2011

I would like to wish you all a very happy New Year. I appreciate your reading this blog; it has been a perfect forum for me to ruminate, vent, propose, recount, reflect. Of course, with the holidays, the frequency of writing decreases a bit, but it will pick up after the New Year rolls around. New Year's today will be quiet and warm, with time to think about things. Best wishes to you all.

W;t

I recently reread the play W;t by Margaret Edson. I had initially read this as a freshman in college for one of my introduction to the humanities courses (I had taken a course called "visions of mortality" - which probably lead to my current fascination with death and dying). I was really struck by this 1999 Pulitzer Prize winner and the film version starring Emma Thompson. I do not read a lot of plays, and I'm not sure I even know how to read a play, but I can say that this short, easy read works a number on the emotions and strikes at the core of end-of-life care and oncology. It describes a professor of English with terminal cancer and her interactions with the oncologists and nurses as she undergoes chemotherapy. The play ties in the Holy Sonnets of John Donne, including Holy Sonnet X (below) which addresses death directly. The language of the play reflects the clinical encounters patients often have, and the self-reflection of the main character reveals the rich internal dialogue that presumably patients have as well. Overall, it is one of the best reads for understanding the patient perspective of cancer and I recommend it to everyone in medicine.

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Holy Sonnet X
John Donne

Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so;

For those, whom thou think'st thou dost overthrow,

Die not, poor Death, nor yet canst thou kill me.

From rest and sleep, which but thy picture[s] be,

Much pleasure, then from thee much more must flow,

And soonest our best men with thee do go,

Rest of their bones, and soul's delivery.

Thou'rt slave to Fate, chance, kings, and desperate men,

And dost with poison, war, and sickness dwell,

And poppy, or charms can make us sleep as well,

And better than thy stroke; why swell'st thou then?

One short sleep past, we wake eternally,

And Death shall be no more, Death, thou shalt die.

Image from Wikipedia, shown under Fair Use.

Hospital Holidays II

The other thing about being in the hospital during the holidays is the isolation. For those of us whose families are not in the area, it is a tough time. We miss the comfort and constancy of family, the traditions of the holidays, the freedom from the burden and stress of work. And during a time when our co-residents and friends are flying home and opening presents and sleeping in, it's not easy to wake up before sunrise and drive to the hospital.

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.

Hospital Holidays I

Holidays in the hospital are a little strange. Especially at the VA, the hospital seems deserted; it runs on a bare-bones staff, and capacity is lower as patients gear up to leave. Resident teaching vanishes, and all of us try to get out early. Not much happens; we can only get blood draws once a day on the floor, and tests like echocardiograms and MRI scans don't happen. Social work and case management are off which means that it's very difficult to discharge patients who have nursing, transportation, or other needs. Things stagnate which is understandable though it is intensely frustrating.

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.

Poem: The Delivery of Modern Medicine

This poem is incredibly early and rough; I didn't really want to post it, but time's up and a blog must be entered.
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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.

The Revolving Door

I'm back on medicine wards at the Palo Alto VA, a reprise of my second month of internship. At the entrance to the VA, there's a big revolving door, and given the frequency of visits by certain frequent fliers, we sometimes think of the whole system as a metaphorical revolving door - although we do our best to optimize our patients at discharge, they occasionally bounce back if they stop taking their medications, miss their appointments, or start eating lots of salt. And now it is my second month back here. It is oddly reassuring. The worst part of every rotation is the first few days, when I have to learn the system, write passwords on the back of my hand, and get to know half a dozen new patients. But this time, within a day, I've reminded myself how everything works, and I was lucky enough to inherit 3 patients (though I did start on call). Each time back here is easier. I'm starting to recognize call-back numbers (6-2200 is the intermediate ICU) and remember nurses' names. And after the first 5 months, I feel that medicine has suddenly become easier; I put things together faster, I understand how to cross-cover better, I am aware of a wider variety of medications, I have more confidence. Despite it being December, I think this will be a pretty good month.

Internet

For the last few days, my Internet hasn't been working reliably at home. This reminded me how dependent our society has become on the Internet. If not for my smartphone, I would have felt completely disconnected from the outside. But once I got over the separation anxiety from my computer, I realized that it is also somewhat liberating not to be refreshing my email q15 minutes, or hovering over my patients with remote access, or (even) blogging. I spent my time writing holiday letters, cleaning, catching up on the mountain of mail and paperwork and to-dos, watching bad movies. It reminded me of a New Year's resolution I sometimes make - which is to take some time for myself, away from my computer, away from the Internet - and since the next New Year is imminent, I will count this one as completed. In any case, I'm working on getting reliable internet back, but regardless, I will probably take a short break from blogs around Christmas at the end of this week. I'm currently celebrating the holidays at the VA but luckily my calls skirt the major holidays. I think I'm done blogging about geriatrics, so next, it'll be VA round 2.

Andrology

One of the more infamous clinics we have is andrology. Andrology clinic turns out to be erectile dysfunction clinic for geriatric patients. I think over the last few years, I have gotten much more comfortable asking patients about their sexual history, but there is still a slight barrier (mental? emotional? psychological?) about asking an 80 year old man about his sexual habits. But it is good to open us up further and help us understand such critical aspects of life, even in the older patient. In this clinic, I've learned all about those mysterious drugs that fill my email spam - viagra, cialis, levitra. I've also learned about testosterone, perhaps (or perhaps not) the male equivalent of hormone replacement therapy. I got a sense of other mechanical solutions to erectile dysfunction. And although it is as far from what I'd like to do on a daily basis as you can get, residency is about education, and this is something I did not know much about before.

