Exhausted!

What a week! I am exhausted in every way. Let me give you the short version as I am too tired to write more for now:
A man with no anus (status post colectomy) -- remember the old advice you got in med school about the only time you cannot do a rectal exam?
A drug-seeking male/female who had undergone a sex change (male to female) with breast implants, -- claims he/she can have sex and orgasms
A domestic violence case with neglected children and a battered wife
An infected artificial knee with large effusion and gout
Too many other things to remember.

I shall be vegetating this weekend...for a while, then I got to go in and catch up with paper work, dictations, billing and letters to patients on labs done, phone calls, emails...ah, the life of a primary care doc!

Isla Bastimentos and the Ngobe

Here is some logistics, facts and trivia gathered on the trip:

1. There are two schools on isla Bastimentos, one with about 90 kids and othe other with 30 kids. There is no school transport and kids walk to school along the coast. Most do not know how to swim and there has been at least one drowning of a 9 year old recently.
2. There are Nogbe communities on: Isla Bastimentos (about 2-3 communities), Charcot, La Loma, Salt Creek, Isla Cristobal and Isla Carinero, and on Isla Solarte. There are about 6 huts near the 'Bat Cave'
3. Healthcare facilities (such as they are) include the hospital in Bocas del Toro, another in Changuinola and a quite decent hospital in David. There is a first aid station on isla Cristobal, Almirante and Charcot.
4. Transport between these facilities is by boat -- expensive, hazardous and slow.

Medical missions trip to Bocas del Toro

Wild cacao growing on Isla Bastimentos. View of the town of Bocas del Toro from the air.


View from the balcony of the the Kapsars' home The hut where the lady with arthritis lives

1. on Isla Bastimentos.
   
   Another view of the same hut A Ngobe village
   I am writing this so-ooo late! During my visit to Panama, I had a memorable visit with Dale and Kim Kapsar (http://agapeinpanama.blogspot.com/). They live on the island of Isla Bastimentos, one of the islands in the Bocas del Toro archipelago in Western Panama. On this and adjoining islands live a group of Indians called the Ngobe (the 'g' is silent in pronunciation and the 'e' is sounded as 'ay').
   
   Dale and Kim Kapsar have lived on this island for several years now. Their house itself is quite a marvel, with solar roofing to generate electricity, a rainwater collection system that connects to 2 large tanks to provide running water through the plumbing and a tower to connect wirelessly to existing internet providers in the larger area. Dale and Kim have made Isla Bastimentos their home and the Ngobe their mission field, trying to reach them with the good news about Jesus. They however, are keenly interested in their socioeconomic situation too, developing projects to bring potable water to their communities, local sanitation facilities, teaching hygiene to local school children and providing basic medical care. They encourage support not to give gifts to the local indians, but jobs instead through which they can provide for their families.
   View of some of the less inhabited islands from the air.
   Throug the past year I corresponded with them through email. When I visited Panama to spend a 2 and half week vacation visiting my family there, I resolved to visit them. My family graciously agreed to let me go for 3 days.
   
   I caught a flight from Panama city to the only commercial airport in the province of Bocas del Toro. Here is a picture of the local airport from the inside. I caught the 45 minute flight and arrived in the town of Bocas del Toro. Dale and Kim received me and we had breakfast in the town. After picking up some supplies, we took their boat, Agape, (shown here with Dale standing next to it) to Isla Bastimentos. The trip lasted about 20 minutes and included a stop at the 'gas station' shown here.
   
   Travelling among the islands in Bocas is interesting. There is no public pier or dock at the town of Bocas del Toro on the island of COlon where the airport is located. Boat owner who live on the other islands make deals with local residents to tether their boats at the small piers in their 'back yards'. It costs about $ 30 in fuel and takes anywhere from 20 to 40 minutes to go between islands, depending on how far apart the islands are. Since there are no buoys or lights and their are unmarked shallow reefs, travelling in the dark is hazardous. Travelling in torrential rain (not uncommon in the area) is similarly difficult.
   
   The island shown in this picture is Isla Solarte and the tip shown here is called Hospital Point (http://www.worldheadquarters.com/panama/destinations/bocas/hospital_point/index.html). As someone who is interested in the healthcare resources in the area, this perked my interest, hence the photo. Well, it turns out that it WAS the location of the medical center for a banana company that was located in the area and no longer has anything to do with hospitals or healthcare.
   
   There are numerous mangrove islands that are quite beautiful to look at and here is a picture of one on the way.
   
   The picture below shows Isla Bastimentos and the Kapsar's home located on higher ground.
   
   When we arrived on the island, our first stop was in a small, half-finished building that will (we hope) eventually become a local clinic. Living there presently was a family, one of the members of whom works for the Kapsars. One the phone the day before my flight to Bocas, the Kapsars had told me of a little boy called Aljillo. This was a 2 year old who weighed about 15 pounds and did not walk. He was very malnourished. Here is his picture.
   
   As we walked off the Kapsars' boat, visiting him was my first stop. He had evidence of malnutrition, scabies, lymphadenopathy everywhere I looked. I treated him with something for worms, another pill for parasites, an intramuscular dose of a broad-spectrum antibiotic and gave the family a multi-vitamin and iron syrup to give him daily. I also recommended passive range of motion of his extremities. Within a few days, his lymphadenopathy had subsided and he was ravenous.
   
   After I left, a YWAM (Youth with a Mission) team continued to care and before they left, this little boy was walking! It turned out that the family was not feeding him because he was born out of wedlock. We tried to arrange to get him into a Nutri-Hogar (a home run by the catholic church on the mainland that provides nutrition to malnourished children before returning them to their families.). However, the family left before we could do this.
   
   Later that day, we visited a local school and participated in a group discussion on how things were going with the newly constructed latrine. The following day we visited a local village and saw several children. I treated impetigo (click on the picture of the little boy and look closely at his face, near his nose), scabies and one elderly woman with severe arthritis. The day before I left, Dale cut his hand and I was able to teach Kim how to suture lacerations -- a very common problem they must deal with.
   
   Teams that have come before me have left medical supplies and I left my stock of brough antibiotics, and supplies too. Here are pictures of my flight back home.
   
   Coming back to Panama I began to research what is known about the Ngobe and their health problems. Infant mortality is highest among the Ngobe compared to the rest of Panama and it is clear to see why. Most of the children are born at home or in the cayuco on the way to the only island with a 'hospital' (which is a very minimal facility run by the MInistry of Health).
   
   Here is the vision:
   The Kapsars are willing to give that little building on Isla Bastimentos to become a clinic / hospital
2. If we can get 21 doctors/nurse practitioners we can staff the clinic/hospital the year around.
3. Each provider would spend two and half a weeks at a time on the island.
4. They would be able to live with the Kapsars in their house. (It is a great place with electricity and running water). However, they would pay for their room and board and bring along what medical supplies and equipment they can.
5. There would be a half week overlap between changing providers for a 'sign out'.
6. Contact between all members of this 'group practice' would be by email and if bandwidth on the island ever permits, video conferencing or at least pictures.
7. Once a year, we would all try to meet someone and discuss our 'practice'.
8. Each physician would return yearly.
9. There would be periodic visits from church supported mission teams that would help with constructions projects and mass medical camps, but our group practice would provide the continuity, follow-up and guide the incoming camps to identified areas of needs.
10. This vision would provide continuity of care, an established presence among the Ngobe and U.S. standard of care.
11. I am signing on as the first doctor. Any other takers?

