Bacterial Portraits

I used to gloss over pictures like this in textbooks because they didn't mean all that much to me. They're always used as an example of electron micrographs. But as I see the clinical relevance of Staphylococcus aureus (the first image) and Escherichia coli (second image), these images become more and more beautiful. The first is 50,000x magnification, TEM; the second is 10,000x magnification low temperature EM; both images are in the public domain.

Both Sides Now

Occasionally, the emergency department and admitting teams disagree on whether a patient needs to come into the hospital. Although for many, the decision is clear-cut, for some it's not easy to know when to pull the trigger. Emergency doctors err on the conservative side and want to admit patients; their role is to stabilize a patient for further care. Admitting teams know the natural history of diseases and identify borderline patients as not-needing inpatient hospitalization. On the medicine side, I've taken many patients where I wasn't convinced of the necessity for inpatient hospitalization. And with the exception of a few diseases (such as PORT score for pneumonia), there aren't always objective criteria of who needs to stay and who can go with close followup.

Now I get to see the other side. There are patients who are borderline admissions and yet I am asked to call medicine and find them a floor bed. Occasionally it is because a diagnosis is not certain. Other times, the justification is legal (if they want to discharge this patient from the emergency department, they need to come put their name in the chart). And it can be incredibly frustrating when I know that the admitting teams think our requests are unnecessary. But hospital politics are here to stay, and I try not to get in the way too much.

Triage

The emergency department is ridiculously busy; some days, it feels like an endless stream of patients. One attending saw 160 patients over an 8 hour shift. Although medicine in America is often practiced at speeds of 10 minutes a patient, it's neither easy nor ideal. Some days, that's what things feel like. The problem is sorting the wheat from the chaff. As mentioned in the previous post, the majority of patients in the "emergency department" don't have true medical emergencies. Some have a "layman's definition of an emergency" - symptoms where it is entirely appropriate to go to a hospital. But some have absolutely nothing; they need refills on medications, they have their usual chronic pain, they need a meal and a place to sleep. The volume of these patients can be so overwhelming that it's hard to identify those who need immediate attention. For example, I've had many, many patients with foot pain, and most of the time it's nothing - an ankle sprain, musculoskeletal strain, plantar fasciitis. But today, I saw a woman with foot pain, and on exam, I couldn't feel a pulse. It turns out that she has atrial fibrillation and threw a clot down her leg, a surgical emergency. Sorting out the true emergencies from the rest is not easy.

We rely a lot on the triage process by which someone determines the order in which patients are seen. For the most part, the most acute cases are easy - strokes, heart attacks, difficulty breathing. And some of the nonemergent stuff is easy to identify as well - young patients with a minor cut, constipation. But a lot falls in the middle - fever, abdominal pain, vomiting. These are the patients in which making an accurate determination of the acuity helps us sort out who needs to be seen first.

Vampire

This week I'm working the graveyard shift: 10pm to 8am. I don't mind it actually. In the middle of the night, the ED (or ICU) is probably the busiest place in the entire hospital (there's even a supply person who's on call in the ED) but even here things start to cool down. Usually we can clear out the waiting room by 2 or 3 in the morning. Patients seem to come in three flavors at 2 in the morning: true emergencies, homeless people looking for a place to stay, and accidents related to drinking. The latter two aren't too exciting, and can be somewhat frustrating at times - spend a day in an emergency department and you will see a dozen people show up with complaints that don't belong in an ED ("I think I might be pregnant, but I can't afford a pregnancy test" and "My teeth have been hurting for months, but I decided to take an ambulance here at 4 in the morning." But the acute emergencies are great cases and with fewer residents at night, I can see more of them, learn more, and do more procedures. The pace is variable, but I've still learned not to procrastinate on my charting because it can get crazy really really quickly. By the end of the night, I'm exhausted, and it's a little taxing on my circadian rhythms as it feels like severe jet-lag. Although the shifts are much better than being on call, it has a different feel since the bulk of my work and wakefulness has to happen during vampire hours whereas on call, that's when I do my least acute work and try to take a nap.

Procedures

Emergency medicine is a very hands-on specialty. I've gotten a couple of really good procedures in the last few weeks. I'd never reduced a shoulder dislocation, but orthopedic complaints are common ED visits. We did two reductions of anterior shoulder dislocations under conscious sedation (which was fun in itself given the anesthetic nature). One was tougher, requiring two people and two sheets. The other was incredibly easy; after getting the gentleman to relax, the shoulder popped right in with minimal external rotation; I hadn't even started abduction yet.

