There's a Day for Everyone

I found out today was Doctor's Day. I guess there's a day for everyone. On some level, it bothers me as it fuels the "everyone is special" message in our society ("Let's celebrate our graduating second graders!"). I have to say, though, I appreciated our luncheon; the private community hospital I'm at goes all out. So the particularly cool thing about National Doctor's Day is that it celebrates the first use of ether anesthesia for surgery at Massachusetts General Hospital. There aren't a lot of public proclamations about anesthesia, and to celebrate all physicians on the day general anesthesia was first used is a big deal. It makes me feel a little tingly inside to be recognized as such. Now, if only we had a Google doodle celebrating this...

Arrogance

The contradiction is this: in our society, in medicine, in relationships, at work, at home, and even at play, we must be confident. We need to have self-assurance in our skills, our abilities, our knowledge, and ourselves. But I think the biggest downfall is arrogance. An anesthesiologist who is arrogant will plunge into a case unprepared when he could have been. A surgeon who is arrogant will promise outcomes that he may not always deliver. A friend who is arrogant grates on the relationship. A spouse who is arrogant cannot see your perspective. When someone is arrogant, they think they own more than they do; a physician owns a disease and controls its progression, a suitor owns the man she chases, a teenager "pwns" his opponents at a game.

Perhaps there is a thin line between pride and arrogance, but I have a subconscious reaction almost immediately. I stand proud with someone who is proud: a friend who just took his boards, a new set of parents, a surprise winner of a board game. But arrogance almost immediately rubs me the wrong way. There are many other faults I accept so much more easily; even incompetence is tolerable as long as the person admits their failings. But a doctor who is arrogant does his patients a disservice just as a friend who is arrogant will find himself without, a politician who is arrogant will create chasms, a self who is arrogant will want for happiness.

I don't usually write such prescriptive blogs about personality, but a convergence of a lot of things - what is happening in the primaries, encounters with friends, thoughts about who I am and who I'd like to be - lead me to scribble this down.

ICU Medley

The bread and butter of the ICU stays the same. Patients after extensive surgeries remain intubated because of fluid shifts or concerns for swelling. I come in the morning, put them on a spontaneous breathing trial, extubate them by lunch, and send them out of the intensive care unit. Other patients have a much longer duration of respiratory failure; intubated for seizures or COPD or altered mental status, these patients are usually older and weaker, without significant reserve. I spend the week exercising their respiratory muscles, making very slow progress as they wean from the ventilator bit by bit. We have our post-cardiac surgery patients, our heart failures, our heart attacks, and our strokes. Although these are straightforward, occasionally, competing interests arise. For example, a patient with a mechanical heart valve on anticoagulation undergoes abdominal surgery. His anticoagulation is held before surgery and resumed post-operatively because with that mechanical valve, he is at high risk for strokes. Unfortunately, he bleeds into his abdomen, requiring a middle-of-the-night emergent laparotomy. Now, how do we decide when to restart anticoagulation? How much risk are we willing to take with regard to strokes or further bleeding? Often, there's no right answer, so both surgeon and cardiologist decide to "keep a close eye on him in the ICU." Along the same lines, GI bleeds tend to come to the unit, even if they are hemodynamically stable; the hospitalists are quite conservative and send them to critical care "just to watch the patient."

Of course, septic shock is the most common admission to the intensive care unit. One of the more interesting cases was a morbidly obese patient presenting with an infected kidney stone. He was anticoagulated for atrial fibrillation. When he came in, he was in septic shock, requiring large fluid boluses and vasopressors. He went to interventional radiology for placement of a nephrostomy tube. Unfortunately, his body habitus made the procedure technically difficult and with his anticoagulation, he had significant bleeding around the kidney. He received a massive transfusion protocol. When he returned to the intensive care unit, now intubated, he had a mixed picture of septic and hemorrhagic (or hypovolemic) shock. His ventilator settings were now very challenging given his body habitus and the fluid shifts he experienced. As a result of his shock, his kidneys stopped functioning and he required continuous renal replacement therapy. The critical care involved a delicate management of his fluids, titration of his vasopressors, decisions around transfusions, and weaning of the ventilator. What started as the oh-so-common "urosepsis" became a real multiorgan system failure. A week later, though, he was on his way to rehab, doing well, off dialysis, and back in good spirits.