The phone call

New experiences don't end with residency. I love that about medicine. Another feature of medicine that makes it uncommon among professions is the human drama that goes with it.

I had seen a late 30-something for a complete physical last week. She looked down and through the course of the interview, I found out she had just finalised her divorce. To make matters worse, her 4 year old daughter had come away from her first visit with her father with bruises on her body. This brave woman fought back tears as she told me these things between looking in her eyes and ears. I felt a bit uncomfortable as a male provider doing this complete physical exam during a stage of her life when surely she must think all men are pigs.

Introducing the pelvic exam, as sensitively as I could, I offered her a complete sexually transmitted disease testing panel. At first she declined, but when I pointed out that in the context of the setting of the divorce, she might consider it, she agreed.

The results came back this morning.

I picked up the phone to call her. I pointed out that the Chlamydia test was positive. As if this was not bad enough news to give, I had to point out that as a notifiable disease, our lab had directly contacted the county healthy department. She asked if her name had been given. Honestly, I did not know, but I found out quickly. Not only was her name passed on, but a county health nurse would be contacting her.

Besides the devastation of getting a sexually transmitted disease from someone who had betrayed her in so many other ways as well, she was not concerned about her privacy and reputation. My heart was in knots as I tried to reassure her that even in a small town like ours, her information would be confidential. However, more and more people seemed involved in the loop: my medical assistant who receives the result from the lab, the lab personnel in charge of notification, the county health department and its share of employees that would be doing following up. I could see her point. I felt helpless and frustrated but that must be nothing compared to what she felt.

I'll follow her closely. I hope she's okay.

Aloepecia totalis

It was a busy afternoon. The student working with me came out of the room and told me that next patient -- a 53 year old male was a caucasian male here for a physical. As busy as we were, I went into the room with her quickly. The patient had wanted us to see his 1 month old in the same visit and Mom came along as well, so there were quite a few people in the room. He took his cap off as I began my physical and I noted he was bald. I asked him when he lost his hair and he said when he was 39. I looked up at his face ready to begin the HEENT (Head, Eyes, Ears, Nose, Throat) part of my exam when I noticed, hello? He has no eyebrows. Wait! He also has no eyelashes and... no nose hair, no hair in his ears, no facial hair, no hair on his arms and legs. He smiled and said 'Aloepecia totalis'. Cool!

I have seen one such case before and it is in this blog. In that case however, it was the side-effect of a drug. In this case, it seems, the patient denied any exposure to that drug and any other for that matter. No-one else in his family has this.

Moral of the story: just when you think the physical exam is a routine...

Is the generalist a relic of the past?

The other day I was talking to my brother. He told me casually in the course of conversation that he had got his physical for the year. He then mentioned that he had had his yearly appointment with the urologist to check his prostate. That got my attention. What's wrong? Nothing. He just sees a urologist once a year to check his prostate. He has no medical history of urinary or reproductive problems. He has never had urological surgery.

I was at a medical meeting and during a break talking with someone about how there isn't enough training in procedures during residency training. The person I was talking to turned out to be a subspecialist. He disagreed with me regarding training primary care doctors-to-be in procedures. He quoted papers that reported better outcomes when these procedures were performed by specialists.

So, should you go to a cardiologist to have a heart exam and evaluation? Should you see a nephrologist to manage your blood pressures? How about an endocrinologist or a diabetes specialist to manage your diabetes? Should a gynecologist manage your post-menopausal symptoms or a rheumatologist manage your osteoporosis or arthritis? Should you see psychiatrist for stress coping with changes in life or depression?

What is the role of the primary care provider? Is he or she to be a triage person, directing the flow of medical traffic to different specialist-destinations?

I am a primary care doctor. I don't treat a single organ or organ system. I don't wear blinders and only want to hear about your medical problems or complaints pertaining to just your heart or just your kidney or skin or mind or bones.

Are we emasculating primary care doctors when we deny them the right to be doctors and treat patients, rather than just refer them to specialists?

Of course, on the other side of the line is the recognition of the limitations of one's scope of practice. I won't do neurosurgery or try to remove your gall bladder or even do an angiogramon your heart. Some things are clear. But what about managing blood pressure in a diabetic, or abdominal pain in a pregnant, depressed young woman? Is that outside the scope of my practice? Who decides that? Me? The specialist? Some regulatory body? The public?

Of course, I have my own answers to these questions. And of course, as Einstein pointed out, the observer affects the observed phenomena. I am biased.

Fortunately, on a personal level, I am not legally limited in my scope of practice in any but the broadest ways.

Guilt

Being a primary care doctor is a privilege in many ways. It is also a sacred position of trust. What is said in a doctor's office is, very few legal exceptions, never to leave the room. Of course, in the day of the electronic medical record, that is not entirely true, or is it? How much of what a patient tells you belongs in their medical record? Most would argue, effectively I think, that personal information divulged in the course of the encounter may not always belong in the record. Such information might be a personal event -- a child winning a ribbon at a competition, or a vacation story. The electronic medical record is accessed by numerous healthcare providers that care for a patient in the course of time. With the HITECH and HIPAA laws, accessing this information without a direct clinical context is a breach of law. However, what if a primary care provider records information divulged in conversation during the physical or during the office visit with their doctor? What if they record this information as part of the documentation?

Okay, this is a long preamble to what I really want to say in this piece. I have a couple of patients in my (young) practice that have varied medical complaints for which I have not been able to find an organic cause. I may add, it is not for want of looking. Healthcare dollars have been spent in procedures, tests and consults, all with no fruit. In both cases however, each patient has something they have done that they seem guilty about. They don't say they feel guilty. But their body language, the looking down, the averting the gaze, the downturning of the corners of their mouth, the sudden change of expression all say it.

There are numerous stories in literature about guilt affecting peopel in different ways, including symptoms of physical illness. Is this what is wrong here?

I have another patient who was abused as a child and is dealing with multiple phantom pains. I sometimes wonder if forgiveness is the 'cure' rather than the years of continued pain medications and periodic absences from work with physical therapy to achieve recovery.

I shall not leave myself out of this equation: I have guilt too. At the end of an exhausting day of planned and unplanned clinical encounters, phone calls, nurse notes, impromptu meetings with colleagues, residents, allied health providers and teaching, I am spent. I leave my office guiltily, leaving a desktop full of notes to be dictated, phone calls to be returned, requests from colleagues, students and residents for this or that -- things I am too tired to do. Did I do right by my patients that day? What about the one that left frustrated because I was running late and she couldn't wait anymore? Did I miss something? Did I miss the right decision in sending this one home? Should I not have admitted that one?

