Passing By

Intern year is the hardest year. It's the period of the most learning, growth, and acquisition of responsibility. It also involves the most "scut work." Interns make the cogwheels turn, to get the system to run. We call for outside hospital records, we put in every painstaking order, we call family members for updates, we write discharge instructions, we round with case management and social work. The year is difficult because there's so much to do - not only are we learning the practice of medicine, but we are learning the mechanics of it as well.

But it gets easier through the year. We figure out what's important and what's not. We become much more efficient, organize our to-do lists, anticipate nursing pages. We learn to start physical therapy early, order special mattresses so patients don't develop ulcers, and ask about a patient's primary care doctor so we can send them a heads-up. And suddenly wards isn't so bad. Last time I did this rotation, I was here consistently to 8pm on noncall days. Now I'm able to tuck things in an hour or two earlier.

If I were to be an intern forever, I could tighten up efficiency even more and probably even deliver better care. But thankfully I'm not an intern forever, I'm just passing by. I could be good at putting in orders and writing detailed progress notes and coordinating care, but the large medical decisions fall in the hands of the attendings, and that's what we want to become. So it ends up being the hardest year because by the time each intern class figures it out, they're out the door and the next group of interns start passing through. Oh well, I don't mean to stay.

Poem: The Map and the Territory

The Map and the Territory
Craig Chen

here, wildebeest of colors crowd

sense & conflagration, in burst

& sway over torrent of wind aloud

& the rustle reply of leaf coerced

drifts among cloud, swift & hope

in somnolent grasp through plea:

run with me, color & elope

over freedom and thrice we see

for it is the opening of sun

after exhaustion of slumber

& our cells cry run run run

lest we get hit by thunder

in map of mind and dream

we in recollection dance

until even twilight's gaze seems

to rivverrun this trance

we fall together hand-in-hand
dream swim & wave abound
over reason and tight lip demand
and drift resounding sound

Korzybski

Of course our illustrious program director Abraham Verghese, a writer, would know of Alfred Korzybski and tell us the famous quote, "The map is not the territory." It took me some time to understand what he meant. He says this when referring to studying versus practicing medicine. The map - that is, the books: Harrison's, Cecil's, UpToDate - is not the same thing as the territory - the patients themselves. And no matter how hard we study the maps, the experience is not the same as the practice of the thing itself. In medical school, we are cartographers. In residency, we become explorers.

Exposures

The history taken by infectious disease doctors includes some interesting questions. In asking about exposures, it's important to elicit unusual activities that might put someone at risk for rare infections. Recently, I admitted a transfer from an outside hospital of a young woman with progressive subacute shortness of breath. She had initially gone to her regular doctor with dyspnea on exertion, fevers, and generalized weakness. She was diagnosed with community acquired pneumonia and prescribed azithromycin. She did not improve after a week so the physician switched her to levofloxacin. A week after that, she was so winded, she could not go to the bathroom without stopping to rest. She was admitted to the hospital and started on ceftriaxone and fluconazole (for coccidioidomycosis, which is endemic in the area she's from). Lab tests at that time were surprising for elevated liver function tests (AST/ALT in the 200s) and CK elevation to 2000-3000. She was then transferred to Stanford for further workup.

Our initial considerations were infectious and rheumatologic. Because initial treatment for community acquired pneumonia failed, we started entertaining more exotic causes for pulmonary disease. A thorough history revealed that the patient rode horses, delivered cattle, took care of hogs, and hunted wild game. A CT scan showed diffuse ill-defined ground glass opacities. A Coxiella burnetti titer came back positive. We started doxycycline.

Q fever is one of those diseases that is often proposed and theorized and never turns out to be true. But this could be the first case of Q fever I've seen. At this moment, no firm diagnosis has been made, but lung biopsies and microbiological samples are pending.

Separately, I had a different patient whose prior occupation was a big game hunter - moose, coyotes, deer, and bears. It's fun to talk to people who have such diverse and unusual experiences.

The Cow Pock

This is the cartoon "The Cow Pock" by British satirist James Gillray. It caricatures a scene at the Smallpox and Inoculation Hospital at St. Pancras, showing Edward Jenner administering cowpox vaccine to frightened young women, and cows emerging from different parts of people's bodies. The cartoon was inspired by the controversy over inoculating against the dreaded disease, smallpox. The inoculation agent, cowpox vaccine, was rumored to have the ability to sprout cow-like appendages. A serene Edward Jenner stands amid the crowd. A boy next to Jenner holds a container labeled "VACCINE POCK hot from ye COW"; papers in the boy's pocket are labeled "Benefits of the Vaccine". The tub on the desk next to Jenner is labeled "OPENING MIXTURE". A bottle next to the tub is labeled "VOMIT". The painting on the wall depicts worshippers of the Golden Calf.

