2011

I would like to wish you all a very happy New Year. I appreciate your reading this blog; it has been a perfect forum for me to ruminate, vent, propose, recount, reflect. Of course, with the holidays, the frequency of writing decreases a bit, but it will pick up after the New Year rolls around. New Year's today will be quiet and warm, with time to think about things. Best wishes to you all.

W;t

I recently reread the play W;t by Margaret Edson. I had initially read this as a freshman in college for one of my introduction to the humanities courses (I had taken a course called "visions of mortality" - which probably lead to my current fascination with death and dying). I was really struck by this 1999 Pulitzer Prize winner and the film version starring Emma Thompson. I do not read a lot of plays, and I'm not sure I even know how to read a play, but I can say that this short, easy read works a number on the emotions and strikes at the core of end-of-life care and oncology. It describes a professor of English with terminal cancer and her interactions with the oncologists and nurses as she undergoes chemotherapy. The play ties in the Holy Sonnets of John Donne, including Holy Sonnet X (below) which addresses death directly. The language of the play reflects the clinical encounters patients often have, and the self-reflection of the main character reveals the rich internal dialogue that presumably patients have as well. Overall, it is one of the best reads for understanding the patient perspective of cancer and I recommend it to everyone in medicine.

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Holy Sonnet X
John Donne

Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so;

For those, whom thou think'st thou dost overthrow,

Die not, poor Death, nor yet canst thou kill me.

From rest and sleep, which but thy picture[s] be,

Much pleasure, then from thee much more must flow,

And soonest our best men with thee do go,

Rest of their bones, and soul's delivery.

Thou'rt slave to Fate, chance, kings, and desperate men,

And dost with poison, war, and sickness dwell,

And poppy, or charms can make us sleep as well,

And better than thy stroke; why swell'st thou then?

One short sleep past, we wake eternally,

And Death shall be no more, Death, thou shalt die.

Image from Wikipedia, shown under Fair Use.

Hospital Holidays II

The other thing about being in the hospital during the holidays is the isolation. For those of us whose families are not in the area, it is a tough time. We miss the comfort and constancy of family, the traditions of the holidays, the freedom from the burden and stress of work. And during a time when our co-residents and friends are flying home and opening presents and sleeping in, it's not easy to wake up before sunrise and drive to the hospital.

But it gives me a fascinating and critical insight into the lives of patients. They, too, would rather not be in the hospital. No one wants to be sick, but to be sick over the holidays is so much worse. And although family and friends may visit, it is simply not the same. So around this time of year, I try to spend a little more time chatting to patients about things that aren't medical - about where they grew up or their family or (at the VA) their stories of the military. That bond we create goes beyond the patient-doctor relationship to an understanding among people bound to the hospital when we'd rather be home.

Hospital Holidays I

Holidays in the hospital are a little strange. Especially at the VA, the hospital seems deserted; it runs on a bare-bones staff, and capacity is lower as patients gear up to leave. Resident teaching vanishes, and all of us try to get out early. Not much happens; we can only get blood draws once a day on the floor, and tests like echocardiograms and MRI scans don't happen. Social work and case management are off which means that it's very difficult to discharge patients who have nursing, transportation, or other needs. Things stagnate which is understandable though it is intensely frustrating.

Calls are interesting as well. Right before the holidays, when we were on call on December 23, we accepted a lot of transfers. Everyone - clinics, other services, other hospitals - tries to decrease their services for the holidays and a lot of them come to medicine. For example, patients who require infusions (such as chemotherapy) that can normally be given as an outpatient come into the hospital simply because the infusion center is not open. Clinics who would normally follow their patient up in a week admit them because they aren't open. Other teams try to transfer their patients to medicine. As a result, we got hit hard last call with tons of transfers, some which I did not think were fully justified. But it is the way of things around the holidays. Hopefully on Christmas Eve and Christmas, the patient loads will decrease as patients shy away from the hospital, and transfers decrease in volume. We might expect after the major holidays for things to pick up again as those patients who had dietary indiscretions or minor illnesses that avoided the hospital start to trickle in.

Poem: The Delivery of Modern Medicine

This poem is incredibly early and rough; I didn't really want to post it, but time's up and a blog must be entered.
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The Delivery of Modern Medicine

starts with a number, eight digits and a band,
a looping, a manacle, a room and a curtain
budding into a nurse, a cuff, another looping,
numbers, more numbers, numbers divided by
other numbers, into a poke and whisper
of the arm, into poles and bags and foot-manacles
to stop the clots that bloom from being bound.

The Delivery of Modern Medicine
echoes with the repetition of story, and again
to each wayward passenger on this medical train
the same prodding fingers, bounding stethoscopes
reverberating into routine alarms,
the voice of the phlebotomist, and then the intern
and then the resident, and then the attending.

Oh, the Delivery of Modern Medicine
quakes with the steps of social work
the power behind the throne, the one
who moves patients, rocks, mountains.

The Delivery of Modern Medicine
trades in pills, tablets, capsules, caplets,
barters in knives and lasers
a commerce in drugs of Janus,
two faces, two names, a dozen colors.

The Delivery of Modern Medicine
ought to start with a touch, with a warmth
with a hand on a shoulder, a grasping
of the willows and oaks, a burgeoning
of sense, a blossoming of age, recapitulation
of that we know, deep within us.

The Revolving Door

I'm back on medicine wards at the Palo Alto VA, a reprise of my second month of internship. At the entrance to the VA, there's a big revolving door, and given the frequency of visits by certain frequent fliers, we sometimes think of the whole system as a metaphorical revolving door - although we do our best to optimize our patients at discharge, they occasionally bounce back if they stop taking their medications, miss their appointments, or start eating lots of salt. And now it is my second month back here. It is oddly reassuring. The worst part of every rotation is the first few days, when I have to learn the system, write passwords on the back of my hand, and get to know half a dozen new patients. But this time, within a day, I've reminded myself how everything works, and I was lucky enough to inherit 3 patients (though I did start on call). Each time back here is easier. I'm starting to recognize call-back numbers (6-2200 is the intermediate ICU) and remember nurses' names. And after the first 5 months, I feel that medicine has suddenly become easier; I put things together faster, I understand how to cross-cover better, I am aware of a wider variety of medications, I have more confidence. Despite it being December, I think this will be a pretty good month.

Internet

For the last few days, my Internet hasn't been working reliably at home. This reminded me how dependent our society has become on the Internet. If not for my smartphone, I would have felt completely disconnected from the outside. But once I got over the separation anxiety from my computer, I realized that it is also somewhat liberating not to be refreshing my email q15 minutes, or hovering over my patients with remote access, or (even) blogging. I spent my time writing holiday letters, cleaning, catching up on the mountain of mail and paperwork and to-dos, watching bad movies. It reminded me of a New Year's resolution I sometimes make - which is to take some time for myself, away from my computer, away from the Internet - and since the next New Year is imminent, I will count this one as completed. In any case, I'm working on getting reliable internet back, but regardless, I will probably take a short break from blogs around Christmas at the end of this week. I'm currently celebrating the holidays at the VA but luckily my calls skirt the major holidays. I think I'm done blogging about geriatrics, so next, it'll be VA round 2.

Andrology

One of the more infamous clinics we have is andrology. Andrology clinic turns out to be erectile dysfunction clinic for geriatric patients. I think over the last few years, I have gotten much more comfortable asking patients about their sexual history, but there is still a slight barrier (mental? emotional? psychological?) about asking an 80 year old man about his sexual habits. But it is good to open us up further and help us understand such critical aspects of life, even in the older patient. In this clinic, I've learned all about those mysterious drugs that fill my email spam - viagra, cialis, levitra. I've also learned about testosterone, perhaps (or perhaps not) the male equivalent of hormone replacement therapy. I got a sense of other mechanical solutions to erectile dysfunction. And although it is as far from what I'd like to do on a daily basis as you can get, residency is about education, and this is something I did not know much about before.

Geri Clinic

Much of geriatrics was clinic-based, and it's the first outpatient rotation I've had in a long time. Although I tend not to like clinic (it's why I'm going into anesthesia), I still find it educational. I think I'm a fairly conservative outpatient doctor; I try very hard to avoid adding on unnecessary medications, and I spend most of my clinic visit seeing if I can peel back medications. This is especially true in geriatrics. Many of my patients took more than 10 medications - indeed, if you follow heart failure guidelines, a patient with heart failure (from coronary artery disease) ought to be on an aspirin, beta blocker, ACE inhibitor, and statin. Some are also on clopidogrel, additional anithypertensives, antiarrhythmics, and anticoagulation as well. The heart medications themselves add up to half a dozen. Then add on medications all vets are on - tamsulosin for benign prostatic hypertrophy, a couple inhalers for COPD, vitamin D and calcium - and you're well on your way to double digits. Polypharmacy is such a major problem, and probably contributes to the cost of health-care - not only the cost of the medications, but the hospitalizations when patients mix them up.