Guilt.

Is treating this root of medical problems within the scope of my practice? Should it be?

Discovering primary care...

Why don't medical students want to go into primary care? Why do even primary care residents want to get out, taking routes such as fellowships, hospitalists positions, academics, even nonclinical jobs?

Perhaps it has to do with the student's experience of primary care. It is incomplete. It is a series of office visits with patients you may never see again. You get to make a diagnosis, fill out a follow-up medication and move on to the next patient, normally never seeing that patient again.

Well, I am in primary care. I think I am beginning to understand the joy of primary care.

Last week, I injected a painful hip (trochanteric bursitis), removed a small pebble from a child's nostril, aspirated a ganglion cyst, met a patient cheerful after beginning an anti-depressant, celebrated a new addition to the family of a little girl I have cared for since residency and got an 87 year old to walk again after I took fluid off his knee and injected it with steroids. Of course, the 87-year old was back the next with an even more swollen knee (he felt so good after the first fluid removal that he went home and got on his treadmill to catch up with exercise after all this time of being immobile).

They say that if you've suffered through a traumatic experience together, like fought in a war alongside someone or being involved in a life-or-death encounter, you form a special bond with that person. Well, bonds are being formed all over the place.

Last week, I was a dermatologist, a cardiologist, a nephrologist, an orthopedist, an endocrinologist and a psychiatrist, sometimes all in the same day. I love it!

Make hay while the sun shines...

I love Peds acute care -- you never know what you're going to get (to borrow a phrase from Forest Gump).

There was an adolescent female in the room with her mother. Her ear had been feeling full and her hearing wasn't so good from that ear. With frustration, the mother and daughter mentioned that they had been seen 2-3 times now and it wasn't getting better. One diagnosis offered was swimmer's ear. The funny thing was that she had not been swimming. I asked her what she had been doing. Well, it was summer in Wisconsin and like many farm hands, she had been making hay all summer. I looked in the ear and saw something I had never seen before: it looks white and black and cottony. I got a sample and sent it to the lab, but I thought I knew what she had and gave her a prescription.

When we called her a couple of days later, she was feeling much better and almost back to normal. The lab studies confirmed the diagnosis: Aspergillus niger.

She had fungus growing in her ear. How might this have happened? During my exam, I noted that her hair was damp and there were pieces of hay stuck in. The damp, golden curls hung over the ear. I'm guessing the warm, damp weather of summer, the fungus in the hay she was making and the environment in her auditory canal probably created the "perfect storm" for the infection. Onychomycosis -- my first.

Paternalism, paternalistic and empathy

I have several young woman in my practice. Well, I'm a Med-Peds doc so I have patients of all ages in my practice.

In the interaction between an adult and a child, paternalism seems quite natural. In medical school, we were warned against paternalism: defined in medical ethics as "A policy or practice of treating or governing people in a fatherly manner, especially by providing for their needs without giving them rights or responsibilities." Appropriately warned, physicians try to walk the fine line between the patient's "beneficience" and "autonomy".

When a 20-something young lady refused the HPV vaccine, tells me that she smokes while on birth control and has had at least 4 sexual partners in the past year, and does not use condoms every time, the 'father' in me wants to break out of the white coat and speak to her as I would if she were my child. After all, I internally reflect, from the perspective of the age difference between us, I could have had a daughter as old as her.

Lest you think there's something psychosexual about this, I feel the same way when my 20-something young man with Crohn's disease and a colectomy tells me one day before he is due to go to college that he has been having some abdominal pain and fatigue. The father in me once again wants to leap across the invisible waves to his cell phone as I'm trying to leave a message to him far away to tell him that his hemoglobin is low and he needs iron supplements and to see someone locally soon.

Okay! (deep breath).

These are adults (technically, at least), with their autonomy and I must not be paternalistic... I must not be paternalistic... I must not be paternalistic... I must...

What does your doctor mean to you?

Dr. F came out of the patient's room to get me. It was a busy afternoon in the clinic and we were all in the middle of seeing our own patients. He wanted me to come and meet one of his patients.

Dr. F leaves our clinic in about a month. He is moving back to the coast to be closer to family. He has been here about 13 years. He did his residency here and is now the director of that same residency program. He is also the head of our department. As part of his last month's activities and in between trips to the coast to find a home, nail the job down and such, he is having to tell his patients that he can no longer be their doctor. He had spoken to me about this particular patient -- someone he wanted me to take over the care of after he left.

I entered the room to find a tearful, crying 50-something year old female. I asked her why she was crying and from her wheelchair she reached out to Dr. F and said, "I'm losing my best friend!"

I think both Dr. F and me fought to maintain composure in the presence of her emotional expression of what Dr. F meant to her. She held onto him for a few moments, tears flowing freely down her face.

This is what Dr. F meant to her. She told me that they shared a history together. He had told me earlier of her close encounters with death, debilitating disease and the march of chronic disease in her life through the years.

Over 13 years, relationships between doctors and their patients are forged in the therapeutic alliance for their health and wellbeing. This continuity, this partnership and ultimately, this friendship is what Dr. F and this patient have. This is primary care.

Biting your lip...

Kind of getting into the swing of things: several days of seeing patients in my clinic, mornings of acute care in Peds, urgent care last evening. Interesting how one evolves after residency. When I see a patient, I'm sometimes torn between: did I work this up enough? Did I do too much testing? Should I have sent this one home or watched them in the hospital? Yesterday a 16 year old football player came in with a dislocated finger. I never set one of those in residency. I looked it up in a text and was all set to numb up the finger with a finger block. I got pre-reduction x-rays that confirmed the finger was dislocated. Then, I asked one of the other docs in urgent care that night -- a family physician with more years of experience if he had done one of these before. He came into the room with me and while talking to the boy yanked on his finger and set it. No pain medicine. He didn't think we should get post-xrays. I thought about the difference in comfort levels we bought had at different stages of our careers. I would have done it, but first numbed up the finger, then set it, then got post xrays, in short, spent more healthcare money and been more cautious. Some cases I think that if I was more experienced I would make the call with fewer tests. Other cases, I wonder if that is necessarily the right thing to do. Work in progress...

The Boards...

Years ago, a physician told me "If you're going to be a doctor, I hope you love studying..."

Well, residency is over. The reading, of course, never ends... and neither should it. There are always new things to learn: new guidelines, new studies, new vaccines and new diseases. What many didn't count on though, was exams! Besides the inservice exams we do every year in residency (and in Med-Peds, because we are doing 2 specialties, we get to do two of these each year), there are the Boards.

After residency in Internal Medicine, graduating residents get to take the internal medicine board exams, held by the American Board of Internal Medicine. It is an all-day computer exam, going from 8:00 to 6:00 with 240 questions set in blocks of 2 hours each (60 questions to a block, so 2 minutes per question). If you pass this (pass rates have been of the order of 91 - 92% with roughly 7,100 taking it every year), you are certified as a diplomate of the Board of Internal Medicine -- a "board-certified" internist. This is the initial certification. One has to re-certify every 10 years. Sounds like fun, doesn't it?

