Preventable Diseases

We've had vaccines against measles since the 1960s. They are surprisingly effective; many doctors today, including me, have never even seen a real live case of measles. We learn from textbooks, and sometimes, we relegate it to the category of diseases like polio and smallpox - things we'll never see. Alas, this is not the case. Despite safe and effective measles vaccines, parents who decide not to vaccinate their children against this put their kids at risk. In recent news, an outbreak of measles occurred in Disneyland, presumably because of close proximity of many unvaccinated kids. As more parents opt their children out of the vaccine, herd immunity - the principle that many immune people can keep vulnerable people safe by limiting spread of a disease - wanes.

Although mortality for measles in the current health care environment is quite low, it's a serious disease with many potential complications. Most importantly, it's preventable. There is no evidence that routine vaccinations have any serious risk, and its benefits are substantial. I hope that outbreaks like this encourage more parents and physicians to vaccinate.

First image shown under Creative Commons Attribution Share-Alike License, second image is in the public domain, and both are from Wikipedia.

Post-Call

There's no feeling quite like being post-call from a 30 hour shift. Looking back, I'm not sure how I did it every fourth night in intern year for nine months. I can't even easily put it into words. There are ebbs and flows of energy, lulls in the day (or night) where you are on the edge of sleep before that racket of a pager shakes you awake. Yet you also go through these energy rushes where you are running from one emergency to another, feeling (or at least thinking you feel) as awake as ever. In the morning, the light of day, when all your decisions overnight are being scrutinized, you shy away from the bright lights, encounter word-finding difficulty in presentations. Little bits of information slip away. Small to-do's are lost, forgotten. You develop a system, to ensure that you keep track of all the tidbits that happen over twenty-four hours. You learn to be more efficient, simply because you have to; otherwise you'd fall asleep typing mid-sentence. The world is a blur; you walk upstairs and forget why you did; when you get back downstairs, you realize you wanted a new pair of scrubs and trudge back up. Time elongates and shrinks just as daylight does. It's the strangest thing. Now, when I hear about interrogations that keep detainees awake for 80 hours, I shudder. That is a cruel and awful state to live in.

Afterwards, driving home, all that energy rushes out, deflating like a balloon. There is a Stanford class called Sleep and Dreams where the motto is "drowsiness is red alert." Driving home post-call is red-alert. You don't want someone who has been tending to critically ill patients for thirty hours on the road. I don't want to be on the road. When I get home, I tip easily. I stumble. And when I sleep, it's like being submerged; I try to surface, and I simply cannot come up. The dreams are vivid. When I awake, it is dark.

I have a lot of mixed feelings about it. The way medical education is going, it is doing away with these ferociously vicious and borderline inhumane calls. It's certainly not safe for us, especially if a commute is involved. It's probably not great for patients. It may soon be relegated to a rite of passage of times past. Someday, it may be relegated to legend, to stories beginning with "back in my day..." I don't have that many twenty-four-plus-hour calls anymore, and I am grateful.

Hospital Shooting

A cardiac surgeon was shot at Brigham and Women's Hospital several days ago. He did not survive. This story went viral in my social circles, especially since I know so many physicians. It spawned the gamut of reactions: terror, fear, shock, sadness, grief, anger. I, myself, felt shock and disbelief. There have always been vague warnings about our safety, but they've always been the typical sorts of things: concealing valuables in the car, watching for strangers after dark, not leaving laptops unattended. I've never considered myself a bigger target because I'm a physician. I have been aware of drills for "hospital shooting" including a special "code" alert for it. But, in my mind, it's always been a theoretical thing, a due diligence by the hospital to cover all its bases.

Episodes like this are terrifying because they ground into reality what was previously simply theory. How could we be in a world with violent crime against physicians? Yet considering that the perpetrator of this crime had two family members die in the hospital with perceived misadventures (whether this is true is not clear, but I would guess unlikely), we can at least guess at a motive, even if we can never be certain. I never consider as consequence for my clinical decisions and actions a threat to my safety, and it's horrifying that this could be the case. Perhaps better bedside manners, patient and family interactions, and compassionate care would not have swayed the perpetrator otherwise. Perhaps stronger gun control laws, increased security, more frequent crisis training would have changed the outcome. We may never know, but we must not stop trying to do the right thing and to protect our clinicians. My thoughts with the victim's community and my sincerest hope that this is an isolated incident.