I also got familiar with lumbar punctures, which I hadn't done very much previously. Meningitis is always a concern with patients presenting with fever and headache, so there's a low threshold for doing LPs (or spinal taps). While I had trouble with the first two, the one I did yesterday went incredibly beautifully. Like everything else, the set-up is the most important aspect and after getting the patient positioned optimally, I slid the spinal needle in smoothly and got clear CSF.

Finally, for the sicker patients, I got to do a central line and even a cardioversion. I'd seen patients shocked in codes, but there's always so much commotion it's hard to tell what's going on. For this older gentleman, a time of onset of his atrial fibrillation was determined so we were able to cardiovert in the appropriate window. Anesthesia came down, gave a slug of propofol, and we sent a jolt of electricity through his body, and I saw a beautiful conversion from rapid atrial fibrillation to a sinus rhythm at 50 beats per minute. These are great moments in the ED.

The Four

This painting of The Four Doctors by John Singer Sargent, 1985 (from Wikipedia, in the public domain) shows the four founding professors of Johns Hopkins Hospital. It's interesting because medicine is steeped in history, and yet we only get bits and pieces in our education. How many of us can name those four physicians? None, I wager (unless you go to Johns Hopkins). But if I mention that one of them created the first residency program, named a finding in bacterial endocarditis, and is part of a 3-name eponym for hereditary hemorrhagic telangiectasia, you might guess Sir William Osler. And if I proposed that the second championed aseptic surgical technique, came up with the radical mastectomy, and participated in the first use of anesthesia, you might remember William Halsted. The third made gynecology a real specialty and has a clamp named after him - Howard Kelly. The final, and hardest to identify, was the first dean of Johns Hopkins, created the public health school, discovered Clostridium perfringens, and has a road at Stanford named after him - yes, Welch road is named after William Welch, professor of pathology.

Psych

We see a lot of psychiatric problems in our emergency department. Most commonly, patients come in accompanied by police for suicidal ideation or an attempt. Occasionally, we have floridly psychotic patients brought in by family members. The last rotation where I saw psychiatric patients was during my third year of medical school. But the plan is actually fairly straightforward: we send off a pretty comprehensive laboratory panel to make sure there's no medical etiology or ingestion that explains the presentation. Then we call psychiatry. But I've found that it's really fascinating talking to these patients. One gentleman with known schizophrenia has an ongoing conversation with himself (or rather, the entity that possesses him). He speaks in one long, convoluted sentence:

I'm possessed. No, you're just delusional. Yes, my delusion is you, you don't exist. Your delusion is that you're in control. I am in control, I'm speaking these words, aren't I? But you're also speaking these words, are you making yourself speak these words? No, I am, watch this, lalalalalala. Stop it! I hate you. You love me! You can't live without me. You and I are the same--. No, we're completely different, get away from me. You're obsessed with me, you don't really want to get rid of me, you think you do, you think you want this doctor to help you, but. I do! Help me, doctor. I'm going to kill you, doctor, and then kill everyone else in this building. I didn't mean that, he spoke through me, he's possessing me.

And so the conversation continues. It's quite scary for an openly psychotic person to point at you and say they want to kill you, but luckily, security always accompanies these patients. This is a reminder of the burden and severity of mental illness, and through seeing these patients and talking to my psychiatry colleagues, I learn a little more about these conditions and how to treat them.

Money

I don't know the answer to this question: should money buy better care? Part of this is already a reality; there are boutique medical offices where one can pay a premium to have more timely and direct access to their physician. But what are the ethics of this idea? On the one hand, many of us live with an ideal notion that health care is health care is health care. Hospitals, clinics, emergency departments should treat anyone who comes in equally, blind to the content of their wallets. Everyone should have equal access to primary care services, ob/gyn, pediatrics, mental health facilities, emergent surgeries, and the like. It shouldn't matter whether you are a millionaire or homeless, these are fundamental rights, some people argue. But I don't want to get into a discussion about universal health care. Instead, I want to probe the question of whether wealthy people should be able to buy better care. Even if everyone had coverage and access, this would still be an issue. Capitalism has its own pedestal in our society. And I think the argument is valid; if you can find a doctor who will be more prompt, send more tests, spend more time, make more phone calls, and hold your hand for more money, why not take it? I'm not sure how I feel about this. I still feel optimistic about what medicine ought to be. I don't want to see all my peers scurrying off to boutique medical establishments where they will live happy rich lives taking care of the wealthy. It is something about spending most of my fourth year in the county hospital of San Francisco, realizing that is where medicine needs to happen, that's where it must be practiced, and that money should not lure the passionate away from the streets. Anyway, I don't know the right answer, but I don't think right now I am the type of person who will treat only the rich.