It's amazing how there's a little cottage-industry that is spawned by the many exams in medicine. There are review courses, study guides, books, DVDs, CDs, MP3s... you name it.Every exam (the USMLEs, the Boards in each specialty) has its own little industry. While no-one can legally tell you what'll be on the boards, you hear a lot of "they're bound to ask you this, or that.

Well, I've been through yet another exam trauma -- the whole ritual of preparation angst, pre-exam anxiety, exhaustion and finally relief. I took the exam on Thursday this past week, so I 'blew off' this weekend (didn't do anything meaningful).

Results come in 3 months.

Oh, did I mention, that because I'm Med-Peds, I have the Pediatrics Board exam to look forward to. I plan to do that next year, but I'll start studying now. Fun, fun, fun!

The first day...er.. first 2 weeks

I had meant to write about my first day in the job as a Med-Peds physician. That was July 27th. It is August 16th as I sit down to write this entry. The first day is a bit of blur, so I'll write about the first 2 weeks instead.

I remember that my first day had one no-show -- a bit anti-climactic. However, there were enough patients to keep me busy, mostly new patients who came to establish care. In these past 2 weeks, I have had a lot of adults coming into establish care and get an annual physical. Similarly, there have been a lot of kids who came for well-child visits and sports physicals. After the first 20 or so, I wanted to see a sick person! I enjoyed the freedom of seeing patients on my own. In the first couple of three visits, I would come out of the room, look for my staff, remember I was it and go back in to finish the visit. Even at the end of the second week, I still had to catch myself dictating "this is resident physician Vijay Aswani dictating..."

The first Peds clinic call was exciting. I was nervous about whether I would be able to keep up with the flow of patients. It was fun! I did end up admitting one 12 year old. My last case of the call morning was a little 2 year old with nursemaids elbow. I was able to click it back into place in seconds.The mother was suitably impressed. This is one of the few things in pediatric medicine where the fix is instantaneous. I was grateful for that case in my first day.

I staffed residents for the first time day before yesterday (the last day of my first 2 weeks). I supervized a resident tapping a left knee effusion that I had seen the day before and saved for this clinic. Everything went flawlessly. The patient felt no pain and we took off more fluid that I can remember taking off a knee.

All in all, I am feeling more at ease in my new job: building new patient relationships, taking care of patients and doing a variety of things with both adults and kids -- what a Med-Peds practice should be. Some highlights were: diagnosing my first case of diabetes mellitus type 2, tapping a knee effusion, setting a nursemaid's elbow, parotiditis, atrial fibrillation, managing blood med side-effectsd (hyperkalemia), performing a pelvic exam on a first time patient... the list goes on.

I have the internal Medicine board exams in about 11 days. Scary. Trying to study while practicing in these early days is hard: almost every patient is a new one that I need to get to know before I can go faster in my visits. Right now, each office visit is 30 minutes and each physical is an hour. I hear that that will change to 20 and 40 minutes respectively, within a month or so. Got to get faster.

My only beef is that I wish I had more time to think about some of the cases. If I could think, read and consider before having to 'move on to the next case', I would probably order fewer tests and maybe get to the answer faster in some cases and get to answer in some cases. Perhaps this will improve with time as I become faster.

Onward and forward to another week...

It's here...

The time has finally come. Residency is over. The post-residency break is over. This Monday, August 3, 2009 will my first working day as a full-fledged physician... after all these years. This past week I was involved in orientation. Although I pretty much know my way around this clinic and hospital, having been a resident here itself, there were still things I needed to learn and being hired as a physician involves some different steps than being hired as a resident.

My fellow orientees were a young dentist fresh out of dental school, a family practice doc fresh out of residency, a research scientist moving to our Research Foundation from Houston, TX where he was faculty, a neurosurgeon, fresh out of fellowship training and a bariatric surgeon. Quite a bunch! It was fun to hang out with these guys who are in the same boat as me: starting their careers as physicians at the Marshfield Clinic.

During the week, I was also able to tour the faclities at the Med-Peds department where I'll be working. I have my own office, with my name on the door. I have my own medical assistant. Monday is a fairly busy first day with 4 patients in the morning and 4 in the afternoon. I know. It doesn't sound like much. But it will be the first time I am seeing a patient in clinic without having to staff it with an attending. I dictate the note under my own signature, not under the supervision of someone else. I don't have to say "seen, examined and discussed with Dr.---" like I'v e done for the past 4 years.

I'm excited and scared. Excited to begin. Scared because I don't want to miss anything. No more is there anyone looking over my shoulder, making sure I haven't missed anything or that I'm not barking up the wrong tree.

Of course, life is not fancy free. I have the Internal Medicine board exams coming up on August 27 and there's a LOT of studying to be done for that (and not enough time).

All told though, I'm looking forward to my real working day and week.

Camp Angel

This weekend (Friday, July 10 to Sunday July 12, 2009), I was privileged to be at the Camp Angel summer camp. This is a summer camp run for children between the ages of 8 and 12 years old, that come from families touched by cancer. These kids have a sibling, parent or grandparent that has or has had cancer. The purpose of the camp is to provide them an opportunity to get away from all that 'heavy stuff' and hang out with kids who have experienced similar situations and just have fun.

The camp is one of several run by the non-profit organization Angel on my shoulder, formed by Lolly Rose (shown standing behind Mr. Chuck in the picture) after she lost her husband to cancer and saw the effect it had on her grandchild. You can learn more about this organization and its camps and other activities at http://www.angelonmyshoulder.org/.

I really enjoyed the experience. Ostensibly, I was asked if I would like to come and be the camp doctor. Jonathon Forncrook, my program director, had been going for the past 10 years and this was to be his last camp before he moves away to California. I had never been to a summer camp in the U.S. before and I was curious on several levels: how are summer camps run here? how are they different from back home? what kinds of medical care is involved at a camp? what makes a camp for kids with cancer in the family different from any other summer camp?

We left on a Friday morning and made the two and half hour drive up to Camp Luther in Three Lakes, WI. Once we arrived, it was only about half an hour before the bus bringing the campers -- 42 kids in all, would arrive. The groups were divided into 2 girl teams (the bunnies and the foxes) and two boys teams (wolves and bears). Each team had several counselors assigned to them. Each team stayed in a different camp -- the fort, the towers, the treehouse and pioneer city (wagons). Each of these camp sites were creatively constructed and looked like loads of fun.

We had a pizza party that night preceded by some icebreaking events. The Northern Lights Harley biking club came over with their bikes and allowed the kids to get pictures. The next day was spent mostly in water activities, with a ride on a pirate ship, run by the Strauss family in Eagle River, cayaking, fishing, swimming, tubing and such. There were crafts (face painting, rock painting, hair braiding and other such stuff) and a special DJ in th evening for a dance.