Anatomy of an Airway Emergency

I walk into the intensive care unit as a "swing" fellow, a put-out-fires, go-where-I'm-most-needed fellow, and immediately, I'm called for an intubation in the unit. A rather obese man was extubated an hour ago but failed. He now has stridor, airway noises that suggest a critical obstruction. He looks in extremis, having visible trouble getting enough air. His oxygenation and vital signs are starting to decline. Another ICU fellow and an anesthesia resident have been at the bedside for the last ten minutes preparing to re-intubate him. I was called as I was the most senior airway expert available; I hear the story and the plan, and I tell them to go ahead.

I recognized several red flags for potential airway difficulty, especially stridor, an emergent intubation, the out-of-OR location, the borderline vital signs, obesity, and even the fact that I just came into the hospital and didn't know the patient's comprehensive history. Nevertheless, the role of the critical care anesthesiologist in this situation is to stabilize the patient. I pre-assigned tasks, putting myself in charge of managing the vital signs and plane of anesthesia. I put the other fellow and the anesthesia resident at the head of the bed.

Each of them took a look with direct laryngoscopy but couldn't get an adequate view. We went to our planned back-up plan, a video laryngoscope, with which we could obtain a suboptimal view of the vocal cords but simply could not get the endotracheal tube to pass. I then decided I needed to take over the airway and handed over the management of medications and vital signs to one of my colleagues.

Following the American Society of Anesthesiologists difficult airway algorithm, I planned for the next few steps. Even though I wanted to look with a laryngoscope myself, I knew that my role at this time was to follow my pre-determined back-up plans and call for more help and the difficult airway cart. I placed a laryngeal mask airway, something seldom done outside the operating room, but with my background, something I felt incredibly comfortable with. This freed up hands, and more importantly, allowed me to continue oxygenating and ventilating the patient during my intubation attempts. Thus, the vital signs during this half hour saga remained extremely stable. With a flexible fiberoptic bronchsocope, I saw significant edema and swelling around the airway, so much that even identifying the vocal cords was a real challenge.

Ultimately, I got the trauma surgeon to come and do a bedside tracheostomy. I couldn't get the tube through the glottic opening, and in fact, the patient had been evaluated for tracheostomy the previous day. With his neck circumference, even that was a real challenge, but the surgeon managed to access the airway. We brought the patient to the operating room to stabilize it. Despite this ordeal, the patient had no additional injuries and left the hospital a week later.

In an airway emergency, the role of the most senior airway expert is to lead a team, continually evaluate the situation, plan for the next several steps, and obtain other consultations as necessary to keep the patient safe. I tried hard not to get telescoped into tasks, and when I did, I assigned roles to make sure all aspects of care were addressed.

Image is in the public domain, from Wikipedia.

Nostalgia

Walking down Palm Drive, through sandstone arches, under starlit open skies, down familiar hallways, I get pangs of nostalgia as I think of leaving Stanford. In bits and pieces, it has been home for almost a third of my life, and in six months, I will have to say goodbye. It is a beautiful campus and a wonderfully nurturing environment. I have learned so much here, found so many dear friends, basked in the wisdom of so many mentors, struggled through so many challenges, made so many irreplaceable memories.

I'm not sure what's triggered these last two blogs, but perhaps it is this impending transition, where I will strike out from the ivory tower and see if I can make a place for myself. I will miss that which has sheltered me for so long, and perhaps some day, I will find an opportunity or occasion to return.

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Memory's Paroxysms

Grief, memory, longing, and ache are strange and untamed features of our subconscious. From time to time, we get seized by paroxysms of emotion, bouts of sadness as we think of those close to us we've lost or opportunities we've missed. The triggers might be small - the scent of a grandmother's garden or the picture of a grandfather - and they may even float beneath our consciousness. But I don't think its uncommon for us to feel waves of feelings from time to time. Why this happens, to what purpose our brains engage this, why evolution has created this, is mysterious. Do we let ourselves bathe in these emotions? Do we try to fight them because they are unproductive? It's strange to realize I know so little about the internal struggles we deal with after experiences of loss, trauma, and bereavement.