Snake

I wrote about the origin of coumadin some time ago, and now I've discovered another drug developed from a quite lethal naturally occurring substance. The venom of the Bothrops jararaca Brazilian pit viper contains a peptide that blocks angiotensin converting enzyme. While the venom is orally inactive, this finding lead to the development of the incredibly common antihypertensive class ACE inhibitors.

Image of Bothrops jararaca snake shown under GNU Free Documentation License, from Wikipedia.

OB/GYN

I figure I'd continue the posts about patient populations I haven't seen since medical school and write about the pregnant patient. Pregnancy is always a consideration in the emergency room with any woman of the right age complaining about abdominal pain. Furthermore, a lot of women with first or third trimester bleeding come in, worried. Luckily, I had just reviewed these issues while studying for Step III of Boards, but real-life patients are of course more challenging than test questions. One of the more exciting things I did recently was a quick belly ultrasound in a patient at 16 weeks of pregnancy to find the fetal heart tones. It was quite satisfying to put the probe on the belly with Doppler and see the fetal heart beating. I have to say, being a jack of all trades is pretty fun sometimes.

Poem: Hands

Hands

Hands fought an axe once.
Best friends, it was a cordial tussle but
well, the odds were against the hands anyway,
and now there's a trickle of blood
and the axe feels sorry.
Swathed in beeswax and oats
the hands still heft the blade,
it arcs over the shoulder
whistling a tune in the cold winter,
the kind of winter that gnaws joints,
numbs hangnails -- it was one of those
brisk and golden winters
the hands and axe stood vigilant
under a canopy of branches
while I slept safely
and owls swept the distance.

Pediatrics

Although medicine interns don't usually see kids in the emergency department, I saw a six year old last shift. I had been pulled because I'm fluent in Mandarin and the patient and his family were Chinese-speaking only. Pediatricians often say "children aren't just little adults," and I learned (again) this true adage. Communicating with children, negotiating an examination, and understanding their fears is an entirely different skill set. One of my friends admonished me that I asked a six year old about school as a way of trying to distract him from pain. (It did not work).

Trauma

Going through the emergency department has exposed me to all sorts of patients I hadn't seen since medical school. As a medicine intern, I almost never see trauma patients, but they make up a core element of the emergency experience. A couple nights ago, we had two major traumas, victims of a high speed freeway chase. Upon hearing the arrival of these two patients, the emergency room sprung into action; patients were relocated to give the trauma activations space, surgeons poured out, and everyone donned on lead aprons. Teams and roles were designated, kits for procedures were opened, face shields were handed out. When the patients arrived, a frenzy of action happened. We all learn in medical school the steps of a trauma resuscitation: airway, breathing, circulation, disability, exposure. But to see it done rapid-sequence by a team of experienced practitioners is somewhat amazing. On one side of the room, a resident was rapidly calling out his exam, the attending was calling for X-ray, an anesthesiologist was placing an airway, a nurse was pushing meds, a pharmacist was preparing drugs called out, a medical student was doing a rectal exam (it's always a medical student). On the other side of the room, chest compressions were started for a patient in pulseless electrical activity, and a code leader was running advanced cardiac life support. Unfortunately, with the injuries sustained, the patients did not make it, but it was a really impressive effort. Trauma is not my thing (I'm an anesthesiologist, I like controlled situations), but there's something to be said about the adrenaline, dynamics, surgery, and medicine that goes into it.

Sick and Well

After just a few shifts in the emergency department, I've learned that I like taking care of the sicker patients. As I navigate diagnoses from the common cold to heartburn to overwhelming infection to the acute abdomen, I realize that I am drawn to the scarier, more high-stakes diseases. I have co-interns who like the primary care, healthy baby checks, and reassurance of generally well patients, and I think that is so, so important. But somehow, I am irresistibly drawn to the sicker patients. Yesterday, for the first time, I took care of a patient in early active sepsis. We learn about sepsis over and over - it is an overwhelming infection of the bloodstream that has a high mortality rate - but I rarely see the initial resuscitation because this happens in the emergency department. We had a young woman who was immunosuppressed due to cancer who presented with a high fever, rapid heart rate, and low blood pressure. It was quite exciting to recognize what needed to be done and follow her progress closely from the initial stages of treatment. Though the steps aren't hard - fluids, antibiotics, ICU consultation, labs - it was still incredibly educational for me to experience.

