poem: The Beginnings of Things

The Beginnings of Things

(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)

Rocks

In perhaps a not-entirely-appropriate manner, we sometimes refer to patients who will be in the hospital forever as "rocks." Every service has a couple of people who for various reasons, simply have no discharge plan. For example, I am taking care of a very pleasant woman whose medical problems have resolved but due to her long hospitalization, she is too weak to walk. My plan for her every day is to work with physical therapy. Unfortunately, she is homeless and has no money. For those with insurance, a reasonable plan would be a skilled nursing facility where she can get therapy and regain her strength. But because she has no insurance, she stays in an acute hospital bed, a level of care that is way higher than what she actually needs. Furthermore, because she is homeless, she has an incentive not to learn to walk because we would then send her to a homeless shelter or medical respite.

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.

The Valley

On the other hand, working at the Valley can be frustrating sometimes. Paper orders make me happy because they remind me of the days as a medical student when I'd carry around stacks of blank order sheets and run around finding charts so I could put orders in. But the truth is, it's incredibly inefficient; every morning trying to pre-round I have to locate 3 separate charts for each patient. Handwritten notes are often illegible and less thorough. Records are difficult to retrieve. Notes can be easily misfiled or lost. It's a wonder that the whole medical system used to run on paper charts.

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.

Onto the Valley

This last month, I've been on the general medicine wards at Santa Clara Valley Medical Center. The Valley has its own residency program, but to broaden the experiences of both programs, we rotate down there and they send residents to Stanford and the VA. A lot of people don't like the Valley, but I really like it. As the county hospital in San Jose, it acts as the safety net for the uninsured, the immigrant population, the homeless, the indigent. The patients we see speak a myriad of languages, have a diversity of backgrounds, and come with both exotic and bread-and-butter illnesses. It is a really good change from the VA for me, and having been trained at UCSF, I feel a strong affinity for the underserved population. Indeed, the Valley reminds me strongly of SFGH. The way the hospital runs, the paper orders, the translators, the diseases, the autonomy all ring a sound chord within me and it makes me very happy to return to a county environment.

Guaiacum

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.

September 11

She is nine today, and in the fourth grade. She likes ice cream and plays four square and never washes her hands before meals. Imagine how big she is; she looks upon the world with wide eyes. She breaks rules sometimes; maybe she stays up past her bedtime drawing under the covers. What does she draw? For reasons unknown to her but stark to us, she draws misery and memory, sketches of fire and loss. They are not sad drawings, only serious ones, ones that outstrip her age, a light that casts generations upon her face. This is the juxtaposition of innocence and reality; she is only beginning to know what she means, how like Helen, she turns fleets. And we turn to her. She is a marking, a pivot point, a child whose grace we cannot take for granted. Give me a lever, said Archimedes, and she will be the fulcrum. She will move planets; they will take flight and hurl out into space, satellites that echo into orbit a refrain she has taught. With crayons, she maps out connections, a gravity that tugs on your heart when you hear of strangers in distress. Oh, it's all propaganda, you say, and it is; what could be more persuasive than a nine year old who teaches us to relinquish selfishness, to volunteer, to donate, to pray, to wish. She is nine this year, but think of what she has endured, and imagine how fast she has had to grow. Listen; don't ignore her because she whispers. No whisper is left unheard. 09.11.10.

ICU Transfer II

I also had a patient who hovered in and out of the ICU. He was a patient with end stage renal disease, dialysis dependent, first admitted with a surprising transaminitis, peaking in the AST/ALT range of the 3000s. Few things give a transaminitis this high: shock liver from hypotension, toxins such as acetaminophen or mushrooms, and acute viral hepatitis (though at UCSF, I saw a Wilson's disease that mounted impressive enzymes). His viral panel was negative and acetaminophen levels were undetectable, but we still started him on an N-acetylcysteine protocol. Shock liver was not too high on our differential because he was fairly hypertensive. But with supportive care, he was transferred out of the ICU, and by chance, onto my medicine service. I only kept him a day on my medicine service. He actually looked pretty good and we sent him home.