Medically, it was quite uneventful (thankfully): just the usual scrapes, bruises, some blocked ears after swimming and some sensitive stomachs. Homesickness was admirably managed by the counselors.

This was my first camp experience and I doubt it will be my last. I plan to go back next year. This organization also has a really crazy event called the polar plunge (read about it on their web site). I'm thinking of doing it!

The only sad event was that this was Jon Forncrook's last camp, after 10 years of service. From the sentiments he stirred up among the kids and volunteers, he will be missed.

Here it is...

I got my residency completion certificate today. It is a grand thing, already framed. Here it is -- the testimony to 4 years of residency

Physician, heal thyself!

It is a little over a week since my residency 'ended' (my last working day was July 1, but I am still a resident on the books until July 12). Last night was the first night that I think I slept right through. Strangely, during the nights before that, I kept waking up every couple of hours. My body seems to finally be making peace with the fact that I shall be sleeping most every night!

My days are spent studying for boards and ... well, I get ahead of myself.

Now that residency is over, I did an assessment of my lifestyle with the help of my brother with whom I had lively discussions on the matter during my family's visit for graduation. The results were not good: at a BMI of 28.1, I am overweight and with a resting pulse of 80, clearly not fit.

I guess it is time to make some life changes (since completing residency set that in motion). I have pledged myself to regular exercise, healthier eating and weight loss. I also made appointments with my doctor for a complete physical and the dentist for cleaning and treatment. Studying for the internal medicine boards (my occupation these days) has only re-inforced to me that I am overdue for these changes.

However, having recognized the problem and put a plan into place (and kept to it for the 1st 2 weeks now), I am hopefully on the way to a healthier me and to heeding the command of the old adage: physician, heal thyself!

Can't sleep

Yesterday was my last day in residency. I was on call during that night so I came off at 6:00 am this morning. After attending a meeting and shopping for ingredients for breakfast, I came home. Since I hadn't slept in 30 hours (for the last time as a resident), my eyes drooped as I ate lunch and I went to sleep by about 3 pm.

So here I am. It's 2 am and I am now wide awake. Whaaa? Why can't I sleep? I am not on call. I am done. I have about 3 weeks off before I start my new job as an Attending in Med-Peds at the Clinic. I guess my sleep cycle is screwed up from the call. It'll sort itself out soon enough. It usually does.

Still.

It's 2 am in the morning and I can't sleep. I called the PICU and the Peds floor to get updates on the little girl I admitted last night. We don't know why see siezed, but she's better. Oh well, I guess that's what counts.

I know it's wierd that I called the hospital, but I can't sleep and I was curious. How wierd is that?

The last day of residency

June 30, 2009: this was the last day of work in my residency in Med-Peds.

I began residency on July 13, 2005. Technically, that means I should work until July 12, 2009 to complete the four year program. However, I saved up some vacation time during my last time so that I could end on June 30. During the month of June, I was doing a rotation in Pediatric Hematology-Oncology.

Something special happened on this morning: as I drove into work, I saw a beautiful complete rainbow arc across the sky. It was a complete rainbow from horizon to horizon. One end of it dipped into the horizon just at the location of the Marshfield Clinic. Okay, I'm not going to read anything into this, but it was really cool and special, being my last day of residency and all. :-)

My last day began with Morning Report in Pediatrics. The ward team presented a case of a 4-year old with a rash and fever and we talked about rashes. It was nostalgic to be sitting there as a resident for the last time.

The morning was spent rounding on the 2 Heme-Onc patients we had. I then had an exit quiz in my attending's office. That went well. Interesting how one learns during these rotations. It's like when you look at yourself in a mirror everyday and can't see the changes accomulating daily. Someone else, seeing you after a period sees them immediately. The quiz gave me perspective on my learning in Heme-Onc.

After lunch, I sat down with the program coordinator and went through the exit list. A day before, I had got to hand over my resident's pager. However, since I am staying on here, it was simply replaced by an identical appearing but newer pager. Kind of an anti-climax: I had heard stories of people being so grateful to finally hand off the pager that had 'killed' many a night of sleep. Somehow, I never felt that way. Each page was an invitation to an adventure, a thrill.

Instead of the exit interview being a simple handing over of everything, it was more like a replacing of 'resident' stuff with 'attending' stuff.

The afternoon was not so busy. At 4:30 pm I went to the Pediatric ICU to get report on the patients I would care for during the night -- my last night on call as a resident. There were jokes about how after midnight, I might switch off my pager or simply tell the caller to page the 'resident' instead of me.

My last night on call was wonderful. I ordered pizza for everyone. Instead of wishing for a 'quiet' night, I actually wanted cases. My wish was granted. It was quite busy, with different, interesting admissions and call issues. I admitted a 20-month old female who had had 5 seizures that day. Her parents were both family practice docs. At 3 am in the morning, I did a spinal tap on her. My PICU attending made me a little plaque to wear on my back for the night that said 'After midnight, the bucks stops here!'.

It was poignant to spend my last day in residency on call. When I signed out at 6 am the next morning, I was officially done. The ward team to whom I had signed out were busy sorting out the admissions of the night. Since it was the start of a new month, it was a new team and you could tell they were a little nervous. Everyone had new roles: there was a fresh intern at the table -- his first day in residency; the second resident at the table was now a 'senior' resident -- he was an intern till yesterday, and the Ward Chief was starting his first day as a third and final year Peds resident and Chief Resident at the table. The PICU resident was busy gathering numbers in anticipation of morning rounds. Until yesterday, she too was an intern, and now she was a senior resident and the PICU resident for the month. And me, I was done.

I walked away from a busy floor of activity, everyone trying to step into their new roles, while attempting to provide continuity of care to our precious little patients. Life, as usual, goes on.

The retired physician

I was in Wal-Mart the other day, when I saw a curious, elderly gentleman of East Indian descent looking at me. I smiled back. He asked me whether I worked at the Clinic and I said yes.

We started talking.

He had joined the clinic in 1967 and specialized as an anesthesiologist in doing cases in pediatrics and cardiothoracic surgery. Before long, he was reminiscing and talking about old cases. His wife spied us from across a few aisles and came up. She introduced herself.

It became clear that there was some element of senile dementia. From his wife's 'take-charge' attitude (she locked arms with him and began to lead him out where apparently, her sister had the car loaded with their purchases and waiting), it seemed like she was the primary caregiver. As she led/almost pushed him along, I could see the misty look in his eyes, as he was being led off almost mid-sentence....

Curious thing. We'll all get old and senile dementia increases with age. From the stories I heard, this was a successfull and trailblazing anesthesiologist with many 'firsts' in his career. Now he was a retiree who needed looking after.

This reminded me of a more tragic case: I was doing an emergency room rotation that month when the code pager went off early that morning. I ran behind the ER doc as we came to the ward floor. The patient was a retired physician who had come in for an elective prostrate procedure. In the early hours of the morning, his heart had stopped and when the nurses' aide came in to do vitals at about 6 am, he was pulseless with no respirations. We ran the code for about 30 minutes when it became increasingly clear that this frail but hitherto functioning individual was not coming back.