Gateway

Although some people say primary care is the gateway into the health care system, I think the emergency department is really the entry-point into the medical care system today. Many of the people we see do not regularly see their family doctor; when they are well, they don't make the time, and when they are sick, they go to emergency. Furthermore, primary care is stretched incredibly thin as it is, and although emergency medicine is equally taxed, laws such as EMTALA require ED's to see everyone whereas a primary care practice can simply say they are not taking new patients. This is a problem. Emergency medicine is designed to treat emergencies; there is a physician trained in critical care medicine, nursing ratios that allow procedures under conscious sedation, 24 hour access to CT scans, surgical, obstetric, medical, and anesthetic consultants, and more. In the emergency department, we should not be seeing chronic stable problems or minor injuries that don't utilize such high-level services. Urgent cares are designed to decompress the emergency department, and they do to some extent, but the truth is, there are too many patients and there is only one destination for them to get their care right now.

Image is from Wikipedia, shown under GNU Free Documentation License.

The Emergency Department

This week, I started my emergency department rotation. We staff the Stanford Emergency Room for 5-6 shifts each week, each shift about 10-12 hours long. I see any adults who come in, and I tend to focus on non-trauma patients. At a rate of 1-2 patients an hour, I can see around 15 patients each shift, each with varying levels of complexity. The emergency department is very different than anything else I've done before. It's really busy. Things move incredibly quickly, and the pace is occasionally exhilarating, occasionally mindboggling, occasionally exhausting. Patients are triaged by acuity and chief complaint, and I try to see a diversity of problems. Within a few minutes of seeing a patient, I try to come up with a tentative diagnosis and put in orders to prove or disprove my idea. It's different than internal medicine where I spend half an hour getting a story; in the emergency department, time is a premium. Unfortunately, this leads to high medical costs. While in the culture of internal medicine, I might spend an hour locating an outside hospital report, in the emergency department, I just repeat the study. This is not good for patient care or our society, but it is the culture of the rotation I am in. The stakes are also high; while many patients have non-acute issues such as chronic pain or a sore throat or a sprained ankle, there are always those who have a stroke or heart attack or other emergent pathology. We will see how this month goes.

Poem: Delusions of Grandeur

I'm doing the evening monthly writing workshop at Stanford again and it's really fun. One of the prompts was to take a poem (shown below), cross out every other line, and then rewrite the poem filling in the alternate lines. (The next step is to cross out every other line - those of the original poem - and fill in the rest, thus creating a completely original poem). I'd never done this exercise before and it was quite fun. Here's the original poem:

Psychology Today
Darnell Arnoult

Have you ever had
delusions of grandeur?
I read all about it
in a magazine
on the coffee table
at Dr. Broadwell's office.

Have you ever thought
you were meant for
something special?
But you were afraid,
Afraid if you tried
you'd fail?
People
would think you
a fool?

You might risk
everything
only for
delusions of grandeur?

I have.
Thought that, I mean.

-
Delusions of Grandeur

It was one of those news stations, called
Delusions of Grandeur,
hounding and cannabilizing fear, horror.

In a magazine
there were six bullets. There were six bodies
at Dr. Broadwell's office.

Your heart stops at such headlines.
You were meant for
worrying -- her name isn't even Broadwell

but you were afraid
and opened the webpage anyway, because someday
you'd fail,

ignore and
would think you
caused it, did it, pulled triggers in outrage.

You might risk
a heart's wayward beat, a run of anxiety
only for

a moment to check the article.
I have.
Thought that, I mean.

