Quality of Life I

Although quality of life feels incredibly fuzzy and subjective, I think it's important to contemplate. It is perhaps the truest and least-spoken goal of medicine. And along with passing on our genetic makeup, it may be our most fundamental want as people. We don't talk about it enough. In all the lectures of medical school, studies and articles in journals, and posts on this blog, it represents a tiny fraction of what we discuss in medicine. In the same way that death and the dying process is glossed over, the ephemeral phrase quality of life usually earns only hand-waving and idealism.

Although there are quality of life measures taken with psychometric tools and surveys, I like to think it is in the "I know it when I see it" category (originally attributed to Supreme Court Justice Potter Stewart). Yet I'm not sure it really is. Outsider (physician) impressions of the quality of a patient's life often differ greatly from the patient's assessment of his own life. We all have our own ideas of whether we would want to go to dialysis three times a week or be wheelchair-bound or not be able to eat or suffer constant pain. But if any of us were actually in any of those situations, we might change our mind.

Nevertheless, I will talk about quality of life as if we knew what it was. The reason we allow surgeons to cut into people, prescribe medications with side effects, and hospitalize patients is because we think it'll improve their quality of life or length of quality life. But we never think of it that way. It's almost a rote reaction; we diagnose a patient with hypertension and prescribe hydrochlorothiazide; we find appendicitis on CT scan and book the operating room; we witness a suicide attempt and place the patient on an involuntary hold. We do so hoping or imagining that as a result, the patient will live longer and/or have a "better" life.

Why is it that medicine's boundary stops there? Should we actively participate in enriching a patient's quality of life? Or is that out of our scope of practice, someone else's responsibility? Sometimes, I think our social workers who find shelters for our homeless patients, reunite families, and help patients cope with their illness have a more direct impact on quality of life. I think of our physical and occupational therapists who help patients get back to their sports or climb the stairs in their house or use a prosthetic limb. Why is it that doctors are concerned only with the disease and its treatment? Is medicine nearsighted this way? Or is it simply a division of labor; we cure disease and defer a patient's happiness to someone else? I'm really just rambling, but I figured this is an important topic of conversation, and I wanted to open the door.

The Future of Medicine

I was asked recently what I thought the next breakthroughs in medicine would be. I have no idea. Although I like to read about where science is going and although I used to participate in research, now my career has greatly diverged from that. Nevertheless, sometimes you get asked a question and you just have to hypothesize.

We've been talking about personalized medicine for (it seems like) forever, but I think it's going to happen. President Obama launched the Precision Medicine Initiative and that helps funnel NIH funding to those areas of research. We are definitely getting more knowledgeable about how all the "omics" (genomics, proteomics,, metabolomics, gut microbiomics) affect disease and health. Despite this, it hasn't translated to everyday clinical application. For example, though whole genome sequencing has become cheaper and more readily available, genetic testing is not widely used by physicians to make clinical decisions. Only a few tests are standard of care (such as testing for an HLA gene before starting someone on the HIV medication abacavir). I believe physicians are just late adapters of technology. Once genetic testing becomes a more commonplace clinical tool, I think personalized medicine will really hit its stride. This will almost certainly increase costs. We just await to see if that translates to better outcomes.

To me, personalized medicine comes in flavors beyond the interaction of genetics and diseases. One form of personalized medicine is the use of feedback loops and technology to achieve our health goals. For example, insulin pumps for type I diabetics can almost work on autopilot. They can test a person's sugar, adjust the dose of insulin, and check to see if it worked in an entirely automated algorithm. Will anesthesia move in that direction? Will we end up having machines that can detect the level of anesthesia for a patient and automatically adjust the medications to achieve a target? (This was attempted with a robotic sedation system which never caught on; it's now off the market). To me, these individualized therapies also represent a kind of personalized medicine.

With regard to areas of medicine that will blossom, I think immunotherapies and treatments for neurodegenerative diseases will become a big focus in the coming decades. We must focus our resources on diseases like Alzheimer's which currently doesn't have effective treatments but will become a growing burden on society and our health care system. These are, at least, my predictions; who knows where things will go in the next few decades.

Youth and Resilience

We see two kinds of youth in medicine: the invulnerable and the sick. The classic young and invulnerable patient is the trauma patient. He is drunk and foolish and thought himself a superhero. He is recalcitrant and won't change his ways. He'll be back with new broken bones or head trauma or stab wounds. It's a terrible story but all too common in trauma centers everywhere.

