Book Review: The Barnum Museum

One of the great things about vacation is the time to read for fun. Steven Millhauser's The Barnum Museum is a collection of short stories, and I really enjoyed two in particular. The title story, "The Barnum Museum", is a story about a location that treads the quiet line between the real and the fantastical. This museum carries an air of mystique, and the atmosphere Millhauser creates is truly magical. The last story of the collection, "Eisenheim the Illusionist", is an amazing story, now made into a movie (The Illusionist 2006) about a magician during turn-of-the-19th century Vienna whose magic tricks take on more and more wondrous feats. In any case, I highly recommend those two stories for anyone who likes fiction that encroaches the border of magic realism.

Image is from fantasticfiction.co.uk, shown under Fair Use.

Back

I'm back from vacation. Vacation is amazing. I forget what it's like to be an intern, what it's like to work such long hours, to deal with illness and death all the time. It's a strange breath of relief, discovering the world again. It's light, sunny, free, it runs and skips and hops. It dances. This is not to say that I don't like work. But work is work, and vacation is a moment to feel the expansiveness of everything else. I spent time overseas with family, ate lots, explored, relaxed.

I like this comic strip because I always wondered who came up with the silly idea of "disproving the null hypothesis."

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Vacation

I am actually going to take a week's break from this blog as I am now on vacation and actually going to Taiwan for a week and a half. I hope you are all doing well and I'll see you in a week.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Iatrogenic

This is a case that I'm going to describe in very general terms. Unfortunately, we were consulted on a patient who had an iatrogenic infection. An iatrogenic problem is one that results from medical advice or treatment. It is the thing physicians dread the most. "First, do no harm." We order all interventions - from diagnostic tests to medications to procedures to surgery - with the intention of helping someone. But everything has its risks and benefits, from the discomfort of an abdominal exam to the radiation of a CT scan to potential allergies to medications to the complications of surgery. Medicine is not a risk-free enterprise. And over the course of a rotation, a year, a career, we will do things that harm people. They may not be mistakes. They may not be due to wrong clinical judgment. But they will nevertheless happen and we must learn to deal with the consequences.

An ID consult was obtained on someone who, as a result of a medical intervention, may now require life-long antibiotics. The patient is in his 50s. Committing this person to life-long antibiotics is a travesty; it comes with so many dangers and side effects. And yet, due to an iatrogenic complication, he has an infection that his immune system may never be able to clear. We were all devastated to hear about this case, but now that it has happened, we are helping the primary team figure out what to do.

Shrek

I only recently learned that there are donkeys in the back of the Palo Alto VA. Just off VA grounds, there is a beautiful pasture with three neighborhood donkeys. Apparently one of them, Perry, was the model for "Donkey" in the Shrek movies (though he only received $75 in royalties). I thought that was a pretty cool random fact.

Image is from Wikpedia, shown under Fair Use.

Scene from the ED

This is a couple paragraphs of creative nonfiction I jotted down during the last writing group based on an experience in the emergency department.

-
When I entered the room I could tell something was wrong by the way the husband stood. There was an air of aggression, the kind that made me want to send him out and pry the poor woman for domestic violence. He hovered, leaning forward, arms across the chest. But when I looked at her, I could see that she was seeing down a row of mirrors. She was afraid, but not of him. He was picking up on some unspoken sense between husband and wife; he raised his haunches to protect her.

She had been crying. She struck me as the type of patient who puts on make-up before showing up at the emergency department, and tonight, she looked a mess. The skin of her hands were white and taut with worry. Her gown was strewn across her shoulders. There was blood on the sheets, in splotches.

I got a translator. Oh, there are times when my Spanish would suffice, even for those in distress, heaving in chest pain, speaking in one-word sentences. But here, I already knew I needed help. It was not a question of diagnosis; I already had a gut feeling, and later I would learn that she did as well. But this was the kind of thing you have to do correctly, the kind of thing where a misstep would ruin everything. The interpreter was curt, dressed in a white coat, looking more formal than I did in my scrubs. When she herself realized the diagnosis, she started shifting weight on her legs. But I anchored her down, forced the conversation down meandering paths.