Post

I can't remember when I last wrote about the autopsy on this blog. It has certainly been a long time since I've thought of it and a few years since I last attended one. The post-mortem examination has historically been a very central part of medicine. Only a few generations ago, advancement of medical knowledge depended greatly on examination of bodies after death. Even now, in most medical schools, gross anatomy and dissection represent a rite of passage and core part of the curricula.

Although I sometimes neglect to do it, I believe asking for a post-mortem is an important part of death in the hospital for any patient. I never push families to do it, but if I remember, I will always ask. In an autopsy, a pathologist (who many don't realize is a physician) examines a corpse to determine the cause and manner of death as well as diseases and injuries present. It is a professional and specialized procedure that achieves specific aims while giving a body the utmost respect.

As an ICU fellow this year, I find myself saying "we are at the limit of our medical knowledge and ability" quite often. Because we deal with the sickest patients, the extremes of physiology, the worst of diseases, we often find ourselves in uncharted territory, making diagnoses based on exclusion and indirect evidence or offering hail-Mary treatments when all else has failed. The autopsy may be the only way to know something for certain. I will readily admit that we may miss diagnoses or misappropriate treatments. It is the nature of medicine, especially medicine practiced at the brink of death. The post-mortem examination is one of the few ways we get feedback. It is critical to determining the cause of death and the state of health of a patient before he died, and it is critical for us to better our practice.

The number of autopsies performed has steadily declined over the years. But I personally think the importance has not diminished. Today I attended the autopsy of a patient I cared for for weeks in the intensive care unit. After examining the gross organs and slides under the microscope, I discussed the case with the chair of pathology and learned a great deal about the case. Even though the autopsy confirmed a diagnosis we knew, it taught me about the time course of events, the severity of the disease, and excluded the possibility that we missed something else. The post-mortem examination made a difference for the treating physicians.

Image of Autopsy by Enrique Simonet (1890) is in the public domain, from Wikipedia.

#PhysAnesWk15

It seems like there's a week for everything. New this year, we have a Physician Anesthesiologist's Week (January 11-17). Although perhaps we have gone overboard with having weeks and months for every different profession and disease, I do take pride in being a physician anesthesiologist and advocating for our specialty. We are dedicated to providing safe, high-quality medical care. We train for years beyond medical school to develop an expertise in the perioperative period, with special focus in pain management and critical care. If you want to know why I love this specialty and what I think is unique about it, read some blog posts below.

Craig

Requiescat In Pace

The hardest and most emotionally trying things I deal with in the intensive care unit is the end of life. Recently, I struggled with one particular situation that was medically, ethically, professionally, and personally challenging. A young man who has a bone marrow transplant for Hodgkin lymphoma has a devastated immune system when he catches the flu. Despite treatment for influenza, he has a horrendous inflammatory response to it. Our intensive care team meets him when he is intubated for low oxygenation. He spends three weeks in the intensive care unit, and I get to know him the last two weeks of his life. His acute respiratory distress syndrome does not get better. ARDS is a vicious disease for which we have little treatment but supportive care. He requires consistently high oxygen and pressures. He spikes fevers, and despite broadening his antibiotics again and again, he does not improve. He undergoes two courses of antivirals. He gets steroids for engraftment syndrome, paralytics for ventilator dyssynchrony, and even inhaled nitric oxide for ventilation-perfusion mismatching. We try standard low tidal volume ventilation, pressure support ventilation, airway pressure release ventilation, mode after mode after mode. In the last week of his life, he is on maximal ventilator settings; he has so little reserve that even routine nursing care makes him unstable. He cannot get any further studies because moving him out of the intensive care unit is too risky.

His mortality is certain. There is no question in my mind that this degree of physiologic injury is unsurvivable. Patients with bone marrow transplants with any degree of respiratory failure seldom recover, and anyone with this level of respiratory failure is on death's door. However, because of his age, his parents refused to let go. Day after day, we pushed on, doing little because everything that could be done was already done. It broke my heart. He was comfortable and sedated, but I knew there was no end point. I recommended transitioning him to comfort care, to have a peaceful end of his life.