Otherwise, geriatrics clinic also focuses us on medical problems we see less commonly in the inpatient setting. I spend my time doing mini-mental status exams to characterize dementia, assessing fall risk, and thinking about health screening. There are special clinics as well for patients who are especially complicated and high-risk; they are seen by a team of social workers, psychologists, and nurses for a comprehensive approach to aging. It's a good experience for us as interns to care for older patients in the clinic setting.

Push It

I had one attending who was known to be "tough" or "mean." He grilled us on our admissions. He focused not only on our history or our presumed diagnosis, but also questioned things I usually do not consider. Why did we admit this patient? Could we have sent this patient out? As an intern, that decision is usually not up to me. For example, we admitted a patient with a blood pressure of 210/110, asymptomatic. This attending asked for specifics: describe the fundus; did you take blood pressures of both arms? But he also challenged us to justify why an asymptomatic man needed to be admitted to the hospital. He would not settle for simply a blood pressure justification, no matter how outrageous the numbers, nor would he allow us to say "the clinic and ED attendings both thought he should be admitted."

In any case, this attending at the end of the rotation told me why he does this. He thinks that attendings need to push interns and residents. Sure, we do a good job, and we take good care of patients, but to really propel ourselves forward, we need to challenge ourselves to learn more, think harder, never be complacent. It is easy, he says, after 24 hours of call to make assumptions, rely on other people's interpretations, and neglect to make our own clinical decisions, but we should resist that urge. I thought this was a very true point. When we are students, our incentive is to do well, get a good grade. But this incentive drops out when we are residents. Our main motivation is simply integrity: to do more than get through residency without hurting anyone; to learn, challenge ourselves, achieve excellence.

Poem: Childhood Dreams

Childhood Dreams

Sometimes I wish I could be evil,
black as flint and glass-sleek,
my hair chopped off and heinous-looking.
You would have been a good henchman
and I, a connoisseur of evil.
I wish we didn't have to be so good all day,
what's in it for me anyway?
Other people will save lives in my absence
and even if they didn't, it'd be fine--
we're being bad today, remember?
We would make true our promises,
get crayons the size of lampposts and terrorize Atherton,
sing sea shanties waving cider
and plop our feet on the arms of couches
without removing our shoes.
We hold peculiarity hostage,
build a fort of pillows, our sanctuary of villainy,
communicating in code,
making our rapscallion reputations
and staying up much, much later than we should.

Jeopardy II

Unfortunately, I was jeopardized a second time to cover a ward team's call. Call is much tougher than an ED shift because it is a 30 hour ordeal where I have to assume care of old patients I've never met. Surprisingly, I was able to discharge 3 of the old patients on the call day, and I admitted six. One was diagnostically perplexing - an older woman with myoclonus and muscle fasciculations of unknown etiology. Another was consult heavy - a new diagnosis of hepatocellular carcinoma. But overall, it wasn't too bad as call nights go. At least jeopardy this time of year is less harrowing than having it earlier because I've been at all the hospitals and know how the logistics go. Unfortunately, it means my light geriatrics rotation was cut prematurely short.

Jeopardy I

The reason why I lost a few days on this blog was because of "Jeopardy." I had thought the worst part of intern year was cross-cover, but I was wrong. The worst part of intern year is definitely jeopardy. Jeopardy is our back-up system. Since housestaff are critical to patient care, we have backups in place in case a resident has an unforeseen absence. Residents on "light" outpatient or elective rotations - where we are not essential - act as backups for those on rotations that depend on us. Unfortunately, in the last two weeks, there have been a rash of illnesses and family emergencies and all the backups have been activated twice.

The uncertainty of it makes it the worst thing. I don't mind taking call or doing extra work, but the fact that I could be activated at any time is awful. I carry my pager around with me 24/7. It is on my nightstand. I check it compulsively at restaurants. I wonder whether I should go farther than a 30 minute radius in case I get called to come back immediately.

Of course it happened. I was jeopardized to the emergency department for the graveyard overnight shift. It was a little tough since there are only two residents in the emergency department overnight, and I had not had been in the ED before. But the resident and attendings eased me in, and at least in the ED, I did not need extensive signout and could cover another intern's shift pretty easily. The ED (I am sure I will write about this in February when I have that rotation) is a fascinating place. It is all about efficiency, multitasking, and figuring out where patients will go (observation, inpatient admission, home) as soon as possible. Unlike what is often depicted in TV shows, the majority of things I saw were not serious and not emergencies. Most of what I saw were sore throats, pain management, musculoskeletal injury, COPD exacerbations. In any case, it's never fun to cover extra shifts, but I do not mind helping my cointerns out. It is simply the uncertainty - that our lives aren't our control and that the hospital can call us in on a whim - that makes jeopardy so hard.

Geriatrics

At the mid-way point of residency, I'm on my geriatrics rotation. Geriatrics is a required rotation for all interns per ACGME recommendations, and it is the lightest of our rotations. As the patient population ages, understanding issues faced by geriatric patients becomes more and more important. And equally importantly, interns need a good outpatient rotation to break up the monotony of wards.

One of the main activities for this rotation is skilled nursing facility (SNF) rounds. We often discharge our patients to SNFs for rehabilitation or hospice. These patients have nursing requirements, but don't need to be in an acute care hospital. But I never thought of what happens when patients go there. Making rounds on SNF patients is really enlightening as it allows us as interns see what issues arise for patients after leaving the hospital. We see the long road to recovery, we begin to understand the physical, emotional, mental, and psychological issues of transitioning to independence. Oddly enough, we get a flavor of how insurance companies and Medicare fit into the scheme of approving or denying care. We get a really important sense of how discharge summaries for SNFs differ from those for patients going straight home; the SNF physician needs to know what rehabilitation or skilled nursing needs a patient has. For those reasons, even though it's not a high yield rotation in terms of learning medical knowledge, it's essential to understanding how the medical system as a whole operates. We also take home call for the SNF to be available for questions or concerns. The issues that come up are similar to cross-cover but require us to understand how to triage complaints over the phone.

Poem: Aging

Again, a poem I wrote in a writer's workshop. The prompt was "write about aging."

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Aging

A pot ages on the stove, effervesces in a film of brine.
A tap with a spoon on its crust, as if creme brulee
and a flame coaxing the soup from its stupor
into a welling of lemongrass and coconut
steaming my glasses as I stir.
Each circle of the ladle draws in new colors,
the fire of a carrot, the silk of tofu,
the lucency of onions, the curry spice.

Do you think it's still good, she asks.
We made it on her birthday, and ever since, she's resented time,
that winged chariot, that muse of poetry.
It rumbles past outside, in the cold.
What is it for our pasts to slough off,
why are we so recalcitrant,
why must we dig in our heels to slow the earth's revolution
or else hide in an hourglass' wake?
What could we want or imagine or have
if we could leash time to our bending, if we cage it
or well it into dams? Unleash it during boredom,
savor it in joy, curl it as a madman or sorceror?

If I could bottle time, I would cork it, hide it,
keep it in the cabinet next to the cinnamon and nutmeg.
I'd add a dash or two every time I make lemongrass soup.

Book Review: Who Will Run the Frog Hospital?

Who Will Run the Frog Hospital? by Lorrie Moore is a novella I recently read, and I love it. It has nothing to do with medicine (do not worry, I did not hope to discover medicine in the title), but it was an easy piece of fiction a friend found for me. Lorrie Moore is a fantastic writer, and I had only read her short stories previously. But this book reads as one of her short stories; it is witty and conversant, aching of personal triumph and poignancy. This novella is a bildungsroman of a woman as she looks back at a loss of innocence and a time of transition in her young adulthood. But what it's about is not as important to me as how it makes me feel; her words have such a genuine ring as she prods and probes our own insecurities about adolescence. I would entirely recommend it as a good rainy-day read.

Image shown under Fair Use, from www.greenapplebooks.com.