We talked, and over talk, we bonded; her husband softened, the interpreter clicked in the background. I learned of her life in Mexico, her two children, her faith, and her job. Then I probed a little deeper, and I learned of her prior and her fear that this was a repeat miscarriage. I held the timber of my voice. I had to ease her in, I did not want to couch ambiguity, and yet I did not want to lay things bare.

The attending did the exam, and I was disappointed in him. Two traumas had arrived; there was a stroke code, a STEMI, a waiting room full of patients. He had to go, without even a parting word. But I knew my part. I sat on a stool, kept my gaze on the patient and her husband, and chose my words carefully. I could not tell whether the diction carried through the interpreter. But to this day, in these situations, I focus on the tone and arc of my voice, the lilt of the phrases, the gestures, the facial expressions. I hope these cross cultures - over not only race and ethnicity, but the vastness of experience, gender, age, hope and fear into some common ground where cold medical dogma and the emotion of loss coincide.

Infectious Disease

In the last two weeks, I had a short consult rotation in infectious disease at the VA. It was really awesome, and I wish I had a longer rotation. I think it is a specialty where a little investment in understanding antibiotics pays off a lot. Furthermore, it is the specialty with the most unique diseases - parasites and pathogens endemic to far-away places and unusual animals. I love it because the medical trivia is endless - and I'm the kind of person who likes learning useless but cool information.

The pace wasn't bad; we got a consult a day and saw a wide range of cases from standard osteomyelitis to unusual and scary organisms such as vancomycin-resistant Enterococcus. It was amazing to have the time to really delve into the case, read the latest literature, and synthesize a coherent plan. When I am on wards and admitting a handful of patients, it's impossible to do that, but here, we have enough time to put together all the pieces. Some of the notes I wrote were the longest I had written since med school and tried to incorporate teaching as well as recommendations. Conferences covered diverse topics from leprosy to the effect of restricting antibiotics (such that they require ID approval for use) to a review of all the gram negative agents. It was a fantastic two weeks.

Salt II

This is a continuation of yesterday's case. In the morning, the attending saw and evaluated the patient and felt that the patient was hypovolemic. At that time, the attending actually decided to give hypertonic saline. The sodium increased ever so slightly. I still felt the patient was hypervolemic and I held my ground. In my note, I put that my exam was consistent with a hypervolemic hyponatremia though certainly there was a degree of uncertainty.

Finally, we got a formal echocardiogram. It showed that the patient was markedly volume overloaded and in systolic and diastolic acute on chronic decompensated heart failure. Her heart could not adequately pump blood forward to her kidneys, and so her kidneys were failing; her sodium was being diluted in the setting of too much fluid on board.

With cardiac and renal consultations, we began dobutamine and an aggressive diuretic regimen. Unfortunately, the kidneys suffered and she eventually required dialysis. She was transferred to the cardiology service for further management of congestive heart failure.

I write these two blogs not to say that I was right and the rest of the team was wrong, but instead to point out the extraordinary difficulty of clinical medicine. This was an excruciatingly difficult case because it pins the diagnosis on a subjective physical exam in an era when we rely more on our fancy tests than our hands and eyes. It is so hard because the patient had a poor outcome from a delayed diagnosis. Who could say whether she would have done differently had I instituted earlier diuretics and inotropic support?

But the more important point is to say this: whether you are a medical student, intern, resident, fellow, or attending, you could be wrong. Our judgment is imperfect. We must allow differences of opinion and check ourselves to see whether everything fits. But on the other hand, we must take a stand. I don't fault anyone else in this case. Everyone else put the evidence together and came to another conclusion -- and that's fine. You absolutely have to go down one path and see whether it's right or not. Medicine is hard. It is an enterprise of judgment, experience, passion, and resolution, and when we are wrong, we must look at what happened and try to understand how to prevent future lapses.

Image of salt mounds in Salar de Uyuni, Bolivia from Wikipedia. shown under Creative Commons Attribution Share-Alike License.

