Cardiology vs. The World

One difference I noted between my cardiology and medicine rotations is the scope of treatment. While in cardiology, we have an intensive focus on issues related to the heart, on general medicine wards, we have a comprehensive look at all medical issues. Many of our patients, especially older ones, come with a host of chronic medical conditions. Although patients come in with a specific chief complaint, we try to address all their problems, which can be over a dozen. A typical medicine patient might not only complain of shortness of breath, but also have diabetes, lupus, chronic kidney disease, headache, anemia, and leukocytosis. A problem list for these patients must make an assessment for all these issues and propose a diagnostic and treatment plan.

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.

A Second Thanksgiving

I just received an email from one of my attendings about a patient I cared for at Santa Clara Valley Medical Center. The patient's son who was extraordinarily grateful for the care his mother received, got his employer to create a matching fund for Valley Medical Center and then donated a good sum of money to the hospital. I was really touched by such an act of generosity. The truth is, anyone could have been the intern for this patient and this likely would have happened. But it makes me feel good to have influenced this patient's family so, and to have helped the hospital indirectly as well.

Work Hours

I have blogged a lot about work hour rules in the past, but this time I would like to write about the new changes. All residency programs run under the purview of the ACGME, a regulatory body and accrediting organization. The ACGME recently issued a new set of work hour rules that will come into effect next year. The total number of hours a week is the same (80 hour limit) but the maximum shift length is changed. While there are many nuances to this, the general big-picture is that interns (first year residents) can only work a maximum of 16 hour shifts; residents can only work a maximum of 24 hours. The justification is that there should be gradation in training, and as one progresses through residency, they should gain more and more responsibility as the workload increases. This is notably a big difference from the philosophy of yore. In the "old days," intern year was the most difficult year, a trial by fire, and each subsequent year would become easier as one gains a more supervisory role.

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.

Thanksgiving

Happy Thanksgiving! I am a little selfish this holiday season and am thankful that this month I am on a light rotation. I had a week-long break, and now I am on geriatrics which has allowed me to go home and spend Thanksgiving with my family. For that, I am grateful.

ST

A 95 year old man is sent from clinic to the emergency department with a preliminary plan of "rule out TB." He has multiple medical problems including HTN, hyperlipidemia, COPD, chronic kidney disease, arthritis, GERD, and a positive PPD and presents with hemoptysis of one month. On further history, he has no chest pain or shortness of breath, but feels that a week or two ago, he suddenly became very weak. As is routine in the ED, they get an EKG simply because the patient is old.

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.

Chest Pain

Chest pain is one of the most common chief complaints in the emergency department and can be one of the more expensive ones to work up. In an older patient, a complaint of chest pain almost always buys an EKG and labs; often, it gets a hospital stay as a heart attack is "ruled out." Being an intern on cardiology means I get all the chest pain admissions. Often, it is trying to find a needle in a haystack; so many things can cause chest pain and only a minority are cardiac. But what I've learned from this rotation is that the history and physical are key. They teach us this in medical school, and it is true; a thorough history can get you much farther on a diagnosis than any set of laboratory tests. The other common cardiac admission is congestive heart failure. This rotation was really good in helping me review the standards of care and goals in heart failure management. Bread and butter cardiology can get a little boring but is so common and important to review

Cold

Although those on the East Coast would pish-posh, it has gotten quite chilly for us Californians. Unfortunately, I often walk to and from work at the witching hour and so I bundle up quite a bit. It's been pretty rainy too, which I don't mind when indoors, but it makes the walk slightly more harrowing. Weather seems to be a pretty poor topic for a blog, but I'll have something much more cardiac tomorrow.

Image is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Poem: Masquerade

I wrote this poem at the last creative writing workshop. It was inspired by Mary Karr's "Viper Rum." The prompt was: masks are a prominent party of Halloween. Write a poem about a mask or masks.

-
Masquerade

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.

Code Blue II

The patient described in the last blog had initially come in with cardiogenic shock of unclear etiology. His troponins were modest, but he had a severely depressed ejection fraction in a normal sized heart. His hemodynamics were so bad that he went into multi organ failure with shock liver, acute renal failure, and respiratory failure requiring intubation. His clinical course was complicated by heparin-induced thrombocytopenia and bilateral deep vein thromboses. He was put on argatroban for clot prevention. He slowly made a recovery; we were able to extubate him, we weaned down sedation, his laboratory abnormalities were normalizing. But then the next day he coded and died. As we got serial ABGs, we realized the patient had a large A-a gradient suggestive of a massive pulmonary embolus. We pushed t-PA but there was really nothing more we could do.