The Coronary Care Unit

In general, interns do not take patients in the cardiac ICU as they can be quite complicated and sick, but we participate in rounds where they are discussed. Most of the patients have cardiogenic shock, requiring vasopressors to maintain their blood pressures, special lines to measure hemodynamics, and possibly devices such as intraaortic balloon pumps or ventricular assist devices. Although heart attacks are the most common etiology, we also see viral myocarditis, severe valvular disease, and heartstopping arrhythmias. I was really struck by how sick these patients can get. Although on my ICU rotation at the VA, I cared for many patients with multi-organ failure or bypass surgeries or severe infections, the patients at the Stanford CCU have a level of complexity that is currently beyond me. I think these are the patients that benefit most from a team pow-wow where we all analyze the data together to come up with an assessment and plan. Although the attendings direct the discussions and ultimately come up with the day's goals, an interdisciplinary team approach is incredibly robust. I have to say, the attendings I worked with on CCU were the best I had in intern year so far; they were engaging and their love for teaching was evident. Although it is always somewhat intimidating to be called on to read an EKG or CXR in front of the group on rounds, it is incredibly educational. The attendings brought in the most relevant and up-to-date studies and role-modeled the most professional behavior. It was an incredibly wonderful part of this last rotation.

Devices

Cardiology was also a really good rotation to learn about devices. There are more devices for the heart than for any other organ system. Although we generally gain an understanding of device indications and what they do in medical school, the nuances escaped me until this rotation. What is the difference between a pacemaker and an implantable defibrillator-cardioverter? When pacemakers are set to "DDD", what does that really mean? How can I tell which device a patient has from an X-ray? Because we admitted patients who needed pacemakers and ICDs, I also got a sense of the common complications of device placement and the arrhythmias and indications that lead to their placement. Furthermore, we got to discuss cardiac assist devices such as LVAD and the Impella pump. Overall, it was a really good review and overview of the amazing biotechnological advances for cardiac care.

First image of Guidant pacemaker and second image of St. Jude's pacemaker are shown under GNU Free Documentation License. Third image of ICD is shown under Creative Commons Attribution Generic License. All images from Wikipedia.

Cardiology vs. The World

One difference I noted between my cardiology and medicine rotations is the scope of treatment. While in cardiology, we have an intensive focus on issues related to the heart, on general medicine wards, we have a comprehensive look at all medical issues. Many of our patients, especially older ones, come with a host of chronic medical conditions. Although patients come in with a specific chief complaint, we try to address all their problems, which can be over a dozen. A typical medicine patient might not only complain of shortness of breath, but also have diabetes, lupus, chronic kidney disease, headache, anemia, and leukocytosis. A problem list for these patients must make an assessment for all these issues and propose a diagnostic and treatment plan.

On cardiology, we are very good with certain issues. We manage blood pressure, cholesterol, thyroid problems, and diabetes closely because those are such pertinent factors in the management of heart disease. But we often gloss over chronic medical problems like arthritis or COPD. As I gain more independence and insight as an intern, I begin to address other medical problems even if they are not the primary problem. On one of my patients, I noticed a chronic anemia. It'd be easy enough to ignore this and defer to outpatient work up - after all, it's been going on for a long time and unrelated to the chief complaint. But I went ahead and sent an iron panel which lead to a diagnosis of iron deficiency anemia.

Should cardiology attendings worry about general medical issues? Of course they should; we must provide comprehensive care for our patients. But the reality is that they are much more interested and skilled at resolving issues of the heart. That is why these patients go to a cardiology service rather than admitting them to the general medicine wards with a cardiology consult. But one of the wonderful things I can do as an intern is to make sure small issues do not fall through the cracks.

A Second Thanksgiving

I just received an email from one of my attendings about a patient I cared for at Santa Clara Valley Medical Center. The patient's son who was extraordinarily grateful for the care his mother received, got his employer to create a matching fund for Valley Medical Center and then donated a good sum of money to the hospital. I was really touched by such an act of generosity. The truth is, anyone could have been the intern for this patient and this likely would have happened. But it makes me feel good to have influenced this patient's family so, and to have helped the hospital indirectly as well.

Work Hours

I have blogged a lot about work hour rules in the past, but this time I would like to write about the new changes. All residency programs run under the purview of the ACGME, a regulatory body and accrediting organization. The ACGME recently issued a new set of work hour rules that will come into effect next year. The total number of hours a week is the same (80 hour limit) but the maximum shift length is changed. While there are many nuances to this, the general big-picture is that interns (first year residents) can only work a maximum of 16 hour shifts; residents can only work a maximum of 24 hours. The justification is that there should be gradation in training, and as one progresses through residency, they should gain more and more responsibility as the workload increases. This is notably a big difference from the philosophy of yore. In the "old days," intern year was the most difficult year, a trial by fire, and each subsequent year would become easier as one gains a more supervisory role.

However, these rules create an even more fundamental change in the structure of residency programs, especially in pediatrics and medicine. While other specialties such as anesthesia and ob/gyn are more amenable to shift work structures, medicine and pediatrics have traditionally been structured with overnight call cycles. The new work hour regulations decrease the flexibility of residency programs a lot, in essence mandating a shift work structure.

Whether this is right or not is a moot point; residency programs must comply with it. Thus, this is effectively a forced paradigm shift in the education of medical residents. The call cycle that has persisted for decades must be replaced by shift work. However, this provides an opportunity for those interested in medical education to do a complete rehaul of the system. Similar to Descartes' thought process in Meditations on First Philosophy, it is time to undermine the foundation of everything existing and decide what things ought to be rebuilt.

Indeed, this is the attitude Stanford has with regard to the residency program. In determining the structure of rotations next year, the only guidelines are the program's philosophy and the ACGME regulations. Of course, many elements will stay the same, but I think this will be a great opportunity to prune those activities that aren't educational and to emphasize the importance of resident well-being.

Thanksgiving

Happy Thanksgiving! I am a little selfish this holiday season and am thankful that this month I am on a light rotation. I had a week-long break, and now I am on geriatrics which has allowed me to go home and spend Thanksgiving with my family. For that, I am grateful.

ST

A 95 year old man is sent from clinic to the emergency department with a preliminary plan of "rule out TB." He has multiple medical problems including HTN, hyperlipidemia, COPD, chronic kidney disease, arthritis, GERD, and a positive PPD and presents with hemoptysis of one month. On further history, he has no chest pain or shortness of breath, but feels that a week or two ago, he suddenly became very weak. As is routine in the ED, they get an EKG simply because the patient is old.

I don't have his exact EKG but I found one that is similar and it is shown above. The ED sees this EKG and calls a STEMI code - they read this as an acute heart attack. His troponin is 0.3 (creatinine is 2). The interventional cardiology fellow comes and is about to whisk the patient away to the cath lab when the family says perhaps angiography and stent is not consistent with the patient's goals of care. They decide to medically manage this STEMI without aggressive intervention. We are called to admit this patient to the general cardiology floor.

The EKG above is not the patient's EKG, but when I looked at the patient's EKG, I also noted some ST elevation in the inferior leads and no reciprocal changes. As a result, I started worrying that this was not a STEMI as advertised but possibly percarditis. It is odd, however, that the patient had no chest pain whatsoever.

When the attending reviewed the EKG and the story the next day, however, he became suspicious that this was neither a STEMI nor pericarditis. Although those are the two most common causes for ST elevation on an EKG, a much rarer diagnosis can do it as well. It turns out that this patient had an LV aneurysm; he likely had an old MI a week or two ago with persistent troponins due to his chronic kidney disease. During the interim, he developed a large LV aneurysm which lead to the false STEMI activation.

This case was a fascinating lesson in EKG interpretation; context is so, so important to diagnosis.

EKG is from wikidoc.org, shown under Fair Use.

Chest Pain

Chest pain is one of the most common chief complaints in the emergency department and can be one of the more expensive ones to work up. In an older patient, a complaint of chest pain almost always buys an EKG and labs; often, it gets a hospital stay as a heart attack is "ruled out." Being an intern on cardiology means I get all the chest pain admissions. Often, it is trying to find a needle in a haystack; so many things can cause chest pain and only a minority are cardiac. But what I've learned from this rotation is that the history and physical are key. They teach us this in medical school, and it is true; a thorough history can get you much farther on a diagnosis than any set of laboratory tests. The other common cardiac admission is congestive heart failure. This rotation was really good in helping me review the standards of care and goals in heart failure management. Bread and butter cardiology can get a little boring but is so common and important to review

Cold

Although those on the East Coast would pish-posh, it has gotten quite chilly for us Californians. Unfortunately, I often walk to and from work at the witching hour and so I bundle up quite a bit. It's been pretty rainy too, which I don't mind when indoors, but it makes the walk slightly more harrowing. Weather seems to be a pretty poor topic for a blog, but I'll have something much more cardiac tomorrow.