Then there's the chronically ill person in her twenties or thirties. At that age we see diseases like inflammatory bowel conditions, schizophrenia, pregnancy-related problems, and even chronic pain. It's hard for me to fathom how it must feel to deal with pain, symptoms, or medications every day for the rest of one's life. How it must change one's dreams, for better or for worse. I've met patients whose experiences have motivated them to pursue incredible art, service, and academic achievements. But I've also met patients whose diseases have broken down their resilience; they struggle every day to survive.

What determines our resilience and reserve? Why do some people fly through adversity while others struggle? Is it one's fortitude, genetics, and upbringing? Or is it one's social support, medical care, and environment? Can we arm others to succeed through hardship? Can we arm ourselves to succeed through hardship?

There's always something. Whether it is a job transition, an elective surgery, a parent with cancer, a newborn whose growth curves are worrisome, divorce, financial trouble, miscarriage, or any number of stressful life situations, there's always something. It may seem way smaller or way bigger than what others struggle with, but it's relative. For the one in it, whatever it is, it's a big deal.

We must all find resilience. We depend on our family and friends. We look to our communities, our faith, our values, and our principles to guide us. We go through anger and rage and moping and sadness and denial and escape and acceptance. Sometimes we are able to reconcile and repair the situation, and sometimes it is out of our hands. In the same way, we must help our family and friends through their own struggles. We must provide for them what measure of strength we can, the patient ear, the kind shoulder, the word of resolve. Together, we overcome the ebbs and tides of everyday life.

(The wonderful thing about writing blogs is that when I start, I have no idea where they are going to go.)

Blogging

"When power leads man toward arrogance, poetry reminds him of his limitations...when power narrows the areas of man's concerns, poetry reminds him of the richness and diversity of his existence." - JFK, 1963

Dear Reader,

One of the challenges I struggle with daily is the limited time and energy I have. So much of myself is devoted to the people I love, the projects I'm trying to cultivate, and my personal well-being. My work and personal life have been really stressful as of late, and trying to eke out more creativity, energy, and productivity has been really hard. I feel spent. As I ponder my priorities and restructure my life, I've become more and more certain that creative writing should and will take up more of my time. As JFK pointed out, I have certainly become more arrogant and more narrow; it is time to allow poetry to expand my perspectives. With writing, I hope to salvage balance in my life. 

This blog, of course, has been a project and adventure that has taken me far beyond where I imagined I'd go. It's been a wonderful exercise in creative writing, commitment, responsibility, and exploration. I've really appreciated everyone who has come across this, commented to me about it (in person or online), and spent a little time on this website. As I think about my life and its transition points, though, I am becoming more certain that this blog will finally come to an end. I'm planning on winding this down over the next few weeks. 

Commitment is such an important thing. It's a strange idea for me that I will part ways with this quasi-daily activity. I spend a lot of my time finding things to write about, refining ideas, and planning my entries. I've learned a lot of what works and what doesn't, and indeed, I have much more to learn. But I started this journey ten years ago, in September of 2006. It seems only fitting that I will say goodbye a decade later.

Commitment wears thin. In an era where young people change jobs every few years, where marriages are perhaps closer to "serial monogamy," where we move and travel and change our identities, I've learned the hard way that the values underlying commitment are mutable. I love this blog so much, and the opportunities it has given me have been tremendous. Through it, I helped a young man change careers, pursue medical school, and choose anesthesiology. Through it, I became involved in The American Resident Project, reaching far bigger audiences. Through it, I have talked to physicians in Canada and India and South America. I've met nurses who've read this blog, medical students who recognize my name through it, and real web presences that have interviewed me about it. It's a commitment that's really paid off. Despite all that, it's time for me to move on. I will miss it and want to linger, but I know new adventures await and new projects are beginning to bloom.

With great affection,
Craig

The Block

Samuel Shem's iconic House of God describes the block with hyperbole. When the emergency department calls for an admission, you try to block the patient and turf him to a different service. If you're an orthopedic surgeon and the patient has a hip fracture, maybe she also has chest pain so she would be safer on a medicine service with an orthopedic consultation. If you're an intensive care physician and the patient is dying of septic shock, perhaps you can dig up an advance directive and POLST saying the patient wouldn't want aggressive medical treatment in this situation.