Congrats on Match Day!

Congratulations to all the medical school graduates this year, and in particular, to my brother who matched into orthopedics. There is a fracture. I must fix it. I remember my own match day, and it's a big deal, finding out where you will be for the next stretch of training. Of all the transitions I've been through, I think the one between medical school and internship carries the most significance, and in some ways, is the hardest. I write for The American Resident Project, and this month, many of our posts deal with the Match Day experience. Check it out!

Book Review: Thing Explainer

Although I toyed with the idea of using Thing Explainer constraints in writing this blog, I decided it would be too hard. If you know me or have been following this blog long enough, you'll know that I am a fan of Randall Munroe. He used to work on NASA robots, but then discovered a talent for drawing fun and witty comics. He's published two books and a long-standing web comic. Thing Explainer is his second book. I checked it out recently and found it greatly amusing and educational. The premise is a "How Do Things Work?" type of book except that in order to be more accessible, he only limits himself to the thousand most common words in English (he calls these the "ten hundred" most common words since "thousand" apparently isn't in the top thousand words used).

With beautifully illustrated diagrams, funny comments, and detailed explanations, he looks at rocketships, laptops, a hospital room, tectonic plates, the phylogenetic tree, and much more. Even when you know what he's talking about, it's pretty fun to see how he describes things with the word constraints he has. And if you don't know how a washer/dryer or airplane cockpit or oil rig work, then it's pretty fascinating learning about it. It's not meant to be a book read from cover to cover, but it was a highly enjoyable way to while away the time. I encourage you to check it out at: http://xkcd.com/thing-explainer/.

Image shown under Fair Use, from xkcd.com

"Give Me Your Tired, Your Poor / Your Huddled Masses"

A young woman with an extensive drug history relapses into her old ways. For a month, she takes escalating doses and combinations of different drugs: meth, heroin, ecstasy, cocaine, alcohol, tobacco, marijuana, prescription opiates, prescription benzodiazepines. It's a mess. She's brought in unconscious by a friend. Her physical exam shows evidence of track marks, recent falls, and poor self-care. Her labs show a large anion gap acidosis, but her lactate, glucose, and creatine kinase are close to normal. Her urine toxicology screen was "pan-positive," that is, had nearly every substance we tested. In the emergency department, she wakes up, flails her arms and legs so violently that she is sedated. Luckily, she protects her airway and continues breathing so she doesn't need intubation. But I am called to admit her (the emergency physician says, "I don't know what's going on, it's a mess, and she's critically ill, I need your help") and as I examine her, I think I could be in SFGH or Santa Clara Valley Medical Center. Our hospital, because of the nearby demographic, seldom sees this kind of patient: the poor, the trodden-upon, the marginalized.

Medically, the treatment for such conditions is mostly supportive. I tried to deduce what she was intoxicated with, what she was withdrawing from. There wasn't a single substance; it was not as if I could shine a light into her pupils and deduce what was happening to the soul within. But in time, her body metabolized its impurities and she emerged. Meanwhile, the anion gap acidosis which scared the emergency physician so much (she received several amps of bicarbonate in the ER) resolved surprisingly rapidly. My hypothesis was alcoholic or starvation ketosis (her ketones were elevated but the glucose was normal). Within just a day or two, she was ready to leave the intensive care unit.

I would love to report that when she woke up, we had a heart-to-heart, she renounced her ways, and I got her to a detox center, but such things never are. She was angry, mean, verbally abusive. But I reminded myself and our staff that this woman deserved as much as we could give. She reminded me of the last few lines on the Statue of Liberty:

"Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

Many of us physicians enter medicine with such golden ideals, warm hearts, and open arms. We scatter into private practice and posh jobs, and a veil falls between us and that which inspired us. From time to time, I reminded of this, how in becoming a doctor, I was drawn to these patients, who need our care, our love, our attention.

The title of his post and the image represent the sonnet "The New Colossus" by Emma Lazarus, which is inscribed inside the pedestal of the Statue of Liberty. The image is in the public domain, from Wikipedia.