The surrogate decision makers were intelligent but had trouble seeing the big picture. I do not blame them. For a child to die before a parent - I cannot think of a worse fate. Each day, we spent hours talking to the family, admitting that while we are not omniscient, we cannot expect anything but the one singular outcome. In the end, he went into multiorgan failure and died. But this is not the death I wished for him. On life support, we can keep anyone "alive." But everyone has to die, and death on life support is a death fraught with artificial lines and tubes, a lack of awareness, technological extremes, machines and devices. It is prolonged, dragged out and thinned so that what substance is left is minimal. It puts families through distress, caregivers through emotional turmoil, patients through suffering.

We could have called this medical futility and withdrawn care ethically. However, putting this into practice is an ordeal for caregiver and family alike. Sometimes, it is not easy being a patient advocate, an intensive care physician, and a fellow human being. Especially at the limits of medical care and the end of life, we face challenges that try everyone involved. We can only approach these with compassion, thoughtfulness, and equipoise.

Book Review: California

Edan Lepucki's California is a debut novel that has received a lot of interesting and mixed press. Similar to many other books I've liked, it takes place in a post-apocalyptic dystopian world. It's quite reminiscent of The Giver and Oryx and Crake. In a world torn apart by natural disaster, dwindling resources, class separation, and desperation, a couple who has isolated themselves in the wilderness trying to survive off the land begins looking for other survivors. More than simply a man-versus-wild archetype, it explores the emotions, feelings, motivations, and intentions of its two main characters in a way that is vivid and captivating without being banal or stereotyped. This is what I enjoyed most of the book, getting into the heads of the two main characters as they struggle to survive, navigate interpersonal conflicts, and confront horrors of the past. This review sounds sensational, and in a way, the book is theatrical in scope, but what I loved most about it was the raw human element. It got a lot of mixed reviews after being praised on The Colbert Report, but I think it is a beautiful first novel.

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Tylenol Overdoses

In the last week, we've had two terrible Tylenol overdoses. Neither was a clear-cut suicide attempt, though both were certainly suspicious for intentional overdoses. It seems to me that every year around the holidays, we have an uptick in suicide attempts; I'm not sure if it's true, but I certainly wouldn't be surprised if it were. It's a awfully sobering feeling, and I wish I understood suicide better at the individual patient level and at the societal level. It's heartbreaking to see and care for these patients.

Both patients overdosed on acetaminophen, presented to outside emergency departments, and were transferred to Stanford for possible liver transplant. Neither survived to get a liver, though both were actually offered an organ. Acetaminophen is a strange drug; the vast majority is processed by the liver to perfectly harmless byproducts. A minuscule amount is excreted directly in the urine. The rest, about 8%, undergoes metabolism to a dangerous byproduct. This byproduct immediately binds a neutralizing agent in the liver, but in the case of overdose, there is a buildup of this toxic byproduct and it causes severe hepatocyte damage. Patients develop fulminant hepatic failure; their liver cells die, they stop processing toxins and stop synthesizing necessary proteins. These patients develop bleeding, brain swelling, kidney injury, electrolyte imbalances, low blood pressure, seizures, and infections among other complications.

Both patients were young, and we were aggressive trying to save them. We placed breathing tubes, started continuous dialysis, supported blood pressure with vasopressors, prescribed antibiotics. In fulminant hepatic failure - acute life-threatening liver injury without pre-existing cirrhosis - patients get a special status on the organ transplant list. They are first in line, but even then, organs come too late. One patient developed refractory brain swelling and had a cardiac arrest. The second patient had raging pancreatitis which lead to intestinal injury. He actually made it to the operating room, and the donor organ was on its way, but when the surgeons looked in the belly, it was clear he would die regardless and futile to transplant the scarce organ. For both patients, this was a race against the clock, and despite what we could do, both died.

It's been an emotional week. These patients were previously healthy and functional members of society. Although the social milieu was complicated - especially if these were suicide attempts - I was tasked with medically trying to ward off the inevitable. And seeing the family at bedside in shock, witnessing the tragic end of life of these two patients, I struggled with the ups and downs of my job.

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