Trick or Treat

I am on call on Halloween and the admissions are quite slow today - is it a trick or a treat?

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).

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Primum Non Nocere

First, do no harm. This is not actually an easy concept. The more I become tied to medicine, the more I realize the practice of something and the theory are very different. Even standards of care, textbook medicine do not always apply. In the classic book of internship The House of God by Samuel Shem, medicine for older patients is to do as little as possible. In the book, the more the characters try to correct abnormal laboratory values and numbers, the sicker their patients get; the less they do, the better they become. This is not far from the truth. For example, the ED recently admitted a 95 year old to the hospital for no good reason. The ED sent a laboratory test that was not indicated, and when it came back positive, she had to be admitted even though she had no complaints that warranted admission. After examining the data, we ended up ignoring that laboratory value and decided to discharge her. But when I looked at her blood pressure regimen, it was not ideal; she was on multiple medications of the same class and wasn't on other medications that were indicated (she had heart failure but was not on a beta blocker or ACE inhibitor). By textbook and standard of care, her blood pressure regimen should be switched. But upon discussion with the attending and team, we decided to do nothing. Why? Because this regimen had worked for her for so many years. She was already 95; how many studies include 95 year olds? How do we know what is best for them? Changing her medications around would have a higher likelihood of harming her with marginal benefit. So I deferred to her outpatient physician - who knows her well, who will follow up - to decide whether to switch her medications to the standard of care. First, do no harm.

Do No Harm

This is something I am learning as an intern, and it is a hard lesson. Do no harm. For me, this applies mostly to older patients. In my last post, I alluded to a patient who I may have harmed by being pressured by family to do something when I should have done nothing. I will be honest. Doctors make mistakes. We will make mistakes, and some mistakes matter. It is incredibly hard for non-physicians to hear - after all, we are treating mothers, fathers, spouses, grandparents, children - but believe me, it is even harder for us as doctors to bear. In a single day, I make a hundred clinical judgments and decisions. If I am 99% accurate, one will fall through as an error. This is inevitable. Every morning, when I see each of my ten patients, I am making a judgment of whether I hear crackles in their lungs, whether their rash looks worse, whether their antibiotics need to stay on or off. I write a hundred orders each day - some of little consequence (stool softeners, diet orders), but some of intense importance (discharge instructions, medications).

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.

Families

The range of family involvement in patient care is pretty stunning and diverse. In the last few weeks, I've had patients who are dropped off by family members outside the emergency department, and I've had families who stay at the bedside night and day trying to micromanage. From the standpoint of a resident, I don't think either is good. Families are a necessary component to care; they support their loved ones in the hospital, they are an invaluable source of information, and they are critical around the time of discharge. It is really hard for me to see patients in the hospital who have no family, no visitors. On the other hand, families that micromanage can be intensely frustrating. Family members have a wealth of information about their loved ones and their diseases, especially if they manage the patient's chronic conditions. Family members know a lot, and they can contribute a lot, but sometimes this makes them imposing. All care, whether inpatient or outpatient, must be a concordant plan of action negotiated among the clinician and the patient. But I've had families demand unreasonable things, and in one case, something that proved detrimental to the patient (this will be the next post).

Sleep Deprivation

Image from A Cartoon Guide to Becoming a Doctor, shown under Fair Use.

Revision: Mythology, and Other Lies

Mythology, and Other Lies

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.

Goodbyes

Goodbyes are the hardest thing. Whether to a patient, a family member, a loved one, a friend, goodbyes are the hardest thing.

Types of Attendings

The personality and styles of attendings vary quite a bit. Some attendings look from afar and give broad-stroke ideas about how to care for particular patients. Other attendings pontificate about theory and pathogenesis of disease. I've had attendings who love clinical trials and spend their time discussing numbers needed to treat and the evidence behind certain decisions. In the last few weeks, I've had a really surprising diversity of attendings. One attending at the Valley gave us lots of independence and room to develop our own clinical judgments. He gave enough oversight that we felt safe, but he pushed us to treat our patients like they really were ours. The next attending I had liked to micromanage. Having completed a chief resident year recently, he understood the nuances of the system and liked the resident role; he helped coordinate care, put in orders, and stayed late. Lastly, I've had an attending who does mostly research and policy work. Because he spends less time on the wards, he defers a lot to the resident to decide and encourages consultations. Overall, the mix is both fascinating and educational, allowing us to approach clinical problems from a multitude of perspectives and develop our own personality and style.

Partitioning

As a tertiary care center, Stanford has many specialized services. There are primary teams for hematology, oncology, transplant, neurology, and cardiac patients. So when we are on general medicine wards at Stanford, we don't admit chest pain, strokes, or oncologic emergencies unless those teams have "capped" (filled up their quota of patients). This is in contrast to the VA where medicine handles everything nonsurgical. In any case, it is both good and bad. It means that those specialized patients get better care - a cardiologist primarily handles the heart attacks, a transplant specialist deals with the kidney rejections. But it also means my perception of medicine is skewed; I am less comfortable with strokes and seizures because I don't see as many.

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.

Mindnumbing II

(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.