The image is in the public domain, from Wikipedia.

Why I Love Medicine

On my call night, I was cross-covering a bunch of patients I did not know. A nurse paged me saying that a patient wanted to leave "AMA" - against medical advice. Multiple staff members had tried to convince her to stay but she was adamant on leaving. As the covering doctor, I was the last-ditch effort to keep her from going. But of course, I had no relationship with this woman; I'd never met her and knew only the medical problems scribbled within two lines on the sign-out.

I sat with her. I held her hand and listened. They teach us to do this as medical students, and somewhere it escapes us. Although both she and I knew that I was there to read her the "AMA" form and have her sign it, I didn't want to do that. I did what anyone else could - acknowledge her feelings and try to understand why she felt mistreated by the system. I apologized as best I could. I offered to fax any medications she needed, offered to call a cab to get her home, and told her that our doors were open if she had to come back. I stood up, shook her hand again, and when I turned to the door, she told me she'd stay. It was a wonderful feeling, trying to create a trust and rapport in 10 minutes amid the chaos of a call day, and it felt good when it worked.

The Patient-Physician Covenant

This is excerpted from Crawshaw R, Rogers DE, Pellegrino ED, et. al. Patient-physician covenant. JAMA 1995; 273: 1553.

Medicine is, at its centre, a moral enterprise grounded in a covenant of trust. The covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick whereever their welfare is threatened and for their health at all times [...]

By its traditions and very nature, medicine is a special kind of human activity - one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest.

Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care [...]

As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor the covenant of trust with patients.

Pointers

This is a somewhat tangential post, but springs from the last post about pagers. In computer science, pointers are a data type whose value refers directly to another value stored elsewhere in the computer memory using its address. The "ghost pager" system reminds me intensely of pointers. All hospitals have had to figure out a way of identifying who to page for what. For example, all patients must be linked to a physician and their pager number. On call days, the accepting team on call must have a pager for the emergency department to contact. The least efficient way is to print out a long list each day of who is on call and who is caring for which patient. In that case, there's lots of room for errors and communication problems. How do you deal with cross-coverage where a primary team has left the hospital but signed over their patients to the on-call team? How does a nurse know who to page?

Another system, which many hospitals use, is to have generic physical pagers. There is an admitting pager and every day at 8am, the post-call team hands over the physical pager to the on-call team. That way, there's one number that is always used for admissions (or codes or consults or whatever) and it can be handed around to the person who needs it. This is also inefficient as it requires a physical handoff, but at least it standardizes a code of communication.

But Stanford's elegant solution is to use "ghost pagers" like pointers. Certain generic roles have pager numbers assigned to them without a physical pager. For example, there is a number for the chief residents, admitting on call team, medicine team 3 intern A, etc. So a nurse, consultant, emergency department, or anyone always has the same number to contact for a certain role. But instead of assigning those numbers to a physical pager, Stanford makes them a "pointer" where that number "points" to a different pager. Through the operator, I can make the admitting pager forward to me. This way, no physical handoff of a pager needs to be made, and we don't do the belt-full-of-pagers look. Only a handful of hypothetical "ghost" pagers point to ours.

I always have the medicine team 3 intern A pager forwarded to me; that way, any patient assigned to my team is assigned to my pager. When I leave the hospital, I forward my pager (as a pointer) to the on-call intern's pager; that way, a nurse trying to get a hold of my role (medicine team 3 intern A) automatically gets the covering intern. I think it's pretty cool.

Image from Wikipedia shown under GNU Free Documentation License.

Pagers

What's the deal with pagers? I think most people have that thought sometime during medical school. When we get our first pager as a medical student and hear it chirp, we get ridiculously excited - someone wants to talk to us! Inevitably, it's just one of our classmates trying to figure out if they can page correctly.

The pager quickly becomes the heaviest thing we carry. Like Tim O'Brien's The Things They Carried, the pager becomes a marker of who we are. While we are at work, it is a tether, a leash we cannot turn off, a link to the hospital at all times. We learn to dread that vibration, to have a reflex of touching our hip whenever anyone's tone goes off.