He came back the next day with a fever at dialysis. Bounce backs are embarrassing events; we want to make sure people are safe before we send them home. But I scoured his chart and his history and I couldn't find any signs that he would return to the hospital. At dialysis, he had a fever and a bit of confusion so they readmitted him to the hospital. His blood cultures grew out Staph aureus, a sticky bug that can cause infection of the heart valves. Unfortunately, the echocardiogram was equivocal because there was heavy calcification of the patient's valves. We decided to empirically treat him as if he had endocarditis.

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.

1111

I just wanted to commemorate that with the last entry, I hit 1111 blogs! There was never really a goal, but it is kind of fun to know that a story here, a thought there really add up. When I was little, I always got excited when a clock or watch hit a magical number like 1111 - and here we are. Some things never change.

Image of a fountain pen shown under GNU Free Documentation License, from Wikipedia.

ICU Transfer I

It turned out to be a windfall that my first month was in the VA ICU and the second month was on the VA wards. The ICU is a weird, isolated world. We get frighteningly sick patients who require lines and tubes out of every orifice, and we nurse them to health, slowly removing one tube here, one IV there until they are ready for the "floor." On being transferred to a regular medicine service, we pat ourselves on the back and forget about those patients as new ones roll in. But when I was on medicine after the ICU, I began receiving those transfers. I knew these patients. I was invested in their care. And now, I could see that slow rehabilitative process to get them home.

We often dread the ICU transfer. Patients could have been there for months, coming with volumes of records, with multiple organ systems involved. But because I had taken care of some of these unit patients, I already knew their stories and they were not difficult admissions. It was also enlightening for me to see that tough road for patients even after their acute medical issues had been stabilized. I got a few ICU transfers who made it out the door to a nursing facility, which was very gratifying.

Unfortunately, I also had a few transfers who went back to the unit for respiratory failure or hypotension. This was really hard for me. I had a gentleman who suffered a massive pulmonary embolus that required every intervention short of tPA - we even gave him inhaled epoprostenol. He was intubated for weeks, almost buying himself a tracheostomy, but finally we got the tube out of him. We started anticoagulating him for the pulmonary embolus when he then had a massive retroperitoneal bleed. I was off the ICU service at the time, but I heard that it was a nightmare; there were 4 anesthesia attendings present resuscitating and reintubating the patient. When he came down to me in the step-down unit, I had a lot of trouble getting him better. He required a lot of oxygen and even small activities would cause him to desaturate. Unfortunately, he bounced back to the ICU when he started retaining CO2. He came back to me a week later and I continued to struggle to decrease his oxygen requirement. Unfortunately, he may get that tracheostomy if we can't get him better, and he may require a prolonged stay at a nursing facility.

Poem: To Zanzibar By Motor Car

I like writing poems late at night; it is when my muse sings. But with this schedule, night is redefined and I have less and less time to put words together, like a puzzle. Most of the time, I don't like the picture that results, but I don't want to be empty-handed so I post it anyway.
-
To Zanzibar by Motor Car

This is a geography lesson.
Here is your nose.
Here is your left eye
and your right one too.
They wrinkle when you smile,
so you do not smile
lest you become an old man.
But you shall not be as old
as the Pardoner or the Miller
and certainly not as old
as the Wife of Bath.

In that last trip to Bath.
you looked into murky green
and saw your face,
traced arcs of latitude
to Zanzibar by motor car.
Why - you cry - you were never
a vain man, and now blood blisters,
spiders within the bending sickle's
compass come, and with every turn
new maps unfold, you chart territory.
This is a geography lesson:
I take my five fingers
and place them on your face
and you take your hand
to wash them off.