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

Poem: Masquerade

I wrote this poem at the last creative writing workshop. It was inspired by Mary Karr's "Viper Rum." The prompt was: masks are a prominent party of Halloween. Write a poem about a mask or masks.

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Masquerade

For nineteen years I danced.
I danced to forget, unknowing, ill-caring.
There were no faces, eyes sanded away
leaving only the frame of things, the rock and sway
of blues, the kiss and linger of waltz.
Masks of glitter, masks of gold,
masks of clay and wood.
The sprung floor ached rhythms
and we wrung tears from the paneling.
A face painted black and white lead me blindly.
Eyes were painted over eyelids,
they fixed me upon my axis,
I could only spot on white pupils with each turn.
A woman with feathers leapt with pas de basque,
skirmishing the others until hearts subsided.
I found a mask on the ground, trampled, formless,
and yet we need not heed the warning.
We danced month after month, year after year
until drumming and fire flickered in ritual,
our madness conjuring motion from dust.

He came for us in the end, how could he not,
and he sent us awry, ascatter.
His mask was white, bloodless, rent and bloodrung.
I knew then he came for me.
The stamping became more furious,
the drums would not hush. I fled.
The mask I wear is the one I destroyed nineteen years ago,
the one my wife, my daughter, my family knew.
The cult-summons gleaned confession from me,
sweat escaped the sides of my face's tomb.
I tore it off, stripped a layer of skin,
recoiled in apprehension. The webs and spiders of the room
flooded me, harnessing, and when in years past,
I would let the rebound catch, this time, I pushed through.
The room was humming in ghosts and macabre.
Out in the river, I emptied my pockets,
the rope, the gun, the razors.
The water caught my glance, then hurled it back.
I touched my face; unconcealed, wet,
the first time I had touched it
since I had last seen myself.

Code Blue II

The patient described in the last blog had initially come in with cardiogenic shock of unclear etiology. His troponins were modest, but he had a severely depressed ejection fraction in a normal sized heart. His hemodynamics were so bad that he went into multi organ failure with shock liver, acute renal failure, and respiratory failure requiring intubation. His clinical course was complicated by heparin-induced thrombocytopenia and bilateral deep vein thromboses. He was put on argatroban for clot prevention. He slowly made a recovery; we were able to extubate him, we weaned down sedation, his laboratory abnormalities were normalizing. But then the next day he coded and died. As we got serial ABGs, we realized the patient had a large A-a gradient suggestive of a massive pulmonary embolus. We pushed t-PA but there was really nothing more we could do.

We got an autopsy on this patient. I blogged a long time ago on autopsies; the last I attended was two years ago. I think they are an invaluable resource. We didn't know the diagnosis; we didn't know why his heart went bad at the start and our theory of pulmonary embolus was hypothetical. But going down to examine the organs was incredibly enlightening. We were able to see the wedge infarcts and visualize the clot burden. We were able to hold the heart in our hands and feel it. We were able to confirm our diagnosis of why the patient coded, and as soon as the pathologists complete their microscopic analysis, we'll have a better sense of why he had cardiogenic shock in the first place.

Code Blue I

The truth is, most "codes" called in a hospital turn out to be false alarms. All medical staff are instructed to call a code if we even think about it; it's the quickest way to get help in the hospital. No one can be reprimanded for calling one; even if it turns out to be benign, better safe than sorry. When a code is called, a ton of staff come out of the woodwork. Not only do you get an ICU fellow, a code team, a host of nearby doctors, nurses, pharmacists, and respiratory therapists, but depending on the hospital, you also get security, a chaplain, and a runner (someone to go find supplies you need). Sometimes it is better to call a code even if you have multiple doctors in the room simply because we'll need someone to get a bipap machine or mix up a drip or place another IV.

The truth is, I have only been at a handful of codes and none that have been incredibly acute. Recently though, in the CCU, one of our patients coded and we were there from the very start. In fact, it happened on rounds; the resident was first called away, then he pulled the fellow in, and then a minute later they poked their heads out and asked for more help. The attending strode in and started directing the code. Although running a code tends to be the job of a senior resident or fellow, it was entirely appropriate in this case and I immediately saw why. The patient had an uncertain diagnosis and the attending's mind worked so quickly. He not only went through ACLS by rote - another round of epinephrine, continue chest compressions, charge to 100 Joules - but talked aloud, allowing us some insight into his rapid and complex thought process. He immediately laid out the differential diagnosis, described the rhythm he saw on telemetry, and proceeded to complex therapies way beyond ACLS (we even tried inhaled nitrous oxide). He remained coolheaded throughout, asking for ideas, maintaining absolute control of this situation. A CCU patient crashing is terrifying because these patients have no reserve; there's no higher level of care; there's no room before they die. But at least in the CCU, the staff is trained for this level of complexity, the patient had abundant access, and he was already on drips we could titrate. He didn't make it, but that's something for the next post.

Students

Another role we take on as interns is that of mother duck. Particularly on ward months, we get assigned third year medical students who follow us around like ducklings. We co-follow patients with them, teach them, review their notes, encourage them to come up with an assessment and plan. I have grown to love this role. It is really fun to realize that I have knowledge to pass on. But more than that, it is so satisfying to see students come up with answers themselves. I remind myself to avoid simply telling students answers to questions that they could potentially figure out themselves. While I am loathe to assign "homework," I do like to prod and push the third years to read independently and think critically about their cases. Their questions challenge me, force me to see different perspectives, renew my enjoyment for learning. I also think students contribute to the care of the patients they follow. Student notes are the most thorough; if I wonder who a patient lives with or whether they have pets or about their family history - things I am notoriously poor at recording - I have no doubt that the MS3 knows. Students also prompt us to broaden our differential diagnoses, look into the most recent treatments for diseases, and address even the small issues. Teaching itself is also such an incredibly important skill to practice and develop. It is one of the best parts of intern year.

Intern Depression

There was a study a few months back that showed that a large percentage of interns meet DSM criteria for major depressive disorder. Of course, this statement is flawed in many ways; the DSM (psychiatric) criteria for depression include symptoms like weight change, appetite disturbance, insomnia, fatigue, difficulty concentrating. Every intern at some point feels these symptoms. The call schedule disrupts our sleep; we can't help but feel chronically fatigued and have poor concentration. Depending on our specialty, our meals are rushed or forgotten. It's no wonder that every intern can check off many of the criteria for depression.

But the two most central aspects of depression are a depressed mood or loss of interest or pleasure. How often do residents meet that criterion? Hopefully, most of us went into medicine because we enjoy it; we love seeing patients, we feel privileged in caring for people, we get a sense of satisfaction from the relationships and interactions that form. But to some extent, residency grinds a little of that out. I go into each call night hoping I don't cap on admissions. I don't necessarily go in hoping I'll admit zero (I feel like then that'd be a waste of time), but I'm not such a work-o-phile as to ache for more patients. When we realize we wake up before it's light out and leave the hospital after it gets dark, it's hard not to have a depressed mood. We see our friends outside medicine making more money, working fewer hours, having less stress, starting families, and cannot help but wonder did we make the right choice?

That being said, I don't think I really ever met the DSM criteria for depression. Despite days here and there where work really affects me, for the majority of time, I love what I do. I don't mind being in the hospital and I cultivate those things outside the hospital which make me happy. The friends I've made in the residency program are so wonderful and supportive. We help one another get through those long call nights, remind each other to take care of ourselves after work.

Image of Vincent van Gogh's "On the Threshold of Eternity" (1980) is in the public domain, from Wikipedia.

Done

I will continue to blog about cardiology, but I just wanted to say that amazingly, I made it through the last five months and finally have a week of vacation. It has been without doubt the hardest five months of my life. I count 35 overnight 30 hour calls. A fourth of my time, I am not sleeping in my own apartment (though that does not change the cost of living). Honestly, it's gone by really quickly though I won't deny there are those nights where I'm not sure how I'll make it. Time to catch up on sleep.