Anyway, what is it about pagers? Is it an obsolete artifact of days of yore, still in place because of physician reluctance to change? The truth is, I'd very much prefer to do everything by cell phone (though giving out my phone number to all the staff would be worrisome). Furthermore, pagers are really inefficient; to text-page someone, I find a computer, log on to a secure site, send my text page, wait at a phone for them to call me back, and then finally talk to them. In medical school, we had two-way text pagers and that was much better.

Pagers, I suppose, remain in use because they are reliable. In the bowels of the hospital, few phones get reception, but pagers magically remain viable. But because of the inconvenience, the hospital has invested in some "bat phones" - wireless phones that work throughout the hospital, carried by those who need to be immediately available (like the ICU fellow).

Image of pager from Wikipedia shown under Creative Commons Attributions Share-Alike License.

Match Day

Yesterday was Match Day, the day senior medical students find out which residency programs they are attending. It is very weird to think that it's exactly a year from when my own Match Day. It's comforting to know that there is light at the end of the tunnel and that replacements have been found for me and my co-interns. Congratulations on those who matched (and now have a job and a salary to pay back those loans)! And rest assured, this year has gone by weirdly quickly and I am sure it will for you too.

Heart Block

On one of my recent call days, I cross-covered a patient with a profound cardiac dysrhythmia. The primary team had been trying to control a rapid heart rate: atrial fibrillation with rapid ventricular response, but had been unsuccessful for several days. Finally, they came upon a cocktail that worked: high dose long acting diltiazem, moderate dose metoprolol, and a touch of digoxin. In the clinical years, we learn that you never use two nodal blocking agents at once; that is, never put a patient on two drugs that slow the cardiac conduction through the atrio-ventricular node because it has too high risk of completely blocking the conduction through that node. Here, the patient required three separate nodal agents. She then became bradycardic with a number of different rhythms captured: a sinus bradycardia, an idioventricular rhythm, a junctional escape rhythm. But she looked stable for the time being and the team put pacing pads on her just in case.

As the on-call intern, I cross-covered the patient - meaning that I took care of her after the primary team left the hospital. I got ominous pages from the nurse and each time immediately saw the patient as I knew she was a high cardiac risk. She was always asymptomatic, but occasionally, her heart rate hovered in the high 30s. Finally, I witnessed something overwhelmingly terrifying: prolonged pauses between heart beats. If you think of the normal heart beat as 60-100 times a minute, a heart beat should go by at least every second. Here, the patient was having up to 4 second pauses before her heart would beat again, a true indication for a pacemaker.

Watching her and listening to the monitor was one of the scariest moments that call day. I could feel my heart skip as I listened for the next heart beat, worried it may never come. I started initial pharmacologic treatment: calcium gluconate to reverse the diltiazem and atropine. Finally, her eyes rolled back and she stopped responding, and we had to call a code blue and start pacing her transcutaneously. Luckily, everything was all prepared and we didn't have any problems. But it was one of the scarier codes where I was the first responder and had to determine the appropriate initial plan of action.

Image of complete heart block from Wikipedia, in the public domain.

Out of the Frying Pan, Into the Fire

I've moved on from the emergency department to the next step in continuity of care: Stanford wards. The truth is, Stanford wards is excruciatingly exhausting, and even though this is my second month doing it, I am very worn out. Nonetheless, there are some interesting cases worth blogging about.

Dispo Comes First

In Samuel Shem's House of God, the Fat Man teaches his eager interns this important adage: dispo comes first. That appears to be the modus operandi of the emergency department. Immediately upon seeing a patient, one must decide where that patient goes next (or, more uncouthly, how to get that patient out of the ED). The entire course of care in the ED is centered around that: either gathering the appropriate tests to prove that the patient needs to be admitted or figuring out the diagnosis and treating the symptoms so that the patient can go home. On all services, "disposition" is the ultimate goal: patients cannot stay in an acute care hospital forever, and they must be stabilized to transition to the next step: to a nursing facility, shelter, home, or even another service. In any case, this process is accentuated in the ED for several reasons: the ED is always just a temporary step, that beds are scarce, and that the ED can do everything (critical care, obstetrics, eye exams, surgical and medical stabilization, orthopedics) but it is inefficient to keep a patient in the ED because no one will need all of those services at once (except polytrauma, I suppose). The ED runs like an ICU; it offers high acuity services and time spent there is valuable and expensive. Once an appropriate disposition is identified, it is a boon to patient, hospital, and community to clear them out of emergency.