The Dead

How many resources should be used on the deceased? Although at first glance, this may seem like an odd question in the health care field, it's actually quite relevant. For example, should we be paying for autopsies? Currently, the expense of most autopsies are covered by the academic institution performing them; weird as it sounds, it's a "free service" that the hospital provides. Autopsies historically were incredible sources of academic knowledge; they allowed physicians to confirm or deny that they had the right diagnosis, and to learn so much more intimately about disease states. Autopsies aren't cheap to do, however; pathology training is longer than that for internal medicine physicians, and they have a set of skills that no other doctor has.

Or what about keeping someone alive until their family arrives? It is such a common ICU theme that someone will be brain dead, or close, and we will maintain their organ functions artificially until the whole family can arrive. While this seems completely reasonable, a night in the ICU can cost thousands of dollars.

What if in order to keep an organ donor alive for the evaluation and procurement of organs, dialysis would be required? Would it be ethical - in a resource conscious way - to dialyze someone who was deceased in order to keep their organs healthy?

I don't think these questions are completely clean cut. We all have our feelings about those who have passed and also an idealized notion of what medicine is about. But in the resource-strapped environment we face today, we have to negotiate what seems reasonable and what doesn't.

Not Quite Textbook II

This is the conclusion of the case from the previous post (scroll down). As one of the readers pointed out, this is lithium toxicity. Indeed, the patient had been tried on multiple agents, but lithium was the only one that controlled his bipolar disease without side effects. The patient's lithium level on admission was 3, and it is unclear why he was toxic (he had been managed without difficulty for ten years). Due to the severe bradycardia, we actually called renal who came in to dialyze him urgently. After several rounds of dialysis, his symptoms began improving.

Interestingly, the patient did not have the classic gastrointestinal symptoms of lithium poisoning. Often, this presents with nausea, vomiting, and diarrhea which can lead to dehydration, worsening renal function, and impaired lithium excretion. He did say that his oral intake was decreased over the last few weeks, which may have contributed to the overall picture. He did have the classic symptoms of bradycardia, ataxia, confusion, tremors, and hyperreflexia. Interestingly, neurologic findings can persist despite clearance of the drug.

Although the VA is generally considered a great source of "bread and butter" cases, this was one of the more interesting, fascinating, and educational cases I admitted last month.

Not Quite Textbook I

My favorite blogs are about some of the fascinating cases I've seen. Patient identifiers have all been changed for these cases.

A 40 year old man with a past medical history significant for bipolar disease and hypertension was brought into the emergency department by a roommate for several weeks of worsening functional status. He's become more and more confused, sometimes unsure where he is. But rather than becoming agitated, he's become more and more withdrawn with decreased interactiveness and a soft voice. By soft voice, I mean serious hypophonia; he whispered so quietly you had to lean in to hear him. He also had an ataxic gait with frequent falls, no loss of consciousness. In addition there was increased tremor. I know what you're thinking, but he denies alcohol and it was negative (besides, that would be too easy). He denied any dizziness, dyspnea, chest pain, nausea, vomiting, or diarrhea.

Vital signs showed bradycardia. His exam was notable for restricted affect, hypophonia, and one-word answers. He seemed to have difficulty finding words, almost an aphasia. He was alert and oriented. Cranial nerves were grossly normal, though I couldn't get him to follow commands. Sensation and motor was grossly normal. He was hyperreflexic throughout with clonus. Head, ears, eyes, nose, throat were normal. Lungs were clear. Cardiac was simply a bradycardia. There was some abdominal tenderness to deep palpation, but otherwise the belly was benign. There was no edema. He did have a tremor, mostly intention.

EKG showed a bradycardia that was mostly 1st degree heart block, but occasionally on telemetry, I spotted third degree AV dissociation. Head CT was negative. Labs were notable for Cr of 1.6, but otherwise lytes, CBC, LFTs, TFTs were normal.

I knew I couldn't finish wards without dodging a neurology case. What do you think it is?