As the ER doc called his wife to give her the bad news, I reflected on the situation. I imagined that this physician had probably done CPR, and ran codes on others before, perhaps even some physicians. Here he was on the other end of that scenario, for the final time. A life spent in medicine and ended in a medical scenario.

As physicians, growing old, becoming senile, being on the receiving end of emergency medical care -- all this seems scary. And yet, it is our future.

Graduation week

Every residency has a graduation day. Ours is called Residents & Fellows Recognition Evening. It was the 32nd one in the history of the Marshfield Clinic and Saint Joseph's Hospital. It was heald on Friday, June 12, 2009.

To attend this historic landmark event in the life of their loved one, my mother, brother, his wife and son came all the way from Panama. I was excited to have them. I took a week of vacation from June 6 to June 14 to host them here. We spent 5 days in Chicago and 2 in Marshfield. I guess, knowing how small Marshfield is, I thought they would enjoy Chicago more. It was a special time of togetherness, laughter, food and fun.

On June 11, my program director hosted a barbeque at his house in my honor. I was so embarrassed by the attention. Nevertheless, my family were touched by the honor. I received a Chief Resident award from him. My mother wept with joy and feeling. While I am embarrassed by attention and awards, I could not help but feel grateful for the recognition if it brought joy to mother's heart.

I truly believe that all our achievements are not ours alone. As one scientist said, we stand on the shoulders of giants. My family has supported me with much sacrifice and I am indebted to them.

A few weeks earlier, my bacteriophage research won me the Nikolai Award for the best Resident Research of the year.

At the 'graduation' evening, we had a great time. I was touched to see so many of our interns show up to support us on this evening. Belonging to the Med-Peds program, mine was the first name announced in the graduation. I picked up a white envelope to applause and returned to our table. I smiled when I saw what was inside: a red sheet of paper with "You may pick up your certification of completion on the last day of your residency" written on it. The ceremony is over, now get back to work :-)

The last event of the evening was an award given by the transitional year residents to a resident who has contributed the most to their medical education. I was pleasantly and genuinely surprised to win this award. I did not expect it, especially after all the glowing things that the resident said before she announced the winner's name. My family was once again proud and me embarrassed.

I am honestly happy that all the ceremony is over and I can get back to the work I enjoy so much in some measure of anonymity. In truth, when people are sick and hurting, awards seem a little crass. My 'award' is the saving of my patients. I pray for that award daily.

Then and Now...

It's June, my final month of residency! Last night was my 4th last call of residency (not that I'm counting or anything...). Things have changed so much since my intern year: I used to have butterflies in my stomach on call nights -- anxious and afraid of what might come up and whether I'd be able to handle it. I was 'afraid' of admissions and codes. Like others on the floor in wards (nurses, aides, unit clerks) I would say "Don't say the 'Q' word (quiet) because we woouldn't want to 'jinx' it and get a lot of admissions, codes or pts in crisis. Now though, I look forward to call night to see what we'll get. I'm not afraid or anxious, although I maintain a healthy respect for the unknown in medicine.

At 3 am I got a call from a 3rd year resident who was on call in the CCU (Critical Care Unit). He had admitted an 80-something year old with severe hypotension. The patient was already on pressors through a peripheral IV and needed a central line. He wondered if I could come and assist. Sleep evaporated and I walked over with a bounce in my step. I was on call for Pediatrics but nothing was happening, so I looked forward to actually doing something that night.

During the first attempt at placing the line, the patient became unresponsive. We called a code, did chest compressions and got him back. The line was placed and an hour later I was back in Peds. In my intern days, this would have pumped me with adrenalin. Not so much last night. It was 'fun'. I know I need to guard against becoming complacent or over-confident. No one knows everything and these are literally life and death situations. But I feel ready for the next step in medicine. I am done with my training at the end of this month and looking forward to the future.

Foreign body (in more ways than one)

This is a story from a little while back. We admitted a 17 year old female with abdominal pain. As part of the admission tests, we got an abdominal x-ray (a KUB). This is what it looked like:

When we saw the x-ray, we all wondered what those radio-opaque circular objects were. During morning rounds, we stood around the computer screen wondering if she might have inadvertently (or purposely) swallowed something, or were they foreign bodies or calcium crystals or pigments from a tatoo. Finally, since this was a patient I had admitted, I was elected to go into the room and ask her. As diplomatically as I could, I asked our little miss if there was something she might want to tell us. I told her I needed to examine her lower back. She dutifully turned onto her stomach and let me pull me the sheets down. I was all prepared to find a tatoo of some sort on her lower back skin but what I saw stopped me in my tracks and instantly provided the answer to our radiologic dilemma. I turned beet red as I saw a pretty pink thong with artificial gems studded in the pattern of a butterfuly on the triangular piece of thong. My colleagues all had a good laugh at me because I was obviously embarrassed by my finding. We all had an even bigger laugh when the radiologist's official read of the x-ray came back as:

"there are multiple radiopaque densities projected in the central aspect of the lower pelvis, probably at the rectosigmoid junction. I presume that this represents residua from suppository or previously-injected material."

Should we tell him?

Tortured thoughts....

Perhaps my turn of thoughts is because I am still recovering in some form from a recent illness.

Still...

Last night, I sat at the nurses station on Peds trying to finish some paperwork. From down the hall, I heard the sound of a child wailing and crying. I could not bear it. I asked who this was and was told that this neurodevelopmentally delayed 11 year old cries unconsoleable like this every night. Incredulous, I walked determined down the corridor to see who this patient was and why she cried like this.

LW is 11 years old. She was born to a mother who drank during her pregnancy. After a period of failing to meet developmental milestones and some physical and mental signs of cerebral palsy, she was diagnosed as having a 'chromosome 8 inversion' abnormality and consequent severe cognitive impairment. In my years as a scientist, cheering excitedly and participating in the revolutionary sequencing of DNA and the human genome, I had never envisioned the face I saw last night. There is no way to fix a 'chromosome 8 inversion'. It occurs in every one of the billions of cell in this little girl's body. It is a life sentence. The ramifications and effects are not completely known. Few people have this.

Needless to say, LW is in a foster home. Not many individuals have the emotional and physical resources to care for such children. They are high risk for abuse and neglect. Sitting in her room, watching her wail and cry, frustration and anger burned within me. Why was she crying? How could I stop it? What was I missing?

Her nurse and me checked her daiper, repositioned her, tried to soothe her, turned the tv on and then off, turned the lights on then off, tried everything we could think of. No effect. I tried a mild sedative, then another -- no effect. The crying continued. I sat at her bedside, making eye contact, trying to look into the window of her soul, praying for insight, a connection, a solution. I can only imagine what parents and caregivers must go through, year after year, night after night. I searched the literature on sleep and behavior disorders among those with cerebral palsy and neurodegenerative disorders. I found lots of articles that talk about the toll it takes on caregivers, things tried and failed. I read her medical records and found that this problem had been going on for a while and several solutions were tried unsuccessfully.