8.9

A moment of prayer for those in Japan and those affected by the earthquake and tsunami.

Image is in the public domain, from Wikipedia.

Acute Appy

It is incredibly satisfying to find a case that is a classic textbook diagnosis. A 40 year old man with no significant past medical history comes into the emergency department with acute onset periumbilical pain that started yesterday associated with anorexia, nausea, vomiting. Today, the pain progressed and migrated to the right lower quadrant. On my exam, he had tenderness in the epigastric and RLQ areas and pushing on the LLQ made the RLQ pain worse. His pain was worse when I let go than when I pushed in. I noted that his abdominal muscles tightened when I pushed down. As is often the case, we still pursued a CT scan which showed acute appendicitis.

It was really wonderful to make the diagnosis. In the emergency department, a dozen or two dozen things can cause abdominal pain and many times, we don't have a good answer. But here, the history and physical exam told me everything. The ED is very satisfying with that respect; we are the first pass to turn an undifferentiated patient into a presumed diagnosis.

Image of acute appendicitis from Wikipedia shown under Creative Commons Attribution Share-Alike License.

Robots

I almost never link YouTube, but I happen to really like robots and really like UCSF. UCSF pharmacy has started implementing behind-the-scenes robots to streamline medications and decrease errors.

http://www.youtube.com/watch?v=oumlYbwfAsI

Self-Advertising

Earlier today, I had a rogue post appear that belonged to another blog of mine. I figure I should again draw attention to another blog I maintain called "Case of the Day" with short medical mysteries (often with images) every Monday and Thursday.

http://caseoftheday.blogspot.com/

Jack of All Trades

My emergency rotation helped me realize emergency physicians are quite amazing as jacks of all trades. As I see what they handle in the ED, I am impressed by the diversity of illnesses and injuries. Of course they handle the bread and butter of internal medicine - pneumonia, congestive heart failure, COPD exacerbation, heart attacks, gastrointestinal bleed - and basics of surgery - appendicitis, pancreatitis, wound infections, abdominal aortic aneurysms. But I was impressed by how much other stuff they handle - strokes, vertigo, migraines; suicidal ideation, hallucinations, psychosis; broken bones of all sorts; eye complaints of all kinds; vaginal bleeding; and all the pediatric cases I don't see. The procedures they do span a gamut of specialties: incisions and drainage, slit lamp exams, sutures, cardioversions, thoracentesis, lumbar puncture. There are also all the things no other doctors know how to handle: snakebites, dental problems, unusual overdoses. They are the only physicians that consistently cross over from surgery to medicine lines of thinking. During traumas, I've seen great attending switch from trauma mode (looking for CSF in the ears, palpating all the bones, getting X-rays and Foleys and calculating GCS scores) to code mode (calling out for epinephrine, slapping on pads, starting compressions) smoothly and without fail. Emergency medicine physicians really feel comfortable with any presenting complaint or symptom.

The Hardest Night

There are a lot of hard nights in internship. I can probably recall a night on each call month that was particularly difficult, whether tough emotionally or technically or due to patient volume or fatigue. Recently, I had a hard night in the emergency department due to patient acuity and emotional stress. One of the early patients I picked up came in with respiratory distress, breathing at 30 times a minute. As I sorted out his history, I realized he was sick; he recently had chemotherapy for a liver tumor, and he looked awfully uncomfortable. A stat lactate came back at 18. Lactate is a marker of anaerobic metabolism, an indirect measure that the body's tissues aren't receiving enough oxygen. We usually call ICU if a lactate comes back >2, and I'd never seen anything as high as 18. Then his chemistries came back showing acute renal failure with a creatinine of 5 and fulminant hepatic failure with an AST of 6000 and an ALT of 3000. We quickly got him on BiPAP and called ICU. It was hard for me, however, because this patient took my entire attention; I sat in his room writing notes, following up films, trending labs, and reassessing the situation. But I also had 4 other patients who I could not keep up with during that time. My mindset is that of an anesthesiologist: one patient at a time. So my night started off rocky with a patient close to death, difficult to resuscitate, and teetering on intubation.

The patient acuity did not lighten. I picked up a patient put in one of the less acute rooms along the back hall for a seizure, no deficits noted at triage. But when I talked to him, I learned he had two prior strokes from cerebral aneurysms. He had 6 known aneurysms ready to bleed, two of which had been clipped by interventional radiology in the past. He was also hypertensive to 200/100 and had the worst headache of his life. I had to quickly move him to room 1, the highest acuity, and start him on an esmolol drip and get stat neuroimaging. I could feel my catecholamines surging.