This is not healthy behavior, but House of God describes why it proliferates; every service is trying to block patients, and if a physician accepts patients indiscriminately, her service will blow up in size. When we are residents and fellows, our clinical volume has no relationship to our salary so there's little incentive to take a lot of patients. Most specialty consultants master the art of the block, and as a result, patients get dumped onto the general medicine or intensive care services. We are the catch-all for any medical problem, so if no one else will admit them to the hospital, medicine will (or the medical intensive care unit if they are sick enough). In general, I was okay with that because the patients got better care, but the idea of blocking always bothered me.

Private practice is the exact opposite. For many of us (but not myself), clinical volume determines our revenue. I was surprised to learn consultants were eager to take on extra work and that there was no push-back when I asked other services to accept patients. A patient's disposition (the medical term of who takes care of them and where in the hospital they go) is determined entirely by medical factors. This is the way the system should be; physicians shouldn't block patients; we should care for them, treat them. Perhaps its not wrong to link this to financial incentives. The goal is to have a collegial and smooth-running system that focuses on the needs of the patient.

Statistics

As I get farther out from school, I start thinking of disciplines I wished I studied more. Some, like English literature or computer science, I think one day I might pick up again. But there's one discipline that I should have studied yet never will, and that is statistics. In the last few years, I've been learning from perusing medical journals (rather than textbooks and lectures which comprise most learning for medical students and early residents). The more I read, the more I realize that statistics matter so much. A study's design is its foundation, and without a solvent knowledge of statistics, I feel like I'm often evaluating the facade of a study rather than its real integrity. Nevertheless, for whatever reason, statistics classes just never engaged me. The one I took in college just passed me by. For me, it is like music theory; growing up, I enjoyed playing an instrument, but never cared for music theory. I guess there will always be a few things where we recognize the importance but just can't make ourselves endure. That being said, I think if we were to rethink the premedical curriculum, statistics is far more relevant than subjects like physics.

Image is in the public domain, from Wikipedia.

Technology and the Cardiac Exam

The stethoscope is the iconic symbol of medicine. There so much I love about it: how it was conceived, the panoply of obscure sounds that indicate specific pathologies, the synecdoche of listening to a patient's heart for the patient-doctor relationship. But I also imagine a time where the stethoscope is relegated to history. Why do we still use an instrument invented in the early 19th century? Physicians are notoriously slow to adopt new technologies, but I can think of two inventions that should replace the stethoscope.

If listening to heart sounds is crucial to medicine, why don't we develop a microphone that we can place on a patient's chest that will record the patient's heart and lung sounds? We have the electronic ability to filter extraneous noises and amplify relevant sounds. Computers can analyze the sounds to dissect out what fledgling medical students struggle to discern. In the same way that the computer reads EKGs, programs can be developed to detect an extra S3 or S4, the type of murmur, or the presence of a rub. Recordings can be saved and compared to prior captures; wouldn't it be fantastic if we could compare today's lung crackles to yesterday's?

And this may be anathema, but I'm not sure listening to the heart offers that much diagnostic value. I definitely think it's important for the patient-doctor relationship and has interpersonal, even therapeutic, value. But it's pretty rare that what I hear on heart or lung exam changes my decision making. This is definitely because of my clinical specialty; in the intensive care unit, I'll often order chest X-rays and echocardiograms, and in the operating room, few heart sounds will cause me to cancel a case. But still, there's less medical utility in the stethoscope than we might wish.

This leads me to wonder when bedside echocardiograms will replace the stethoscope. Handheld echo probes are starting to drop into the affordable range. There's certainly a learning curve, but once bedside echo is mastered, it gives a lot more information than listening to the heart. One day, I think this will become the cardiac exam.

Image is in the public domain, from Wikipedia.

One More ICU Story

It is Saturday midnight, and I'm called by the emergency department to admit a patient who was intoxicated at a party with unknown substances. I ask the nurse if we know anything more about the patient - his identity, other medical problems, etc. She replies, "We don't know too much but we searched his pockets and found a little plastic bag with what looked like crystal meth. But when we gave it to the police, the police replied, 'That's not crystal meth.' I asked, 'What is it?' And he replied, 'That's just crystals. Like decorative crystals.'" That made my night.