Salt I

Hyponatremia, or a low sodium level in the blood, is an interesting problem. If a patient is noted to be hyponatremic, the next clinical question is about their "volume status." Volume status refers to whether a patient is dehydrated, normal, or congested with fluid. Based on that, the diagnostic tests and treatment diverge greatly. It seems like it would be an easy question to answer, but it's really not that simple.

On my last wards rotation, I admitted a patient with a sodium of 120 (normal is 135-145). He had a history of congestive heart failure, a heart attack, diabetes, and arthritis. He was taking no medications. He presented with a couple weeks of nausea, vomiting, and watery diarrhea. He was not eating much. He didn't know whether he had gained or lost weight.

On examination, I easily saw his jugular venous pressure while he was sitting upright. He had edema or swelling in his legs, but not too impressive. His lungs were crystal clear. He had a huge belly but it appeared more obesity than fluid-filled. His labs were remarkable only for some kidney insufficiency. We did a bedside ultrasound which showed an inferior vena cava that was dilated to 2cm with minimal respiratory variation.

The question is simply: is the patient fluid overloaded or dehydrated? It's an interesting question because I had a strong opinion the whole time but the team went back and forth on the right answer, and due to delay, the patient suffered.

In the emergency department, the patient was felt to be hypovolemic. His sodium went to 122 with 2 liters of normal saline. However, I felt very strongly that the patient was fluid overloaded; the gestalt of looking at him and the exam reeked to me of congestive heart failure. I spend a lot of time doing things that are highly subjective such as looking at neck veins, but I convinced myself that they were elevated, not consistent with dehydration. My resident disagreed; she trusted the history more, and with vomiting, diarrhea, and poor oral intake, she thought the patient was dry. She was confused by the bedside echocardiogram but nonetheless wanted to give the patient more normal saline. My argument at the time was that congestive heart failure often presents with nausea, vomiting, and poor PO intake. We agreed to free water restrict that patient and not give more fluids. That first night, I wrote for a baby dose of lasix because I thought it was the right thing to do, though both the ED and the resident disagreed with my clinical assessment. I also added on a BNP (an imperfect laboratory marker for congestive heart failure) to the labs. Although I initially felt the patient needed to be admitted to cardiology, I did not make a strong argument, and so he was admitted to my general medicine team.

More on the case tomorrow.

Image of salt crystals from Death Valley National Park is shown under GNU Free Documentation License, from Wikipedia.

Poem: The Act of Writing

The Act of Writing
Craig Chen

Writing exhumes.
It unearths, resurrects--
and not from tombstones
(except on days we write of zombies)
no--writing is tilled earth;
stillness ingrained, deeply planted;
it is sweat and callous,
work-song.
Writing draws out seedlings
and occasionally it floods.
We work fields
and writing scrubs off layers of skin
and finds a different word than raw
to describe beneath.
Writing buoys.
It floats, bubbles out, a splash inverted,
expands larger than you or I could have said,
levitates away.

Significant

I've actually been bothered by this before. As physicians, when we send too many lab tests, one of them is bound to have a false positive that sends us barreling down the wrong road.

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Code Status III

As a last post on code status, I wanted to write about a patient I had with metastatic cancer who was able to articulate his goals at the end of life better than anyone else. He said, "I understand what the cancer means for me. I am happy with the life I've lived so far, and each day longer that I live is a blessing. I don't want any heroic measures at the end of my life, and I want to die with dignity. I don't want any machines or tubes, and ideally, I don't even want to be in the hospital. I want to work until the day I die. I'd like to travel to Europe, though I know I might not be able to. I don't need or want my life extended artificially." This conversation, however mushy it appears on this blog, was extraordinarily satisfying and taught me a lot more about his character, value, and wishes than anything else.

Code Status II

This is a continuation from yesterday's post. I'm not even sure the ideal code discussion is possible. The ideal setting is for a patient and her primary care physician, who has known her for a long time, to have an engaged two-way conversation regarding how she envisions the end of her life. It involves presenting the data in an unbiased manner and exploring how the patient's values and underlying conditions intersect with the practicalities of CPR, intubation, etc. But how is someone to know what she'd like at the end of her life (if she were not there yet). Certainly I think I would not like aggressive resuscitation, and yet, I can't imagine at all what it would mean to be critically ill and at the brink of such an intervention. I just don't know. Should code statuses be a wish we have when we are well? Or something we finally understand when we are sick? How would you like to die?