The final difficulty of the evening was a woman at 12 weeks of pregnancy with vaginal bleeding. Our pelvic exam showed products of conception, a failed pregnancy. How do you break the news in the emergency department? I met the patient for the first time that day, I did not know a single thing about her hopes for this pregnancy, whether she was decorating a room, whether she'd dug out the old baby toys. I had no idea whether she'd torture herself with guilt, deny what happened, or hide the fact from her friends and family. I didn't even know whether her husband would be supportive or abusive. There are so many roads this could go down. I'd delivered bad news before, but never like this. And here, in the emergency department, rocking in cacophony, chaotic beyond tolerance, loud and dirty and noisy and unsubtle, I had to tell this woman. Even more than that, she did not speak English, and I had to deliver the news with an interpreter. And though I tried, tried so hard, at the end of this night, it was the hardest thing to do.

Resilience

Part of medical training is building up resilience. There will always be difficult attendings and patients. We will always make mistakes or overlook things or be shortsighted. As a medical student, this is quite hard. When an attending criticizes our physical exam or points out all the things we missed on our differential or yell at us for nothing at all, we feel awful. Medical students are pliable, scared, and easily intimidated. When we witness harsh or unreasonable criticism, we are greatly affected. But as we go through training, we build up more resilience. As an intern, I'm more grounded in what I know and don't know. When an attending points out my oversights or mistakes, I am more receptive. When they make comments that I find unreasonable, I let it go a lot easier. Work is very different than school; now, I don't let emotions overtake me. I think this is a very crucial survival skill in residency which can often feel harsh, cold, and unsympathetic.

Story: Dialogue

One of the exercises in the last writing group involved creating voices and characters out of objects and incorporating them into a dialogue. Dialogue is one of my weakest points. Here's what came out of the exercise:

-Is she asleep?
-I think so; after 3 days of insomnia, she's succumbed.
-Ah well, it was fun while it lasted. That was some car we crushed, wasn't it?
-Some car you crashed. She had no part in it. You had me locked in some backwater part of the brain, near the cerebellum.
-Sorry about that; you know you wouldn't have allowed her to frolic like that. She had more fun in the last few days than she's had in your entire dominion.
-And now she's going to have the biggest hangover.
-Yeah, well, you're going about it all wrong. You're treating it with lithium when ritalin would do the trick.
-You'd fry her brain. I should shove some lithium down your throat.
-Why not? Let's break into a pharmacy tomorrow, it'll be fun.
-We are not shoplifting. I've finally turned her around.
-But if you give me a chance, a whisper, she'll listen to me.
-How do you manage that, to poke your head in every few months?
-I build my house in the heart. I palpitate, I throb, I skip beats, I swoon her.
-You swoon her?
-It's a verb, trust me. I pressure her speech. I goad and plead. I masquerade as you for a bit. It's fun, you know, she believes me. She likes me much better than your cold-fisted government.
-You're talking rubbish. How could you usurp my throne? I sit upon the Turkish saddle, keep reins on the neurons tentacling. She calls herself by me. I wade through her mind and she sleeps and wakes in comfort that I linger. I cling. I define her.
-You define one side of her, the side that bores and languishes. The other side, the true self, starts a small revolt in your cerebral empire. She forgets her meds. I take over.
-Until I can put her back to sleep again.

Multitasking

The emergency department requires a lot of multitasking. As we pick up more and more patients, we have to keep track of ongoing studies or consultations, medications, lab results, radiology results, disposition. It was really quite overwhelming at first. While on my other rotations, I'd have neat checklists of things to do and tests to follow, in the emergency department, the pace simply does not allow that. We have to juggle in our mind those things that are most pertinent for a handful of patients. What I've found is that I have to categorize patients in my head into those who are sick and require much of my attention and those who are well and awaiting results or symptom management. It is also easy to box patients into simple diagnoses: pneumonia, congestive heart failure, pulmonary embolus, appendicitis. I might be wrong in my diagnosis, but I have to start somewhere, usually assuming the worst. This allows us to juggle multiple cases at once because we've simplified it in our minds.

The other thing about emergency medicine is that the volume can change incredibly quickly. We had a slower evening a couple days ago, but all of a sudden, we had a car accident with an adult and six children coming in. It's an unpredictable place, and I think that's hard for me.