Billing and the Review of Systems

Some parts of the current reimbursement system do not make sense to me. In particular, the "complexity" of an outpatient case is dependent on the number of "systems" checked. That is, regardless of what the patient comes in for, how we bill for that visit depends on whether we ask about all 14 organ systems. To be honest, I can't even think of what all these organ systems are, but in a complete 14-point review of systems, we ask about fevers and chills, nausea and vomiting, chest pain, shortness of breath, cough, weakness, urinary incontinence, swelling, muscle and joint aches, hearing changes, and a host of other particulars that likely do not affect the diagnosis or treatment of the patient at all. This is a bad way to do medicine; although we want to reward thoroughness, this is essentially saying that everyone should have everything checked on every visit, a mentality that pervades through American medicine as we order CT scans, ultrasounds, and MRIs with little justification, driving up health care costs. Furthermore, the clinical complexity of a case has nothing to do with this "review of systems." Indeed, most clinics maximize their billing potential by giving the patient a long checklist of symptoms so the doctor doesn't have to do this mundane laundry list. Attendings occasionally admonish me because I don't document in my note certain phrases to meet billing requirements. For example, family history can be essential in some diseases but irrelevant in others, and yet our billing schemes do not differentiate between the two (plus, I have blogged in the past about the utility of family history anyway). In any case, as a resident whose salary is fixed but whose role is to make the department money, trying to understand the quagmire of billing is intensely frustrating.

Pre-operative Clinic

All of the medicine residents have continuity clinic, a residency-long outpatient clinic where they see a panel of general medicine patients; they act as the longterm primary care physician or family doc. But a handful of us doing an internship in internal medicine are actually going into other specialties such as dermatology, neurology, or radiation oncology. I am going into anesthesiology next year. So it doesn't make all that much sense for us to have a primary care clinic, and indeed, because we're only here for a year, it isn't fair to patients. So instead of a continuity clinic, all of us "preliminary" interns have clinic in our specialty.

I work in pre-operative clinic which I really enjoy. The pre-operative clinic sees a huge volume of patients and it is run mostly by nurse practitioners supervised by an MD. It allows us to talk to the patient about anesthesia and answer their questions as well as make an assessment of the patient's pre-operative risk. It's a really educational experience. Although at first I focused on learning which medications to continue or stop and what elements of the exam are relevant, I'm now getting a sense of what medical problems are pertinent and important, and indeed, what issues might lead us to cancel a surgery. The directors are outstanding teachers and working in this clinic gives me a better insight into what to look out for next year.

Psyche

The word psyche comes from Greek meaning soul or butterfly. In fact, the insect appears on the coat of arms of Britain's Royal College of Psychiatrists.

It has been a long time since I've seen a patient admitted for a primary psychiatric diagnosis. We were consulted on a patient in a locked unit on a 5150 for a suicide attempt. She was a young type I diabetic with chronic fatigue who threatened to kill herself. She was involuntarily held for danger to self, and as the psychiatrists made their assessment, we were asked to help with insulin management. We kept her on her home dose, and she did well for a while. Then one day, she was about to eat lunch, got her prescribed insulin, and then purposefully refused to eat anything. Furthermore, she then barricaded the door so that none of the doctors or nurses could get in. They called a code on her and when they finally got to her, her fingerstick glucose was 30 and she had passed out.

We were caught off guard with this in-hospital suicide attempt. I'd seen one successful hospital suicide attempt as a student and it was awful. We then recommended that insulin be given after she ate her meal (routinely, it is given before a meal because the kinetics make more sense). But this reminded me how a very common hospital drug - insulin - can have deadly potential whether intentional or unintentional. It also reminded me of the precautions that we must take when working with someone with serious psychiatric illnesses.

Image from Wikipedia, shown under GNU Free Documentation License.

Cystic Fibrosis

Patients with cystic fibrosis are somewhat unique. At Stanford, a special cystic fibrosis service takes care of adults with the disease, but on endocrinology, we've consulted on several of these patients. They aren't on a resident medicine service because the educational value is limited; CF exacerbations are treated with a highly specialized selection of antibiotics, patients often stay for a while, and management of the disease, although it affects every organ, is similar in every patient. Furthermore, cystic fibrosis specialists offer the patient more directed care than a general internal medicine practitioner would.

Of most of the diseases I've seen, cystic fibrosis is one in which the patient always knows more than the medical student or resident. It's strange because there are many chronic illnesses - CHF, COPD, arthritis, anemia - which patients have for years but know nothing about. But for some reason, cystic fibrosis patients know everything about their disease. They are often young, Internet-savvy, and invested in understanding their genetic condition.

The image shown above (Creative Commons Attribution License, from Wikipedia) demonstrates "clubbing" of the fingernails, a very common finding in cystic fibrosis. Sometimes, physical exam findings like this are interesting and educational; indeed, as a medical student, I followed a cystic fibrosis patient and learned quite a bit from her. But overall, after consulting on several of these patients, I think it is most appropriate that they are on a non-resident cystic fibrosis service.