This patient came to us with a horrible wound at the back of her head and neck. We are unsure what it is, how it got there and exactly how to make it better. At about 4 am in the morning, I thought I would try giving her something for pain. A little bit of morphine put her into much needed sleep! There was no aha moment. Maybe this was pain. Maybe she was exhausted. Maybe she was just done for the night. Who knows? But she slept.

What does the wailing and crying of someone with 'severe cognitive impairment' mean? Is it pain? Is it just the behavior of a disorganized and disregulated brain that cannot calm itself? The patient cannot communicate verbally and does not appear to follow verbal commands, so who knows? As I sat beside her trying to calm her and soothe her, I felt like I was listening to a scrambled brain cry out. In a dark moment of frustration and despair, I found myself thinking, " why do we prolong such a life? Are we really making any difference with what we do?" Dark, scary thoughts that come not from impatience with the patient, but from a mourning heart and mind that cannot think of an answer to make the suffering better.

We live to fight another day. It is morning again. I hear that she slept for a couple of hours and is up and quieted down... for now. My heart is still in knots. I hear the sound of a scrambled brain in a spastic body crying and I don't know what to do. I am driven to find answers. I love what I do. I am haunted by what I do. I want to be better, smarter, wiser.

Sickness

It was Monday, the first day of the work week. I had feeling unwell all weekend and dragged myself into work Monday. After a busy clinic, I was feeling really run down. My nose dripped, my eyes were red and itchy and my body ached. As the night wore on, I found myself getting sicker. Fortunately, it is near the end of the academic year and the intern I was on call with was more than willing, and able to step up to the plate and field most of the calls. Still, as I lay on the couch in the residents' room feeling miserable and useless, I was overcome by guilt at leaving him alone to 'do it all'. I was afraid to go into the Pediatric ICU or the Oncology sections where our sickest patients with the most compromised immune systems lay, lest I infect them with whatever I had.

The next afternoon, after returning home, I felt I was getting worse. I agonized over the decision: should I go in to work or beg off sick. Healthcare workers are a strange breed. When we are sick, we feel guilt and dismay at not showing up for our patients and leaving our overworked and tired colleagues to take up the slack. And yet, who knows more the risks of exposing the sick to more sources of infection from the ones they come to for help and care?

I called in sick. I did present to the Urgent Care and was dutifully swabbed for swine flu, and the two common forms of seasonal flu. Fortunately, I was negative for all three. Fortified by this knowledge, I was able to return to work last night -- no runny nose, a minimum cough and a healing body. Perhaps one of the benefits of working with sickness is the constant exposure and 'education' our immune systems get, and the ability to consequently heal a little faster.

A colleague took my night of call. I shall have to 'pay her back' by taking her call in the future sometime. While I would not let such a good deed unnoticed or want her to gratuitously do my work, I do feel bad that our system does not allow for sickness. Maybe it does, but there is no equitable trade. I'm better and back on the other side of the sick bed, where I belong. By the way, those swabs hurt! OUCH! I guess I know how my patients feel when I order these tests...

A strange night of call in Pediatrics - Part 2

We were only getting started.

We received a 6-month old little girl as a transfer from another hospital in a nearby town. While the story was not clear, apparently, her mother and 2 and 3 year old siblings were all dead of gunshots to the head. Her father sat dazed in their home, with the furnace running full and the vents shut off. There was a strong smell of gasoline and natural gas in the home as well as on the baby. Police rescued the little girl and seeing how she smelt of gas -- it came from her breath as well -- arranged for her transfer to us. The transferring physicians wanted her closer to access to a Pediatric ICU if she needed it. Ours is about 50 feet walking distance from our wards. A urine drug screen was positive for sedatives. The little girl was screaming, agitated and wouldn't take a bottle initially.

We activated the CAN (Child Abuse and Neglect) workup.

There was a lull from 1 am to 5 am (no admissions). At 5:45 am we received a little girl with a right eye swollen shut and some steristrips holding lacerated skin together at her right eyebrow. The family had had a picnic in the park the day before and encountered a dog without tags. He seemed friendly enough and came and sat under their picnic table. During the course of the picnic, the family made friends with the dog. Feeling sorry that no owner was in sight and no identifying tags were evident, they called the Humane Society to come and 'rescue' the homeless animal. A Society van was pulling up to the edge of the park. The little girl went to pet the dog goodbye and he bit her on the face, narrowly missing the eye but tearing open the skin of the eyebrow.

The rabies status of the dog is unknown. The girl became sick with a fever several hours later. A bite to the head from a dog of questionable rabies history, now showing signs of systemic illness, fever and increasing swelling and redness closing off the eye is cause for concern. I wrote admit orders and quickly examined the girl before rushing to make the 6:00 am signout to the incoming team.

What a night!

A strange night of call in Pediatrics - Part 1

I was Ward Chief in Pediatrics Wards last month. That meant that I did not have any night or weekends call (I know, great, isn't it?). My last day on service, I switched call with a colleague who desperately needed the time off. What a night it would prove to be...

1. We had a young teenager on the service that had transferred out of the Pediatric ICU just that morning. She had been admitted for a suicide attempt (not her first). She had ingested some sedatives and ADHD meds and we were monitoring her for side-effects, with the intention to transfer her to a mental health facility in the morning. She had been 'chaptered' -- meaning that a sheriff's department had activated Chapter 51 of Wisconsin state law: detention against one's will for declaring intent to harm oneself or another. Towards evening, she became irritable, wanting to do things she was not allowed to -- these restrictions being part of a suicide watch. The 'sitter' (person who sits in the room and watches the patient who is on suicide precautions) called for help. The patient had tried to wrap the curtain in the room around her neck and shouted "I want to die!". Nursing responded. Apparently, the patient had a history of explosive rage disorder -- something we were not familiar with. Unfortunately, we were about to find out. She 'lost it' and began screaming at the top of her lungs. She attempted to leave the room. Her nurse attempted to restrain her physically and was bitten, hit and kicked. There was pandemonium. I rushed in.

Okay, time-out.

Medically, here's the situation. She had ingested an amphetamine and a benzodiazapine (to those of you to whom this means anything). We were monitoring for side-effects of the ingestion -- heart arrythmias, respiratory distress, altered mental status. I had to make a decision: am I going to give Haldol (drug that could cause or summated with the previously ingested meds, precipitate a life-threatening cardiac arrythmia) or not?

Back to the scene.

I added my weight (literally) to the bodies trying to physically restrain this large teenage (who weighed more than some of the adults in the room). I made my decision: I called for Haldol and repeated the dose three times, including adding a sedative as well. Since the patient had chewed off her IV, all these meds were given intramuscularly. The needles did not add to the patient's state.