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.

Code Blue I

The truth is, most "codes" called in a hospital turn out to be false alarms. All medical staff are instructed to call a code if we even think about it; it's the quickest way to get help in the hospital. No one can be reprimanded for calling one; even if it turns out to be benign, better safe than sorry. When a code is called, a ton of staff come out of the woodwork. Not only do you get an ICU fellow, a code team, a host of nearby doctors, nurses, pharmacists, and respiratory therapists, but depending on the hospital, you also get security, a chaplain, and a runner (someone to go find supplies you need). Sometimes it is better to call a code even if you have multiple doctors in the room simply because we'll need someone to get a bipap machine or mix up a drip or place another IV.

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.

Students

Another role we take on as interns is that of mother duck. Particularly on ward months, we get assigned third year medical students who follow us around like ducklings. We co-follow patients with them, teach them, review their notes, encourage them to come up with an assessment and plan. I have grown to love this role. It is really fun to realize that I have knowledge to pass on. But more than that, it is so satisfying to see students come up with answers themselves. I remind myself to avoid simply telling students answers to questions that they could potentially figure out themselves. While I am loathe to assign "homework," I do like to prod and push the third years to read independently and think critically about their cases. Their questions challenge me, force me to see different perspectives, renew my enjoyment for learning. I also think students contribute to the care of the patients they follow. Student notes are the most thorough; if I wonder who a patient lives with or whether they have pets or about their family history - things I am notoriously poor at recording - I have no doubt that the MS3 knows. Students also prompt us to broaden our differential diagnoses, look into the most recent treatments for diseases, and address even the small issues. Teaching itself is also such an incredibly important skill to practice and develop. It is one of the best parts of intern year.

Intern Depression

There was a study a few months back that showed that a large percentage of interns meet DSM criteria for major depressive disorder. Of course, this statement is flawed in many ways; the DSM (psychiatric) criteria for depression include symptoms like weight change, appetite disturbance, insomnia, fatigue, difficulty concentrating. Every intern at some point feels these symptoms. The call schedule disrupts our sleep; we can't help but feel chronically fatigued and have poor concentration. Depending on our specialty, our meals are rushed or forgotten. It's no wonder that every intern can check off many of the criteria for depression.

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.

Done

I will continue to blog about cardiology, but I just wanted to say that amazingly, I made it through the last five months and finally have a week of vacation. It has been without doubt the hardest five months of my life. I count 35 overnight 30 hour calls. A fourth of my time, I am not sleeping in my own apartment (though that does not change the cost of living). Honestly, it's gone by really quickly though I won't deny there are those nights where I'm not sure how I'll make it. Time to catch up on sleep.

Pediatrics II

One other patient I saw was a 20 year old girl who had gone through more than most people do in a lifetime. Born with a fairly subtle congenital heart defect, she caught an infection of a heart valve that sent her to surgery after surgery. The literature in antibiotic prophylaxis for dental work for those with congenital heart defects is mixed. Previously, we would give antibiotics to patients who had abnormal valves before they saw a dentist. Mucking around with teeth, it turns out, is a risk factor for seeding the blood with bacteria. More recently, guidelines have changed, suggesting that it is not necessary to give pre-dental antibiotics. Large studies suggest it's not cost-effective. But take this patient in particular. She did not receive antibiotics, and got a valve infection that could not be cleared with antibiotics. She had a valve replacement, but it was complicated by an aneursym of the aortic root. When she got the aortic root repaired, she had heart block and required a pacemaker placed in her teenage years. Then she does well for a few years until her mechanical heart valve gets infected; mechanical heart valves are so prone to infection that in someone her age, it was inevitable that some time, she'd probably get endocarditis. She had her aortic valve replaced again which caused more trauma to her aorta until the surgeons deemed her inoperable. Finally, she gets a heart transplant. Although we think of heart transplants as new slates, they unfortunately aren't; she works hard to stick with her transplant medications, more medicines than most people take until they are senior citizens. She tries to live a normal life - make friends, go to college, find a job. But finally she comes in to the hospital because she starts to have neurologic signs - vision cuts, vertigo. It's a little worrisome. On exam, I find that she has bulky lymph nodes. Initially, I was concerned about meningitis (since patients are immunosuppressed with their transplant medications) but now I was putting together a picture for a disease I knew only a little about - post-transplant lymphoproliferative disorder.

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.