Pediatrics II

One other patient I saw was a 20 year old girl who had gone through more than most people do in a lifetime. Born with a fairly subtle congenital heart defect, she caught an infection of a heart valve that sent her to surgery after surgery. The literature in antibiotic prophylaxis for dental work for those with congenital heart defects is mixed. Previously, we would give antibiotics to patients who had abnormal valves before they saw a dentist. Mucking around with teeth, it turns out, is a risk factor for seeding the blood with bacteria. More recently, guidelines have changed, suggesting that it is not necessary to give pre-dental antibiotics. Large studies suggest it's not cost-effective. But take this patient in particular. She did not receive antibiotics, and got a valve infection that could not be cleared with antibiotics. She had a valve replacement, but it was complicated by an aneursym of the aortic root. When she got the aortic root repaired, she had heart block and required a pacemaker placed in her teenage years. Then she does well for a few years until her mechanical heart valve gets infected; mechanical heart valves are so prone to infection that in someone her age, it was inevitable that some time, she'd probably get endocarditis. She had her aortic valve replaced again which caused more trauma to her aorta until the surgeons deemed her inoperable. Finally, she gets a heart transplant. Although we think of heart transplants as new slates, they unfortunately aren't; she works hard to stick with her transplant medications, more medicines than most people take until they are senior citizens. She tries to live a normal life - make friends, go to college, find a job. But finally she comes in to the hospital because she starts to have neurologic signs - vision cuts, vertigo. It's a little worrisome. On exam, I find that she has bulky lymph nodes. Initially, I was concerned about meningitis (since patients are immunosuppressed with their transplant medications) but now I was putting together a picture for a disease I knew only a little about - post-transplant lymphoproliferative disorder.

PTLD is a lymphoma-like picture seen in the post-transplant patient population. Unfortunately, it meant we had to cut back on the patient's immunosuppressants, risking a higher chance that she'd reject her new heart. My post-call morning was a-flurry. Oncology felt that the neurologic involvement made this a near-emergency; they wanted a stat biopsy by interventional radiology, neurosurgery, or ENT as well as an emergent consultation by radiation oncology. This was all complicated by the fact that she concomitantly had an acute surgical emergency, but surgery wanted to hold off on operating because it would set her chemoradiation back. I realized how complicated it was juggling recommendations from differing services. In the end, we managed to treat the surgical emergency with aggressive medical care, got a stat biopsy, and began chemotherapy to decrease the disease burden of PTLD.

Throughout the course, I was awed by this patient's self-sufficiency. She went through hardship after hardship with nothing but perseverance and the hope to achieve a quasi-normal life. It really is a privilege for me to meet and work with and treat these patients, and I have a lot to learn from them.

Pediatrics I

Oddly enough, on my cardiology rotation I had a few patients that were really close to pediatrics. I had a young patient in his early 20s with pulmonary hypertension from a congenital heart defect. He was extremely dependent on his mother who was at bedside 24-7. The patient dynamic was interesting. Even though he was technically an adult, he deferred all his decision-making to his mother. I sometimes felt that I was treating her as much as I was treating him. She made lists of questions and concerns while the patient didn't want an active part in his care. Perhaps growing up with a chronic disease keeps one in an earlier developmental stage; perhaps infantilization is a defense mechanism. But on the other hand, I met a girl who was also in her early twenties who grew up with a double inlet single ventricle. While our hearts have separate chambers for oxygenated and deoxygenated blood, she only had one chamber and the mixing of blood causes her to be cyanotic (blue). Her body has compensated for the lack of oxygen; her red blood cells are much higher than yours or mine. She's undergone at least a dozen surgeries to create shunts to alleviate the consequences of this congenital heart defect. And yet, she is incredibly self-sufficient. She understands her disease better than anyone else, can draw out diagrams of her heart, manages her many medications. I was impressed by how independent this patient was.

Sub-sub-specialties

The cardiology service at Stanford is partitioned into many sub-sub-specialties. After CCU rounds, we find individual attendings for various services from cardiac transplant to pulmonary hypertension to electrophysiology. Thus, we get to learn about these very specialized patients from those who know their diseases the best. This is especially educational and interesting. For example, I'm only beginning to understand the host of complications and medications associated with heart and heart-lung transplants. One of my patients has been in the hospital over two months for infection after infection, and only now is he finally looking ready for discharge. Although I've learned about rejection from a theoretical standpoint, it is so different than seeing someone who may actually have rejection. It is a similarly educational experience to care for patients with severe pulmonary hypertension on medications I had not learned about or for patients with arrhythmias undergoing very specialized electrophysiology testing and ablation.

Learning

I alluded to this on the last post. Learning has changed for me. Education in residency is experiential. The cases I see, the patients I care for all make an impression on me. When I read, what sticks most in my mind are those things that change decision points for my patients. I learn about each disease as I come across it, rather than by perusing a textbook that lists them in order. But of course, residency comes with formal didactics. We have morning reports with presentations of instructive cases, noon conferences with lectures on common topics, grand rounds describing important advances in knowledge. When I was a medical student, I took copious notes at these didactics. But now, whether right or wrong, I find myself too exhausted to mentally attend to these sessions actively. I absorb what I can, but they have been relegated to an adjunct, a supplement to my learning. I find this change interesting, and necessary.

Home Is Where the Heart Is

Finally, the twilight of my five month call marathon. After inpatient wards at Stanford (which ended a while ago, but blogs always lag), I moved onto the cardiology service. Unfortunately, I am feeling burned out, which is sad because if I had boundless energy, I would really love this rotation. It has a good mix of ICU and quick-turnover ward cases, simple bread-and-butter and complex patients. The attendings have been some of the best in intern year so far. The experience is high-powered, demanding, and rich. I feel like I'm just chugging along, but I try to get as much out of it as I can.

We begin each morning in the coronary care unit, the cardiac ICU. I love the ICU. It feels oddly reassuring to me. We discuss all the new overnight ICU admissions in a Socratic method style. The CCU attendings I've had have been phenomenal, weaving in education with the evolving stories of each patient. From acute heart attacks to frightening cardiac rhythms to dramatic heart failure, the cases illustrate some of the best physiology I've seen in a while. We pore over EKGs, analyze Swan-Ganz tracings, labor over chest X-rays. CCU rounds can be fairly exhausting, but they are always thoroughly educational.

Image is from Wikpiedia, in the public domain.

Pain

I find pain one of the more difficult things to manage, something I hope to learn more about when I am in anesthesia. Pain is subjective. It's experiential. What objective markers and tests we have for pain are crude and rudimentary. I've written about this before, and the philosophy of it is fascinating. We live in internal worlds and we know only our harbored experiences. The shared world - the external world - acts as a bridge for us to interpret the worlds others live in. This objectivity is limited. If someone is in pain, then they are in pain, unless we have reason to doubt them. Few objective markers allow us to confirm or deny that statement.

But rather than wax philosphical, I wanted to write about two sickle cell patients. Sickle cell crises are intensely painful, and I recently admitted two sicklers in the midst of excruciating pain. They kept on demanding more and more narcotics, to the point that I felt uncomfortable; one who was allergic to half a dozen conventional agents wanted meperidine (demerol). It is an opioid with dangerous drug reactions - it may have lead to the death of Libby Zion, a college student whose death gave rise to the work hour restrictions we have today. Furthermore, exceeding the FDA-approved dose increases the risk of seizure dramatically. This patient demanded more and more demerol, past the maximum dose of the drug.

So what is pain? Of course these patients are in pain; sickle cell is a painful disease. But on the other hand, continued escalation of pain medications has its risks. I worried about exceeding maximum doses, causing tolerance, even feeding drug-seeking behavior. Yet all I had objectively was the word of the patient, his vital signs, and how he looked in bed. I wanted to treat this patient's pain; it's unethical not to. But the patient demanded more and more until he was so somnolent we could hardly wake him. What do we do in these cases? How do we approach them?

Notochord

At Stanford, I see diseases I've never heard of. We recently admitted a patient with a pelvic chordoma. When I first heard that word, I didn't even know how to spell it. But with some investigation, I realized it was a cancer of the notochord, an embryonic remnant. It makes sense; anything can form cancers, even parts of us that are no more. This slow growing tumor had become extensive and unresectable and in his sixties, this patient required placement of a colostomy to drain stool as well as a suprapubic catheter to drain urine. These had been working reasonably well and the patient was doing fine until one day, on routine tests, an outside hospital found a significantly elevated creatinine, a sign of declining kidney function. She was sent to us for further workup. When I saw her, I found something odd on exam - I saw urine in the colostomy bag. We got analyses of the urine from the colostomy bag and the suprapubic catheter, and the plot thickened. There seemed to be a fistula (connection) between the urinary tract and the gastrointestinal tract. Renal, urology, and colorectal surgery were consulted and we sent for a nuclear study I had never heard of - radiolabeled lasix. I interpreted the images as soon as they came up - there was tracer in the colon. Unfortunately, the patient was not a good operative candidate and so in consultation with all the surgical services, we decided not to try to treat this surgically. Instead, she will live her life with a strange anastamosis and might be dialysis bound due to chronic tubular necrosis from seeding of the kidneys from the colon. It is unfortunate, but also something that is not textbook at all. There is a stereotype that internists don't look under dressings or in drains and that is mostly true; I am glad I did this time though.