Central Databases and Clearinghouses

I don't actually advocate this idea, as I think there are too many ways it can go wrong, but I propose it as a thought experiment. The other day, halfway through my anesthesia cases, I get a call from a pre-operative nurse. An 85 year old gentleman having prostate surgery visited his cardiologist for "preoperative clearance." He remembers having an EKG done in the office, and was told, "It's fine." He doesn't have a copy of it. When the preoperative nurse calls the cardiologist's office, they say their system is down and they can't fax over the EKG. The patient is next in line for surgery; the nurse would like to know whether I want to order an EKG. For me, the answer is simple: yes. I trust the patient and expect the EKG will be "fine." But if I went forward with anesthesia and he had a cardiac complication and I didn't actually review the EKG, that wouldn't be sound clinical judgment. The EKG is simple and quick; it's ready for my review by the time I meet the patient in pre-op. Indeed, it is normal sinus rhythm with left ventricular hypertrophy, nothing to write home about. The anesthesia proceeds smoothly.

This happens often, especially with labs and EKG in the preoperative setting. But over time, this incurs a significant expense. If we had access to his cardiologist's data, we wouldn't reorder the test, which probably gets billed for a couple hundred dollars. Why not build a national database as a repository of every single lab, EKG, and radiology study done on patients throughout the country? Most hospital systems now already use electronic records. Many people are struggling to build ways for these systems to communicate. But labs are pretty standard, and it seems that having them reported to a central clearinghouse and then retrieved from that database could eliminate the problem of "having labs done but no one can find them." Of course, patient privacy, regulating access, preventing unwanted intrusions, and other HIPAA related issues rise to the forefront. But I imagine if those security issues can be appropriately addressed, this can significantly reduce unnecessary testing, improve population research, and aid clinicians everywhere.

Status Updates

As airlines become better at updating passengers when flights are delayed, I wonder, briefly, whether this will ever come to the operating theatre. Rather than waiting a couple extra hours at the airport, I was able to get some errands done and arrive at a reasonable time before the delayed flight departed. So many patients, especially at the end of the day, wait around because their room has been delayed. Wouldn't it be ideal if there was some automated system that could let patients know that they could have a sip of water or come in a little later if their case might be delayed?

Magic

There is a part of me that believes in magic. I'm not sure how to explain it, and almost certainly, it stems from deep within, from my youth, from my world view. No matter how much science, mathematics, and logic go into medicine, there is still some measure of magic in the simplest moments: the clasp of a hand, the holding of a vigil, the crestfallen grief, the elation of success. Maybe these are just emotions, but part of me believes there's something more, something almost sacred. It is the same as the quivering voice making marriage vows, the same as the quiet in a memorial service or the susurrus of the ocean. For how can you stand under century-old redwoods or witness a birth or connect with a human being at their most naked and vulnerable and not feel some sort of magic? We say we go into medicine "to help people" or because we "like physiology and pharmacology" or even because we "want to deeply touch others." But the truth is, there has always been some touch of magic for me, the moments that are truly special, and that is somewhat addicting. I still remember what it felt like the first time meeting a person who I knew would die; what it felt like when I delivered a newborn; what it felt like when I saw lungs transplanted into another body and inflate when I squeezed air into them. There is still magic in this world.

A middle-aged woman who had never been to a doctor in her life collapses at home. Paramedics bring her into the emergency department, chest compressions ongoing. Her heart is in disarray, squeezing erratically and ineffectively, a call for help. Everyone in the emergency bay recognizes the rhythm, ventricular tachycardia, a precursor to flat-lining. Pads are slapped on her, she is shocked; her body convulses, and we are on top of her again with compressions. This is our laying of hands, our most desperate measures. We pump epinephrine through her veins. All of a sudden, her rhythm converts to sinus, but there are ugly wide complex beats threatening to take over. Her heart teeters on some edge between life and death, a cliff on one end, and a large gray zone on the other. We rush her to the cardiac cath lab where a cardiologist finds a blockage in the vessels of the heart, stents it open, and brings her, still alive, to the intensive care unit. She is cooled so that the brain, reeling from this trauma, can recover. Over the next three weeks, her heart cries out; every few nights, she goes back into ventricular tachycardia and requires a shock to reset. The cardiologists ply their trade: amiodarone, lidocaine, potassium, magnesium. We entreat the heart.