This fundamental ethical question may be as important as how we would like to live. But none of us (possibly? presumably?) have died before, and in much of the literature of death and dying (all of my posts are labeled "Death"), the talk of "dying with dignity" and "the good death" are all extrapolated from observing and interacting with loved ones in that situation. But how we feel about our death now, when we are healthy, may be different than how we feel about it when we are in extremis. Which is more reflective of our core values and identity? I don't know how to answer that question.

Most of us may imagine that at the end of life we would not want to overdose on pain medications to commit suicide. But how many cancer patients have I seen who beg for relief of their unrelenting pain? How valid are their wishes? When one is in pain (or depressed, or nauseous, or in a psychotic break), one says things that are irrational, unreasonable. Perhaps their wishes for death are tortured out of them. But on the other hand, I can't imagine how much pain that end-stage cancer patient is in. How could I know that I wouldn't ask for narcotics to kill myself? How could I be sure that my opinions now are valid in circumstances I've never experienced?

Code Status I

I don't know what to think about the "code status" discussion. Briefly (and bluntly), the code status of a patient addresses what we do in the case that the patient's heart or breathing stops. In its barest skeletal form, we want to know whether someone wants to be intubated ("have a breathing tube placed and be hooked to a ventilator or breathing machine"), have CPR ("chest compressions"), undergo defibrillation ("shocks"), and be treated with vasopressors ("special medicines for blood pressure"). It is a requisite piece of information for everyone being admitted to the hospital.

To be honest, I could almost always force a particular code status on a patient if I wanted. It is the same as a magician forcing a card trick by giving the audience an illusion of free will but pre-determining what they will pick. I might say, "Some patients would like CPR, also known as chest compressions. This comes with a great deal of pain; indeed, we occasionally break ribs while doing compressions. Although it may restart a patient's heart, they almost never regain the same level of function and quality of life they had prior to the cardiac arrest, and many don't even make it out of the hospital." Or I might say, "Chest compressions, or CPR, can be undertaken if your heart were to stop in the hospital. As you might imagine, cardiac resuscitation in the hospital is more likely to end in a better outcome than if your heart were to stop out in public and require CPR there. Although there are side effects like rib fractures, this would be part of this life-saving maneuver and we'd certainly treat those problems." Presenting the matter - which is incredibly serious, life-determining, and difficult for the layman to understand - means everything.

More on code status in tomorrow's blog.

Chocolate

There is a secret repository of chocolate in the pre-operative office across from the intensive care unit. The first thing I do is look furtively down the hall, and when the coast is clear, I pocket a piece. Then I look again and take a second piece. Then a third. Why I take them one-by-one I can't explain; it just seems wrong to take off with a handful of free things. Through the day, my stash slowly wanes. A Snickers to replace lunch, a Butterfinger after a tearful family meeting, a Tootsie Roll while fielding phone calls, a Hershey's on the way out of the hospital. At the end of the day, I empty my pockets and among dried pens, scraps of paper, a pager and keys, I throw out wrappers and count how long that day was.

Image shown under Creative Commons Attribution Share-Alike License.

The Social Admit

Occasionally, we take the completely inappropriate social admit. Tonight, I admitted a patient who I feel has no medical needs, but has nowhere to go. He previously resided at a nursing facility, but because of progressive Alzheimer's, has exceeded the ability for the nursing facility to care for him. A family member brought him into the emergency department because frankly, he has nowhere else to go. The ED is unable to find him a suitable disposition (destination) and so he's admitted to the medicine service under my care. But there's very little for me to offer him. He has no symptoms other than his dementia, for which he's already receiving the right medications. Since it's the weekend, social work and case management won't help find him a more suitable nursing facility. So he stays here without a clear indication, using up resources. This is modern medicine.