Mindnumbing I

There is a case at Stanford which has been haunting me for the last week. (Note: details have been changed). We were told about a ridiculously sick transfer from an outside hospital. A young woman with a history of lymphoma, immunosuppressed with chemotherapy presents to an outside hospital several months ago. There she is diagnosed with MRSA endocarditis, possibly from IVDU, with septic emboli to the lungs. She is put on vancomycin for 6 weeks via PICC line. She goes home, then returns to the hospital about a week later with epistaxis (nose bleed). In the emergency department, they pack the nose with gauze to stop the bleed, and because she is slightly thrombocytopenic (presumably from chemotherapy), she was admitted to the hospital. A CT scan (unclear why this was obtained) showed cavitary nodules which were worrisome and a sputum culture grew out Aspergillus. The CT also caught part of the liver and showed a mass which was biopsy-proven hepatocellular carcinoma. Separately, the patient started having altered mental status and becoming more somnolent. A lumbar puncture was not consistent with meningitis. An MRI of the brain showed ill-defined lesions of unclear etiology. There was also concern for endocarditis, but transthoracic echocardiograms were negative (it is not clear why a transesophageal echocardiogram was not pursued). Meanwhile, the epistaxis started draining purulent material and a CT scan of the sinuses showed maxillary and ethmoid sinusitis. She also had facial swelling on the same side, and an ophthalmology consult diagnosed periorbital cellulitis. As the patient became more and more complicated, she accumulated antibiotics and more tests until finally the outside hospital transferred her to us. Although ostensibly, the transfer was for diagnosis of the brain masses, this is what the patient looked like when she reached us.

Image is in the public domain, from the CDC.

The Big House

Finally I am at the big house. My schedule is such that I didn't make it over to Stanford until my fourth month. I am, again, on wards (it is relentless). But I've turned the corner on this stretch; it is now my 4th out of 5 straight call months. Stanford is a big change; while I had to drive half an hour to get to Santa Clara Valley Medical Center, I walk to Stanford (though it still takes me twenty minutes); perhaps one of these days off, I'll get myself a bike. Wards here is a straight q4; we take 30 hour overnight call every fourth night. Unfortunately, recent restructuring of the program makes this rotation ridiculously busy. We cap at admitting 12 patients every night, and our service runs close to the maximum of 20 patients all the time. There is a wide variety of patients; although some of course come through the emergency department, others are transfers from hospitals or direct admits from clinic. We see the bread-and-butter alcohol intoxication, failure to thrive, pneumonia, sepsis, but we also get transfers for cancers I've never heard of (spindle cell) or end-stage diseases refractory to management by other hospitals. Although it's a good experience, it's really tiring as patients can be awfully sick.

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.

End-Stage

One of the things about being at Santa Clara Valley Medical Center is that due to the patient population, we see a lot of end-stage disease. The patients often do not have regular medical care, and so they only come in when they are extremely sick. As a result, we see a lot of terminal cancer, heart failure, COPD, liver disease. I found that during my time at the Valley, I was able to focus on end-of-life care and discussions. I had several patients with terminal disease, and I think that physicians have such an important role during this time for the family. The demeanor, attitude, and engagement of a doctor at the end of a patient's life can make the experience meaningful or awful for the family, and I try so hard to achieve that essence which they never teach in medical school. The severity of disease also reminded me of the importance of fundamental and routine access to primary care. Those patients who do not have regular physician contact are so much sicker at a younger age.

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.

Valley Fever

I am perpetually behind in blogging; I've actually been away from the Valley for two and a half weeks. But in thinking back on my time there, the thing I appreciate the most about Santa Clara Valley Medical Center was the independence I developed. This is not to say anything particular about county hospitals, but I found that at the Valley, residents were given a lot of independence in making clinical decisions. We had adequate supervision, but it was really a resident-run hospital and I appreciated that. At other hospitals, consultants, fellows, and attendings manage the grind, but at the Valley, I learned so much because I was calling the shots.

Poem: Window

I signed up for a writing workshop associated with the medical school. It is a three-session evening class with 15 writers, all members of the Stanford medical community. Somehow it fit in my call schedule and I am very excited about this. We focused on creating new work. Here is one of those poems.

-
Window

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.

The Good Doctor

On the last call cycle, I admitted a patient with a fairly mundane disease, and he was going to be fine. On the post-call day, I stop by to see my patient, and his primary care doctor is there. She had stopped by to see him prior to going into work at 7. I occasionally see primary care doctors at the inpatient bedside, and I think it is wonderful and amazing when that happens. How do they stir up that well of time, effort, and energy to see one of their patients who's been hospitalized when they are sick? You would hope that this is done commonly, but the truth is, it's a rare and inspiring thing when it happens.

Documentation

One thing about being at the Valley is that daily notes are handwritten. This creates an interesting phenomenon; we write less because it takes more effort and time. But because we are constrained by time and physical writing effort, the notes we produce are more direct. When I write computerized medicine notes, I might expound on the theoretical aspects of a specific problem. "Anemia may be categorized into microcytic, normocytic, and macrocytic. This patient's anemia is microcytic and our differential diagnosis therefore is iron deficiency anemia, anemia of chronic disease, thalassemia, and lead poisoning." But when I am at the Valley, I instead write, "Anemia - MCV 75. FOBT. Iron 325 BID."

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.

Congratulations!

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.

To Be Honest

It's been a hard week. I mean to write, but I don't know when I will get around to it. During residency, priorities get accentuated. Patients come first. Then taking care of myself. Then learning. Then everything else.