But when I hear of this case, I ask: what of the brain? What of Descartes' "seat of the soul?" Will she be who she was? When we lighten her sedation and wake her up, we find only howling wind and thunderstorm. Her eyes are vacant. A voice, a light tap, a pinch, knuckles on the chest - none of these cause her to stir. But she is not brain dead; her brainstem still glimmers; she breathes, but not much more. I say we wake her up, but the entire week I attend in the intensive care unit, I wonder whether there is a person to wake up, or whether the state she is in counts as awake. 

I talk to the neurologist. We pour over EEGs, brain scans. Uniformly, we hold a grim expression. We don't think she will wake up, we tell the family. Yes, there are cases in which a patient may improve from a persistent vegetative state, but nothing here gives us optimism. We wish we had something different to say. Hands are held. Prayers are whispered. We ask those dreaded words: "What would she want in this situation?"

I go off service, but the following week, I go up to the intensive care unit to visit. To my astonishment, a month after her initial heart attack, after weeks of shocks and cooling and chest compressions and blocked vessels and medication after medication after medication, something happened. She began to move purposefully, and to the disbelief of every clinician in the ICU, she followed directions. We say "followed commands," but that word is so harsh; I would never command a patient to do anything, but at our gentle suggestion, she gave a thumbs-up, showed two fingers. She - not just her body, but something more, something sacred - survived.

There is magic in this world. In my professional and my personal life, the more experiences I have, the more I am convinced of this deep, wonderful thing.

Too Many C-Sections

There are a lot of places in the health care system where we can save money, but C-sections are a real potential. Although there are many situations where a Cesarean is indicated for the safety of the mother or baby, there is a pretty big gray zone of situations where C-sections are performed but perhaps unnecessarily. I've even encountered an extreme where the mother simply didn't want to labor, and wanted to go straight to C-section. I think if we tumble down the slippery slope of offering C-sections simply to avoid the normal process of labor and delivery, we will run into a lot of problems. C-sections are, in words from Macbeth, a child "from his mother's womb / Untimely ripped." The process of labor is important both for mother and child. The recovery is much easier. The amount of anesthetic required is much lower. The risks are fewer. And though we balk at thinking of costs in the U.S., the cost difference is significant. A C-section buys a patient more days in the hospital; it makes future pregnancies more likely to go to C-section; it involves operating room time; and it uses up a lot of resources which are ultimately finite. It's so easy to forget that a Cesarean is an actual surgery. We should only invoke it when necessary. Unfortunately, the financial incentives are against it; surgeons, anesthesiologists, and even the hospital makes more money from a C-section than a regular delivery. So it can be so easy for a clinician to offer it when the patient is in that gray zone. To fix this, we need culture, policies, and education around decreasing unnecessary C-sections.

Labor and Delivery

I'm always surprised how grueling labor and delivery call feels. I've probably worked hundreds of 18-30 hour overnight shifts in training, but each time I go through a call night like that, I am just exhausted. It makes me really respect the obstetricians who do this all the time. It's a recipe for burn-out.

I think the challenge is the unpredictability of the call night. When I take call in the main operating room, I know what's coming: a hip fracture, an appendectomy, an ectopic pregnancy, a craniotomy. It may be a nonstop marathon all night, but at least I know what to expect (especially since we aren't a trauma center). On OB, though, there is so little certainty. I may feel like I've tucked in patients; everyone with an epidural is asleep, all the "multips" (those who've had a baby in the past, and for whom the process is usually faster) are blocked, all the "primips" are still in the early stage of labor. But half an hour later, two people show up in active labor requesting epidurals at the same time a C-section is called. The night can go from quiet to hectic in a blink of an eye.

I didn't get any sleep whatsoever last night, but one thing that did make my day was running into an old friend I hadn't seen in years and catching up. Time grows very long between one and four in the morning, and company helped me push through those witching hours.

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