Image of a chordoma in the brain from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

Poem: Crisp

Crisp

Sun-baked cinnamon, mulled senses and flame,
November's whisper dances circles across the floor.
We cannot be but horizontal,
eating to the sky, our tongues lavishing
stewed tart apple, our cheeks brushed with brown sugar
ice cream droplets scatter the pillows framing our heads.
We lap up cider, aroma like tea, lemons bobbing,
the flicker of shadows as a draft caresses candle.
Amber, woody, auburn, fall,
basking in the luxury of sense, texture of smell.

Pain

Image from A Cartoon Guide to Becoming a Doctor, shown under Fair Use.

Trick or Treat

I am on call on Halloween and the admissions are quite slow today - is it a trick or a treat?

You'll often find residents gasp at such statements for the fear that we might jinx a pleasant call night. This is quite amusing to me. Physicians are some of the most rational, logical people I know - we call upon data and science and reason to justify our decisions and statements - and yet, almost every resident has this superstitious belief that we can jinx our call night if we say the wrong thing ("gosh, it's slow today"). I actually don't worry too much about what I say (you may notice this in the blog) but if five chest pains roll into the ED at midnight, I guess I might change my feelings about it all.

In other news, it makes me happy that the radiology techs today are dressed up in costumes (a pirate, a knight, a cowgirl).

Image shown under Creative Commons Attribution Share-Alike License.

Primum Non Nocere

First, do no harm. This is not actually an easy concept. The more I become tied to medicine, the more I realize the practice of something and the theory are very different. Even standards of care, textbook medicine do not always apply. In the classic book of internship The House of God by Samuel Shem, medicine for older patients is to do as little as possible. In the book, the more the characters try to correct abnormal laboratory values and numbers, the sicker their patients get; the less they do, the better they become. This is not far from the truth. For example, the ED recently admitted a 95 year old to the hospital for no good reason. The ED sent a laboratory test that was not indicated, and when it came back positive, she had to be admitted even though she had no complaints that warranted admission. After examining the data, we ended up ignoring that laboratory value and decided to discharge her. But when I looked at her blood pressure regimen, it was not ideal; she was on multiple medications of the same class and wasn't on other medications that were indicated (she had heart failure but was not on a beta blocker or ACE inhibitor). By textbook and standard of care, her blood pressure regimen should be switched. But upon discussion with the attending and team, we decided to do nothing. Why? Because this regimen had worked for her for so many years. She was already 95; how many studies include 95 year olds? How do we know what is best for them? Changing her medications around would have a higher likelihood of harming her with marginal benefit. So I deferred to her outpatient physician - who knows her well, who will follow up - to decide whether to switch her medications to the standard of care. First, do no harm.

Do No Harm

This is something I am learning as an intern, and it is a hard lesson. Do no harm. For me, this applies mostly to older patients. In my last post, I alluded to a patient who I may have harmed by being pressured by family to do something when I should have done nothing. I will be honest. Doctors make mistakes. We will make mistakes, and some mistakes matter. It is incredibly hard for non-physicians to hear - after all, we are treating mothers, fathers, spouses, grandparents, children - but believe me, it is even harder for us as doctors to bear. In a single day, I make a hundred clinical judgments and decisions. If I am 99% accurate, one will fall through as an error. This is inevitable. Every morning, when I see each of my ten patients, I am making a judgment of whether I hear crackles in their lungs, whether their rash looks worse, whether their antibiotics need to stay on or off. I write a hundred orders each day - some of little consequence (stool softeners, diet orders), but some of intense importance (discharge instructions, medications).

One patient I had at Stanford had loving family members who knew him very well. They micromanaged each little condition. They called around to multiple doctors and would meet us in rounds each day with a list of suggestions. Some were clearly inappropriate and some were clearly indicated. But much of medicine is gray, and this is the problem. The patient was mildly anemic and actively bleeding; his hemoglobin was not at a level that transfusion was clearly indicated, and it was not at a level in which transfusion was absurd. I felt that I did not want to transfuse this patient at the time. But the family requested that I do. This was not an unreasonable request and in consultation with the resident and attending, we did transfuse. It is important not to confound correlation and causation but I felt the transfusion marked the transition between him getting better and him getting worse. There are actually a lot of medical reasons why the transfusion could have harmed him (and medical reasons why the transfusion could have helped). We will not know which happened. But I have since been haunted by this incident not necessarily because I think I harmed this patient, but because I was persuaded to do something I was not inclined to do, and because it ended up correlating with a poor outcome.

Families

The range of family involvement in patient care is pretty stunning and diverse. In the last few weeks, I've had patients who are dropped off by family members outside the emergency department, and I've had families who stay at the bedside night and day trying to micromanage. From the standpoint of a resident, I don't think either is good. Families are a necessary component to care; they support their loved ones in the hospital, they are an invaluable source of information, and they are critical around the time of discharge. It is really hard for me to see patients in the hospital who have no family, no visitors. On the other hand, families that micromanage can be intensely frustrating. Family members have a wealth of information about their loved ones and their diseases, especially if they manage the patient's chronic conditions. Family members know a lot, and they can contribute a lot, but sometimes this makes them imposing. All care, whether inpatient or outpatient, must be a concordant plan of action negotiated among the clinician and the patient. But I've had families demand unreasonable things, and in one case, something that proved detrimental to the patient (this will be the next post).

Sleep Deprivation

Image from A Cartoon Guide to Becoming a Doctor, shown under Fair Use.

Revision: Mythology, and Other Lies

Mythology, and Other Lies

And when I smother myself in poison,
find clumps, hills in the shower,
negotiate nausea, pain, itch
I wonder how Prometheus did it,
letting vulture consume that which he did not want
hoping to regenerate the purveyor of iron --
oh, I know of the Prometheus support groups
pre-transplant, post-transplant kumbayas --
but I defy absolution! I bathe in your
widowed, your winowed -- I roar
against cages, cells, cancers --
I am not so sure we are not Titans,
that we aren’t chained some precipice
to have our organs devoured.
Burn me, hold me, let scars radiant
beam down that valley, shadow, light.

Goodbyes

Goodbyes are the hardest thing. Whether to a patient, a family member, a loved one, a friend, goodbyes are the hardest thing.

Types of Attendings

The personality and styles of attendings vary quite a bit. Some attendings look from afar and give broad-stroke ideas about how to care for particular patients. Other attendings pontificate about theory and pathogenesis of disease. I've had attendings who love clinical trials and spend their time discussing numbers needed to treat and the evidence behind certain decisions. In the last few weeks, I've had a really surprising diversity of attendings. One attending at the Valley gave us lots of independence and room to develop our own clinical judgments. He gave enough oversight that we felt safe, but he pushed us to treat our patients like they really were ours. The next attending I had liked to micromanage. Having completed a chief resident year recently, he understood the nuances of the system and liked the resident role; he helped coordinate care, put in orders, and stayed late. Lastly, I've had an attending who does mostly research and policy work. Because he spends less time on the wards, he defers a lot to the resident to decide and encourages consultations. Overall, the mix is both fascinating and educational, allowing us to approach clinical problems from a multitude of perspectives and develop our own personality and style.

Partitioning

As a tertiary care center, Stanford has many specialized services. There are primary teams for hematology, oncology, transplant, neurology, and cardiac patients. So when we are on general medicine wards at Stanford, we don't admit chest pain, strokes, or oncologic emergencies unless those teams have "capped" (filled up their quota of patients). This is in contrast to the VA where medicine handles everything nonsurgical. In any case, it is both good and bad. It means that those specialized patients get better care - a cardiologist primarily handles the heart attacks, a transplant specialist deals with the kidney rejections. But it also means my perception of medicine is skewed; I am less comfortable with strokes and seizures because I don't see as many.