Geri Clinic

Much of geriatrics was clinic-based, and it's the first outpatient rotation I've had in a long time. Although I tend not to like clinic (it's why I'm going into anesthesia), I still find it educational. I think I'm a fairly conservative outpatient doctor; I try very hard to avoid adding on unnecessary medications, and I spend most of my clinic visit seeing if I can peel back medications. This is especially true in geriatrics. Many of my patients took more than 10 medications - indeed, if you follow heart failure guidelines, a patient with heart failure (from coronary artery disease) ought to be on an aspirin, beta blocker, ACE inhibitor, and statin. Some are also on clopidogrel, additional anithypertensives, antiarrhythmics, and anticoagulation as well. The heart medications themselves add up to half a dozen. Then add on medications all vets are on - tamsulosin for benign prostatic hypertrophy, a couple inhalers for COPD, vitamin D and calcium - and you're well on your way to double digits. Polypharmacy is such a major problem, and probably contributes to the cost of health-care - not only the cost of the medications, but the hospitalizations when patients mix them up.

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.

Push It

I had one attending who was known to be "tough" or "mean." He grilled us on our admissions. He focused not only on our history or our presumed diagnosis, but also questioned things I usually do not consider. Why did we admit this patient? Could we have sent this patient out? As an intern, that decision is usually not up to me. For example, we admitted a patient with a blood pressure of 210/110, asymptomatic. This attending asked for specifics: describe the fundus; did you take blood pressures of both arms? But he also challenged us to justify why an asymptomatic man needed to be admitted to the hospital. He would not settle for simply a blood pressure justification, no matter how outrageous the numbers, nor would he allow us to say "the clinic and ED attendings both thought he should be admitted."

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.

Poem: Childhood Dreams

Childhood Dreams

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.

Jeopardy II

Unfortunately, I was jeopardized a second time to cover a ward team's call. Call is much tougher than an ED shift because it is a 30 hour ordeal where I have to assume care of old patients I've never met. Surprisingly, I was able to discharge 3 of the old patients on the call day, and I admitted six. One was diagnostically perplexing - an older woman with myoclonus and muscle fasciculations of unknown etiology. Another was consult heavy - a new diagnosis of hepatocellular carcinoma. But overall, it wasn't too bad as call nights go. At least jeopardy this time of year is less harrowing than having it earlier because I've been at all the hospitals and know how the logistics go. Unfortunately, it means my light geriatrics rotation was cut prematurely short.

Jeopardy I

The reason why I lost a few days on this blog was because of "Jeopardy." I had thought the worst part of intern year was cross-cover, but I was wrong. The worst part of intern year is definitely jeopardy. Jeopardy is our back-up system. Since housestaff are critical to patient care, we have backups in place in case a resident has an unforeseen absence. Residents on "light" outpatient or elective rotations - where we are not essential - act as backups for those on rotations that depend on us. Unfortunately, in the last two weeks, there have been a rash of illnesses and family emergencies and all the backups have been activated twice.

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.

Geriatrics

At the mid-way point of residency, I'm on my geriatrics rotation. Geriatrics is a required rotation for all interns per ACGME recommendations, and it is the lightest of our rotations. As the patient population ages, understanding issues faced by geriatric patients becomes more and more important. And equally importantly, interns need a good outpatient rotation to break up the monotony of wards.

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.

Poem: Aging

Again, a poem I wrote in a writer's workshop. The prompt was "write about aging."

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Aging

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.

Book Review: Who Will Run the Frog Hospital?

Who Will Run the Frog Hospital? by Lorrie Moore is a novella I recently read, and I love it. It has nothing to do with medicine (do not worry, I did not hope to discover medicine in the title), but it was an easy piece of fiction a friend found for me. Lorrie Moore is a fantastic writer, and I had only read her short stories previously. But this book reads as one of her short stories; it is witty and conversant, aching of personal triumph and poignancy. This novella is a bildungsroman of a woman as she looks back at a loss of innocence and a time of transition in her young adulthood. But what it's about is not as important to me as how it makes me feel; her words have such a genuine ring as she prods and probes our own insecurities about adolescence. I would entirely recommend it as a good rainy-day read.

Image shown under Fair Use, from www.greenapplebooks.com.

The Coronary Care Unit

In general, interns do not take patients in the cardiac ICU as they can be quite complicated and sick, but we participate in rounds where they are discussed. Most of the patients have cardiogenic shock, requiring vasopressors to maintain their blood pressures, special lines to measure hemodynamics, and possibly devices such as intraaortic balloon pumps or ventricular assist devices. Although heart attacks are the most common etiology, we also see viral myocarditis, severe valvular disease, and heartstopping arrhythmias. I was really struck by how sick these patients can get. Although on my ICU rotation at the VA, I cared for many patients with multi-organ failure or bypass surgeries or severe infections, the patients at the Stanford CCU have a level of complexity that is currently beyond me. I think these are the patients that benefit most from a team pow-wow where we all analyze the data together to come up with an assessment and plan. Although the attendings direct the discussions and ultimately come up with the day's goals, an interdisciplinary team approach is incredibly robust. I have to say, the attendings I worked with on CCU were the best I had in intern year so far; they were engaging and their love for teaching was evident. Although it is always somewhat intimidating to be called on to read an EKG or CXR in front of the group on rounds, it is incredibly educational. The attendings brought in the most relevant and up-to-date studies and role-modeled the most professional behavior. It was an incredibly wonderful part of this last rotation.

Devices

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.