Five Days in ICU

Monday

A young man is picked up by emergency medical services unresponsive and hypotensive. He is intubated but despite liters of fluid, his blood pressure remains barely measurable. On exam, his belly is rock hard; I think it's filled with blood. After we start a massive transfusion, we're able to get him to the CT scan, and we find a massive retroperitoneal bleed. He is whisked off to the operating room. On return, his drains pour out liters and liters of blood. The color of the blood coming from the drains is the same as blood drawn from the arterial line. Of course, he returns the operating room and then to interventional radiology for an emergency TIPSS because he has severe cirrhosis. All in all, over a 12 hour period, he gets 25 units of blood, 25 units of plasma, 4 six-packs of platelets, and 2 units of cryoglobulin. Over the week, he goes into acute respiratory distress syndrome with impressive oxygenation requirements (FiO2 100%, PEEP 18), cardiovascular collapse needing pressors, renal failure requiring continuous renal replacement therapy, alcohol withdrawal, continued transfusions, and a return trip to the operating room.

Tuesday

I sign out to the night-time intensivist at 6PM. I finish my notes over the next two hours, clean up pending items, and get ready to go home. On my way out, the nurses flag me down because a surgical patient who was doing fine and planning to leave the ICU had an acute aspiration. After intubating and stabilizing the patient, I sit down to finish those notes as well. I get home well past 9.

Wednesday

I am called by the emergency department to help with an intubation for a cardiac arrest. When I rush down, I see the nurses doing compressions on a child. A three year old previously healthy girl presented with ventricular fibrillation and seizure. Other than accidental overdose of medications, I'm not even sure what causes cardiac arrest in a child. I intubate her, but an hour later when I am admitting a separate patient from the ER, I see that they call time of death. The family is in hysterics. I go home to wrestle with family crises of my own.

Thursday

I see twenty two patients today. We only have 21 beds, but we started with 17 patients and despite sending a bunch to the floor, I get 5 new admits. I'm not even sure if clinic physicians see 21 patients in a day. I make myself a spreadsheet to keep track of notes, orders, and to-do items. The most interesting patient is a person who comes in with torasdes de pointes (shown below). We all learn about torsades in medical school, but this may be the first time I've actually seen a case. It is caused by medications she takes. That first afternoon, she kept having scary episodes of polymorphic ventricular tachycardia, but they finally subside as the medications metabolize off her system.

Friday

I get my most interesting patient on my last day on service. A young woman is intubated in the emergency department because of "bizarre behavior." When I get the call, I wonder how bizarre her behavior was to necessitate intubation and sedation. Apparently, she hasn't been herself for two months. She works at a cafe in the daytime, but according to her boyfriend, she started going out every night to four or five in the morning. She'd sleep for three hours, then go back to work. He wasn't sure what she did at night, but wonders if she was smoking, drinking, and doing drugs. The day before admission, she parked her car on the shoulder of a freeway and ran across the highway. Fortunately, she was picked up before getting hurt and brought to our emergency department. Initially she was admitted to psychiatry, but over the course of the day, she became more combative, even hitting a nurse and harassing another patient. She got 25mg of haldol, an impressive amount, as well as atypical antipsychotics and benzodiazpines. Finally, the ER decided she simply needed to be sedated so they intubated her to get a lumbar puncture and head imaging. She was negative for meningitis, encephalitis, or structural abnormalities. Her toxicology showed benzos and marijuana. I really don't know what was happening with her, but I suspect either intoxication or withdrawal of drugs or a new psychiatric diagnosis with a manic or psychotic episode.

I haven't worked this many hours since fellowship. Along with these cases, I also had the usual old person presenting with sepsis from a nursing home, cirrhotics with low blood pressure, slow ventilator weans, chronically ill patients who had been hospitalized for over a month, gastrointestinal bleeds, and postoperative patients. What a week.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

The Originally Celebrated Curiously Strong

In an attempt to understand how acetaminophen might help some musculoskeletal pain I have, I tried to conduct a blinded placebo-controlled trial on myself. It wasn't very successful, which might have been for several reasons. First, I'm pretty sure I could tell when I got an altoid rather than the trial medication. Second, the acetaminophen I was using is expired. I'm pretty sure nonsteroidal anti-inflammatories would have been a better intervention. Oh well, this is why I never made it as a research scientist.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Expectations and Medical Decision Making

A pregnant woman at term comes in with active labor. However, she is adamant she does not want her vital signs to be checked, an IV to be placed, or labs to be drawn. She insists on having none of it despite understanding the risks. There's no compelling reason; it's simply her birth plan and preference. It's not clear why she decided to deliver in a hospital rather than at home or a birth center. Nevertheless, she is declining hospital standards of care by refusing an IV and vital signs.