The patients admitted to the general medicine wards are generally of two types. The typical emergency department admits include little old ladies with failure to thrive, run-of-the-mill pneumonias, patients at nursing facilities who aspirate, patients with liver disease. But at Stanford, we also accept transfers from outside hospitals (like the case described previously) that can be nightmarish. Those patients can be exceedingly complicated. Other types of complex patients are those with rare diseases or congenital malformations. In fact, one patient on my service was 20 years old and had 45 surgeries in the past. Though it is a good educational mix, it is also so overwhelming to a newly minted intern.

Mindnumbing II

(This is a continuation of the case below).

Astute readers, of course, recognize this as the dreaded mucormycosis. This fungal sinus infection progresses rapidly toward fulminant death. The mortality rate of rhinocerebral mucormycosis is extremely high. When we called ENT for this patient, they wanted a stat MRI scan which showed fungal invasion into the brain. ENT placed the mortality at 100% even with all aggressive treatments. Infectious disease also looked at the case and put the mortality at >95%. Mucormycosis - a disease so rare that I had only thought I'd see it in textbooks - is truly a sobering diagnosis.

With the concern of almost-certain fatality, we held multiple family meetings to try to understand what the patient would have wanted. She would not have wanted her face disfigured, and indeed, the marginal benefit of such a heroic intervention was not worth the cost. Eventually, the patient was made comfort care and with the aid of the palliative care service, we let her go peacefully and quietly.

The real question that came up was whether this was an appropriate transfer and whether there was delay in diagnosis. I felt that the patient was not necessarily stable for transfer; she carried with her a definite surgical indication, and she came from a hospital that had an ENT physician. Then again, I wonder whether the accepting physician at Stanford knew how dire this condition was; when we were told about the patient, we had simply thought she was here for a workup of the brain lesions. Lastly, and closest to my heart, I wonder whether I could have made the diagnosis quicker. When I examined the patient, the worry of necrosis and mucor rhinosinusitis did come up like a nagging thought, but I was loathe to call it and call the surgeons for an emergent evaluation. Did the couple hours I waited before calling ENT make a difference? Most likely it did not as the disease was quite progressed when the patient arrived, but sometimes I worry that I did not do enough.

Mindnumbing I

There is a case at Stanford which has been haunting me for the last week. (Note: details have been changed). We were told about a ridiculously sick transfer from an outside hospital. A young woman with a history of lymphoma, immunosuppressed with chemotherapy presents to an outside hospital several months ago. There she is diagnosed with MRSA endocarditis, possibly from IVDU, with septic emboli to the lungs. She is put on vancomycin for 6 weeks via PICC line. She goes home, then returns to the hospital about a week later with epistaxis (nose bleed). In the emergency department, they pack the nose with gauze to stop the bleed, and because she is slightly thrombocytopenic (presumably from chemotherapy), she was admitted to the hospital. A CT scan (unclear why this was obtained) showed cavitary nodules which were worrisome and a sputum culture grew out Aspergillus. The CT also caught part of the liver and showed a mass which was biopsy-proven hepatocellular carcinoma. Separately, the patient started having altered mental status and becoming more somnolent. A lumbar puncture was not consistent with meningitis. An MRI of the brain showed ill-defined lesions of unclear etiology. There was also concern for endocarditis, but transthoracic echocardiograms were negative (it is not clear why a transesophageal echocardiogram was not pursued). Meanwhile, the epistaxis started draining purulent material and a CT scan of the sinuses showed maxillary and ethmoid sinusitis. She also had facial swelling on the same side, and an ophthalmology consult diagnosed periorbital cellulitis. As the patient became more and more complicated, she accumulated antibiotics and more tests until finally the outside hospital transferred her to us. Although ostensibly, the transfer was for diagnosis of the brain masses, this is what the patient looked like when she reached us.

Image is in the public domain, from the CDC.

The Big House

Finally I am at the big house. My schedule is such that I didn't make it over to Stanford until my fourth month. I am, again, on wards (it is relentless). But I've turned the corner on this stretch; it is now my 4th out of 5 straight call months. Stanford is a big change; while I had to drive half an hour to get to Santa Clara Valley Medical Center, I walk to Stanford (though it still takes me twenty minutes); perhaps one of these days off, I'll get myself a bike. Wards here is a straight q4; we take 30 hour overnight call every fourth night. Unfortunately, recent restructuring of the program makes this rotation ridiculously busy. We cap at admitting 12 patients every night, and our service runs close to the maximum of 20 patients all the time. There is a wide variety of patients; although some of course come through the emergency department, others are transfers from hospitals or direct admits from clinic. We see the bread-and-butter alcohol intoxication, failure to thrive, pneumonia, sepsis, but we also get transfers for cancers I've never heard of (spindle cell) or end-stage diseases refractory to management by other hospitals. Although it's a good experience, it's really tiring as patients can be awfully sick.

I'm always running behind on my blogs, and there is so much to write about but so little time. In looking at my schedule, I think I will have to take a week-long break from blogging. Alas, residency comes first. I'll be back next Monday.

Image is in the public domain, from Wikipedia.

End-Stage

One of the things about being at Santa Clara Valley Medical Center is that due to the patient population, we see a lot of end-stage disease. The patients often do not have regular medical care, and so they only come in when they are extremely sick. As a result, we see a lot of terminal cancer, heart failure, COPD, liver disease. I found that during my time at the Valley, I was able to focus on end-of-life care and discussions. I had several patients with terminal disease, and I think that physicians have such an important role during this time for the family. The demeanor, attitude, and engagement of a doctor at the end of a patient's life can make the experience meaningful or awful for the family, and I try so hard to achieve that essence which they never teach in medical school. The severity of disease also reminded me of the importance of fundamental and routine access to primary care. Those patients who do not have regular physician contact are so much sicker at a younger age.

Medicine at the Valley is also a great experience because we do everything. There is no primary neurology service, and so I admitted and managed stroke patients, racking my brain to remember how to localize the lesion. I was able to do several paracenteses on patients with liver disease. I saw overdoses of the widest array of medications. It was a really good bread-and-butter experience and a reminder of how wonderful it is to take care of county patients.

Valley Fever

I am perpetually behind in blogging; I've actually been away from the Valley for two and a half weeks. But in thinking back on my time there, the thing I appreciate the most about Santa Clara Valley Medical Center was the independence I developed. This is not to say anything particular about county hospitals, but I found that at the Valley, residents were given a lot of independence in making clinical decisions. We had adequate supervision, but it was really a resident-run hospital and I appreciated that. At other hospitals, consultants, fellows, and attendings manage the grind, but at the Valley, I learned so much because I was calling the shots.

Poem: Window

I signed up for a writing workshop associated with the medical school. It is a three-session evening class with 15 writers, all members of the Stanford medical community. Somehow it fit in my call schedule and I am very excited about this. We focused on creating new work. Here is one of those poems.

-
Window

Each morning, I wake to a new window.
Today it is the window of an officer's glasses
eyes magnified, serpent-like
in an expression encountering halitosis alighting
that breath of rum and vodka,
and the next window is the torch:
look at my nose, the prodding voice commands
and I dodge into the next room
the images swim up, portals of access and descent
until another window consumes, a window
with a blackberry vine, a meander across
the splintered barn, my shoulders aching
from the beat and welt of days.

You are too serious, I tell the bars
and like you, their insistence is silent.
Oh, the windows say the same thing every day
shelter among shelter, and believe me,
if I could climb through, I would have long ago.

The Good Doctor

On the last call cycle, I admitted a patient with a fairly mundane disease, and he was going to be fine. On the post-call day, I stop by to see my patient, and his primary care doctor is there. She had stopped by to see him prior to going into work at 7. I occasionally see primary care doctors at the inpatient bedside, and I think it is wonderful and amazing when that happens. How do they stir up that well of time, effort, and energy to see one of their patients who's been hospitalized when they are sick? You would hope that this is done commonly, but the truth is, it's a rare and inspiring thing when it happens.

Documentation

One thing about being at the Valley is that daily notes are handwritten. This creates an interesting phenomenon; we write less because it takes more effort and time. But because we are constrained by time and physical writing effort, the notes we produce are more direct. When I write computerized medicine notes, I might expound on the theoretical aspects of a specific problem. "Anemia may be categorized into microcytic, normocytic, and macrocytic. This patient's anemia is microcytic and our differential diagnosis therefore is iron deficiency anemia, anemia of chronic disease, thalassemia, and lead poisoning." But when I am at the Valley, I instead write, "Anemia - MCV 75. FOBT. Iron 325 BID."