Pediatrics I

Oddly enough, on my cardiology rotation I had a few patients that were really close to pediatrics. I had a young patient in his early 20s with pulmonary hypertension from a congenital heart defect. He was extremely dependent on his mother who was at bedside 24-7. The patient dynamic was interesting. Even though he was technically an adult, he deferred all his decision-making to his mother. I sometimes felt that I was treating her as much as I was treating him. She made lists of questions and concerns while the patient didn't want an active part in his care. Perhaps growing up with a chronic disease keeps one in an earlier developmental stage; perhaps infantilization is a defense mechanism. But on the other hand, I met a girl who was also in her early twenties who grew up with a double inlet single ventricle. While our hearts have separate chambers for oxygenated and deoxygenated blood, she only had one chamber and the mixing of blood causes her to be cyanotic (blue). Her body has compensated for the lack of oxygen; her red blood cells are much higher than yours or mine. She's undergone at least a dozen surgeries to create shunts to alleviate the consequences of this congenital heart defect. And yet, she is incredibly self-sufficient. She understands her disease better than anyone else, can draw out diagrams of her heart, manages her many medications. I was impressed by how independent this patient was.

Sub-sub-specialties

The cardiology service at Stanford is partitioned into many sub-sub-specialties. After CCU rounds, we find individual attendings for various services from cardiac transplant to pulmonary hypertension to electrophysiology. Thus, we get to learn about these very specialized patients from those who know their diseases the best. This is especially educational and interesting. For example, I'm only beginning to understand the host of complications and medications associated with heart and heart-lung transplants. One of my patients has been in the hospital over two months for infection after infection, and only now is he finally looking ready for discharge. Although I've learned about rejection from a theoretical standpoint, it is so different than seeing someone who may actually have rejection. It is a similarly educational experience to care for patients with severe pulmonary hypertension on medications I had not learned about or for patients with arrhythmias undergoing very specialized electrophysiology testing and ablation.

Learning

I alluded to this on the last post. Learning has changed for me. Education in residency is experiential. The cases I see, the patients I care for all make an impression on me. When I read, what sticks most in my mind are those things that change decision points for my patients. I learn about each disease as I come across it, rather than by perusing a textbook that lists them in order. But of course, residency comes with formal didactics. We have morning reports with presentations of instructive cases, noon conferences with lectures on common topics, grand rounds describing important advances in knowledge. When I was a medical student, I took copious notes at these didactics. But now, whether right or wrong, I find myself too exhausted to mentally attend to these sessions actively. I absorb what I can, but they have been relegated to an adjunct, a supplement to my learning. I find this change interesting, and necessary.

Home Is Where the Heart Is

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.

Pain

I find pain one of the more difficult things to manage, something I hope to learn more about when I am in anesthesia. Pain is subjective. It's experiential. What objective markers and tests we have for pain are crude and rudimentary. I've written about this before, and the philosophy of it is fascinating. We live in internal worlds and we know only our harbored experiences. The shared world - the external world - acts as a bridge for us to interpret the worlds others live in. This objectivity is limited. If someone is in pain, then they are in pain, unless we have reason to doubt them. Few objective markers allow us to confirm or deny that statement.

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?

Notochord

At Stanford, I see diseases I've never heard of. We recently admitted a patient with a pelvic chordoma. When I first heard that word, I didn't even know how to spell it. But with some investigation, I realized it was a cancer of the notochord, an embryonic remnant. It makes sense; anything can form cancers, even parts of us that are no more. This slow growing tumor had become extensive and unresectable and in his sixties, this patient required placement of a colostomy to drain stool as well as a suprapubic catheter to drain urine. These had been working reasonably well and the patient was doing fine until one day, on routine tests, an outside hospital found a significantly elevated creatinine, a sign of declining kidney function. She was sent to us for further workup. When I saw her, I found something odd on exam - I saw urine in the colostomy bag. We got analyses of the urine from the colostomy bag and the suprapubic catheter, and the plot thickened. There seemed to be a fistula (connection) between the urinary tract and the gastrointestinal tract. Renal, urology, and colorectal surgery were consulted and we sent for a nuclear study I had never heard of - radiolabeled lasix. I interpreted the images as soon as they came up - there was tracer in the colon. Unfortunately, the patient was not a good operative candidate and so in consultation with all the surgical services, we decided not to try to treat this surgically. Instead, she will live her life with a strange anastamosis and might be dialysis bound due to chronic tubular necrosis from seeding of the kidneys from the colon. It is unfortunate, but also something that is not textbook at all. There is a stereotype that internists don't look under dressings or in drains and that is mostly true; I am glad I did this time though.

Image of a chordoma in the brain from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Poem: Crisp

Crisp

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.

Pain

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