For generations, decision-making was entirely up to the physician. Medicine was paternal; a doctor would tell a patient the plan. In the last few decades, we've recognized the ethics of patient autonomy and shared decision-making. We do our best to inform and educate a patient about the nature of their condition and the risks, benefits, and alternatives of diagnostic or therapeutic interventions. We may give our recommendation but we would never force a patient to undergo something he or she did not want.

I wonder sometimes whether we've reached the other extreme, allowing a patient to dictate everything. One reason to deliver at a hospital over home or a birthing center is the insurance against an emergency. The vast majority of patients do fine, but a few need interventions like an urgent C-section. By declining vital signs, IV access, ultrasound examination, and other tests, that benefit is negated. This patient did not receive prenatal care so we had no idea whether the placenta was normally implanted, whether she had pre-eclampsia, even whether the baby was breech (other than by physical exam). The patient was of "advanced maternal age" and there was a real possibility of needing a Cesarean (fortunately, she did not).

While one could argue that with adequate counseling, a patient can understand that risk and decline those interventions, I think that is ultimately unfair to the providers. In a case like this, unacceptable risk is transferred to me. I am not comfortable in a situation where someone may need emergent surgery but does not have an IV. Even if that's what a patient demands, do I have to acquiesce? (Ultimately I did, but these issues are real conundrums).

Like every relationship, the one between patient and provider cannot be controlled entirely by one party. Biomedical ethics is much more than simply reciting "autonomy, beneficience, nonmaleficence, and justice" (what they teach in medical school). We have to learn and approach real-life ethical dilemmas with care, nuance, and compassion.

Satisfying

In nearly every hospital I've been, when there is a patient who is a difficult IV and everyone else has failed, the anesthesiologist gets called. Usually when I arrive, everyone feels relieved, including the patient who often has two armfuls of bruises. I always get (and still get) a little knot in the pit of my stomach because I'm the last resort, and often these patients absolutely need IV access.

There are a few tricks I've picked up over residency. Most nurses won't try the ventral (inner) part of the wrist (the veins are fragile and tortuous and it is painful). In adults, there are usually visible veins on the fingers (including the thumb). I'll look at the ankles and feet. I'll consider the external jugular in the neck. IV drug users who have scarred every other vein usually miss the back of the elbow. And there's always ultrasound and the central line as a last resort.

It's most satisfying though, when I manage to get an IV with a single attempt after the patient is exasperated, exhausted, and at wit's end. A 7 year old boy comes in with appendicitis. Four nurses have each tried once, and finally I am called. I sit down and we chat about Finding Dory, second grade, and swimming. I make out a bluish tinge along the wrist which we sometimes call the "intern vein" and he doesn't even flinch when I get it.

It's strange how anesthesiology involves so much, so many procedures, so much cerebral decision making, but on some days, the most satisfying thing is a simple IV.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Types of Anesthesia

I was recently asked by a patient, "How many types of anesthesia are there?" It's an interesting yet odd question because I wasn't sure how to answer it. One interpretation might be that anesthesia can be delivered as a general anesthetic, through a neuraxial technique (like an epidural or spinal), through a regional nerve block, through local anesthetic, or as IV sedation. But I'm not sure that's how I think about it. In my mind, anesthesia is a sophisticated art and science where the nuances, details, and decisions matter, and that is what distinguishes each individual anesthetic.

Although the vast majority of anesthetics are performed with a limited number of medications and agents, the tailoring of an anesthetic to a patient, surgeon, and procedure is rarely "cook-book." I was talking to an anesthesiologist at a different institution and we were surprised how differently we do our anesthetics. Most of it is institution-specific; the culture of a place affects the medical decision making. At this hospital in New York, for example, anesthesiologists use a lot more laryngeal mask airways and rarely use long-acting opiates like hydromorphone. When I moved from an academic hospital to private practice, I adjusted my anesthetic techniques to the medications that were available. It's a good reminder that there's no "one right way" to anesthetize a patient, and that a lot of different factors influence our decision making.