Whether this is good or not, I am not sure. As a medical student, notes are of paramount importance, but as a resident, they are a nuisance and necessity. Notes have an important documentation and legal value. Good notes also convey thought processes and communicate. But in the overall scheme of things, my priorities are focused on patient time and orders, not documentation. I found that having to write less at the Valley gave me more time to think about the "doctory" stuff - thinking about a patient and deciding what to do rather than writing about it.

Congratulations!

The end of medical school and the start of residency is a wonderful time for some of my friends. My friends and classmates are starting to hit that stage of life when they are thinking of starting their own families and committing to their loved ones. Indeed, this summer was a blossoming of weddings, and just today, I walked from Stanford Hospital to Memorial Church to attend one of my friends' weddings. Congratulations to all the newly-weds. And to those in the midst of their residencies or med school or first jobs, I am so incredibly impressed by your sustenance through such a stressful time.

Image is in the public domain, from Wikipedia.

To Be Honest

It's been a hard week. I mean to write, but I don't know when I will get around to it. During residency, priorities get accentuated. Patients come first. Then taking care of myself. Then learning. Then everything else.

Nostalgia

"Every day's so caffeinated, I wish they were Golden Gated / Fillmore couldn't feel more miles away / So wrap me up return to sender, let's forget this 5 year bender / Take me to my city by the Bay" - Train, "Save Me, San Francisco."

Though it is wonderful being back down in the Peninsula, I do miss San Francisco. Every time I return to visit friends, I am astonished by how beautiful and striking the city is.

Image from Wikipedia, in the public domain.

Volume Overload

Congestive heart failure is one of the core concepts learned in medical school. When the heart is unable to push fluid forward, it backs up into the lungs and the rest of the body, as demonstrated by the chest X-ray shown above.

The principle was clearly illustrated this last call when my team was on "Super Sunday" (when we cross-cover all the medicine patients in the hospital). On Saturday night, the hospital was bolused with a huge number of patients; 17 patients were admitted overnight. Normally on Sunday, the "on call" team takes 12 total and no other teams pick up patients. But given this extraordinary number of admits, the chief residents had to activate the short call and pre-call teams, giving them patients when they normally would not get any. The pump - the admitting team - simply could not move things along. The entire hospital was volume overloaded and patients were backing up into services that should have been free. It was somewhat of a nightmare since if we did not try to break the cycle, it would get worse and worse.

We ended up taking 13 patients total (one more than we usually do and three more than we do at the valley). It was fairly painful but we had to relieve the pressure on the system and allow services to diurese patients. I've never seen something like this happen before, and when it does, the system can barely handle it.

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

Book Review: Superfreakonomics

Reading during residency is hard, but I picked up this book a while ago. I really enjoyed its predecessor Freakonomics, but to be honest, the sequel fell short of expectations. Although most of its topics are superficially interesting, it did not carry that interest through for me. Other than the chapter 0n global warming, I found the writing, research, and revelations to be lukewarm at best. They make a big deal over not having a "unifying theme" but I think that's what killed the book; the writing tried too hard and the train of thought wasn't all too coherent. Unfortunately, I would not recommend this book.

Image shown under Fair Use, from freakonomicsbook.com.

Gatekeeper

I once played a game in which there was this boss called the Gatekeeper who was extremely hard to defeat. Nobody could get past him, but if you got a group together, you could sneak someone by. (You would think there was a paradise beyond that bridge, but unfortunately, it was a dead end. Why we were so fixated on beating him I never figured out).

In any case, the emergency department often acts as a gatekeeper to the hospital. Most patients pass through the ED to become inpatients. Thus, ED physicians have a huge responsibility and burden to triage patients correctly. With defensive medicine, increasing complexity of problems, overwhelming patient burden, and decreased time, ED physicians are starting to get conservative on who they admit. I've found on the medicine wards that we often get "soft" admits: patients who we don't think need to be in the hospital. They stay for a day, we get a few tests, and we send them out the next day.

This is a quandry. On the one hand, hospitalized patients are the most expensive patients, and inappropriate admissions cost the system a great deal of money. We have a shortage of hospitals and hospital beds, and even physicians are becoming an increasingly rare commodity. Filling hospital beds with healthy patients takes away from those who need our attention the most. Even "easy" and straightforward patients come with a mountain of paperwork (oh, discharge summaries) and pages.

On the other hand, I completely sympathize with the emergency department. They are overflowing with patients and they must make snap judgments without being able to go through all the past medical records. The medico-legal climate does favor conservative decisions such as admitting to the hospital even just for observation. It is not easy being an emergency medicine doctor.

I have no good solutions. But I feel that if we do not nudge the pendulum the other way, we will be spending resources on patients who do not need them. The emergency department is the gatekeeper to the hospital, and they have that extraordinarily difficult job of wading through the patients flooding the gates and determining who needs that precious hospital bed.

q3

I have a quick stretch of "q3" meaning that I am on call three nights after my last call. This is because we just switched rotations. Thus, I was on call Sunday, post call Monday, and I'm on call tomorrow. The problem is that it only leaves me one day for my blogs. So today's will be short and unfortunately it'll only make sense to those in medicine.

My attending said, "back when I was in medical school, we had a gastroenterology professor who was extremely boring. He liked to pace from side to side in the classroom. We called him shifting dullness."

Poem: The Beginnings of Things

The Beginnings of Things

(as such may be)
flitter me away
to that edge, sky to sea where
cloud burns to seaspray
and scientists goggle
at The Beginnings of Things
and I simply want to leave
to bury my head
where I love it so much
and I give it all away
to The Beginnings of Things
(that refrain we sing)
as if we were not always here
as if becoming safe in our skin
makes us statuesque
and rumbling tide turns
rock into sand all the way until
(you know where we return)

Rocks

In perhaps a not-entirely-appropriate manner, we sometimes refer to patients who will be in the hospital forever as "rocks." Every service has a couple of people who for various reasons, simply have no discharge plan. For example, I am taking care of a very pleasant woman whose medical problems have resolved but due to her long hospitalization, she is too weak to walk. My plan for her every day is to work with physical therapy. Unfortunately, she is homeless and has no money. For those with insurance, a reasonable plan would be a skilled nursing facility where she can get therapy and regain her strength. But because she has no insurance, she stays in an acute hospital bed, a level of care that is way higher than what she actually needs. Furthermore, because she is homeless, she has an incentive not to learn to walk because we would then send her to a homeless shelter or medical respite.

We see this all the time; the uninsured and underinsured cost the health care system way more because of that. In a time when there are not enough doctors, not enough hospital beds, not enough nurses, we need to triage patients to the places that are most suitable for them. I hope that requiring universal health coverage may ameliorate this situation, but the truth is that it may not; people may still be underinsured if skilled nursing facilities cherry-pick the patients with the best insurance. This situation reminds me that medicine is entirely a social affair and doctors must be advocates for social justice.

The Valley

On the other hand, working at the Valley can be frustrating sometimes. Paper orders make me happy because they remind me of the days as a medical student when I'd carry around stacks of blank order sheets and run around finding charts so I could put orders in. But the truth is, it's incredibly inefficient; every morning trying to pre-round I have to locate 3 separate charts for each patient. Handwritten notes are often illegible and less thorough. Records are difficult to retrieve. Notes can be easily misfiled or lost. It's a wonder that the whole medical system used to run on paper charts.

Resources at the county hospital sometimes seem limited. Santa Clara Valley Medical Center actually has pretty much anything you'd want, but I find that beds are often limited. Each morning, we get a routine page - now a joke almost - to transfer and discharge our patients because there's a host more in the ED waiting for inpatient beds.

But I think the thing that bugs most people - and will probably be a separate post - is that county hospitals are a repository for people who have no discharge plan. I have at least two patients who have no medical indication to be in an acute care hospital, but will probably never leave. The social reasons that keep people in the hospital, using up resources, time, money, can be ever so frustrating.

Onto the Valley

This last month, I've been on the general medicine wards at Santa Clara Valley Medical Center. The Valley has its own residency program, but to broaden the experiences of both programs, we rotate down there and they send residents to Stanford and the VA. A lot of people don't like the Valley, but I really like it. As the county hospital in San Jose, it acts as the safety net for the uninsured, the immigrant population, the homeless, the indigent. The patients we see speak a myriad of languages, have a diversity of backgrounds, and come with both exotic and bread-and-butter illnesses. It is a really good change from the VA for me, and having been trained at UCSF, I feel a strong affinity for the underserved population. Indeed, the Valley reminds me strongly of SFGH. The way the hospital runs, the paper orders, the translators, the diseases, the autonomy all ring a sound chord within me and it makes me very happy to return to a county environment.