Within minutes, the patient was quietly asleep. No cardiac arrhythmias, no respiratory depression. Just calm. Our nurse was sent to the ER for antibiotics. We were all rattled.

Peds is usually a lovely place to be: there is a little Winnie the Pooh forest, and pictures of doggies, brightly colored beach balls, flowers and toys painted on the walls. Most of our patients are cute, cuddly and make you smile.

Fearful and tearful, mom stood behind the scenes. Grandma stood next to her with fire in her eyes. There would be long conversations with them afterward.

Brain turns to mush

The hardest part of Peds to me is when a child suffers an injury or gets a chronic disease that changes their lives forever. A permanent injury or chronic disease is a tragedy to anyone. The sad fact that it happens early in life makes it more tragic.

We have been caring for a previously functional, to most accounts, normal, 6-year old girl. Over the course of a few short weeks, she has transformed from a talkative 1st grader to a hemiplegic (one-sided paralysis), non-verbal body in a bed. Her eyes open and she grunts and cries when you approach her. She does not recognize her parents or grandparents.

What happened?

The truth: we don't know for sure. It has not been for lack of trying to find out. Last week, we went the final mile and did a brain biopsy -- understandably a last resort diagnostic. The neurosurgeon who performed the procedure reported dismally to the family that the consistency of the brain indicated breakdown and the sample he obtained may not have been sufficient.

After considering and rejecting multiple hypothesis, we now believe that this a form of post-influenza encephalitis -- a rare complication of the flu (which she had in early March).

It is our best guess that the changes that have occurred in this little girl are for the most part irreversible. I have no more to say in this case: the rest cannot be put in words.

Walking from room to room on a Pediatric floor in a hospital reminds me of that verse in the Bible: "Weep with those who weep and rejoice with those who rejoice."

Surfin' USA

Well, I'm back in Pediatrics for the final 4 months of my training. On call this weekend, I learned something new about American culture: car surfing. The trauma code pager went off and announced a 'Level II Peds trauma'. Gathering information from the field reports on this soon-to-arrive patient to our ER, I overheard a dictation describing the 'car surfing accident'.

Car surfing: what's that. A nurse nearby smiled and told me that there was 'car surfing' and 'car skurfing'. Apparently, (according to this local authority, anyway) car surfing is when you stand on the roof of a car while someone else drives. You then put your hands out in the air (allegedly, to steady yourself) to 'surf' the wind. Skurfing is when you're on a skateboard and hold onto a bumper or some other part of a car while it drives.

Back to our trauma. A 17-year old female had climbed onto the roof of the car and getting ready to stand up on it and 'surf'. Unfortunately, her boyfriend started the car in motion a moment too soon to her and she 'wasn't quite ready' and fell off. 'Fortunately', the only injury she suffered was a nondisplaced skull fracture.

There you have it: surfin' USA.

Apology to Plastic Surgeons...

I'm spending a couple of weeks rotating through plastic surgery. Okay, so you're wondering what a primary care doc is doing there? I want to hone my skills to perform office procedures and learn techniques that will help me when I do international medical work.

I confess: I felt a smug moral superiority to plastic surgeons. Sure, they make the big bucks, I believed, but they did so by taking medicine and turning it into a cosmetic shop to indulge the shallow whims and fancies of clients with money to burn. This is what I thought. I thought plastic surgery was all about tummy tucks, breasts (reduction, augmentation), nose jobs and such. And of course, it is about these things... but not all about them.

During the two weeks, I have seen reconstruction of wounds, repair of hand injuries, restoration of dignity and the crown of them all -- the repair of cleft lips. I apologize to plastic surgeons who are artists, creative surgeons and smart and skillful doctors who heal wounds and rebuild beauty and dignity.

In Memory of Miller Lite and other patients....

Okay. HIPAA forbids me from using names. However, with a name as common as Miller or Smith, I think I may be safe.

During my last 2 months of back-to-back internal medicine wards, our team took care of a wonderful, witty, very sick 70-something male with the name Miller. Mr. Miller had suffered a massive heart attack several months ago that ended up with him getting bypass surgery. Although he pulled through the heart problems okay (sort of), he never really bounced back. By the time he came to us from the nursing home where he was (still) recuperating, he had developed fluids in both lungs and had lost so much weight, he appeared pale and cachectic. With the graveyard humor that hids the pain that is unavoidable as one watches life ebb and patients die, I nicknamed him Miller Lite.

Over the 8 weeks that we were on the wards, Miller Lite from "let's keep fighting" to "I want to die". Miller Lite always had something funny to say to you when you went into his room. He never sounded bitter, critical, frustrated, although sometimes he sounded sad. He had one living child, a daughter he had raised practically by himself. It was touching to go back and forth between daughter and father and hear the exact same admonition:

"Things don't look good, do they. Well, be easy on (insert 'dad' or 'daughter'). I don't want him (her) to suffer!"

I don't think I will ever forget Miller Lite. He died almost within days of being moved from the medicine ward of the hospital to the Palliative Care unit.

It reminds me of another patient that died. Ms Mindy was a 50-something female with cognitive delay with a moppy disposition who had endured multiple abdominal surgeries and wasn't recovering. I was a third year medical student and it was my first surgery rotation. I was married at the time and once wistfully remarked to my attending after countless days in the hospital:

"I think I know more about when Ms Mindy last passed gas or had a bowel movement than I know about how things are with my wife or my family." We both laughed and then there was the awkward silence that comes after a sad truism has been uttered.

Taking care of patients is emotional business (this clinical distance is a myth) and with the long hours and years of training of medicine, is it any surprise that a number of your emotive experiences and memories become those of your patients?

The psychologist who lost his mind

I am spending the month in neurology. I got to spend a day working with a specialist in dementia. We saw a 73 year old male for a follow-up appointment. This gentleman was a Ph.D. psychologist by profession. It was moving to be a part of this encounter.

"Mr. J, I am sorry to inform you that I will not be able to support your application to the Department of Transportation to let you drive."

"That's... I can... why...."

Mr. J, I understand how frustrating this must be for you. You've probably had patients with Alzheimer's and might remember what this disease does..."

"I used to be.... I know! I... Alzheimer's... not fair..." and after a painful pause, 'frustating!

There is an irony in this encounter. The psychologist who measured the slipping away of memory is now in the 'driver's seat' of the very condition that will take him...literally... out of the driver's seat.

The IMGs

IMG stands for International Medical Graduate. In the U.S. medical system, it used to identify a physician who went to medical school outside the United States. A subset of this group is sometimes identified as FMGs (Foreign Medical Graduate) -- to distinguish 'Americans' who studied outside the United States from foreign nationals who did their medical training elsewhere (often their home country) and who have come to the United States to pursue residency and perhaps fellowship training and perhaps to stay on and practice in the U.S.

I am an IMG. In the eyes of some, IMGs are viewed as somehow being inferior in their training and abilities to practice medicine in the U.S. As I finish residency training, I want to highlight a few of the IMGs I know...

Dr. RD is from Sri Lanka. He went to medical school in St. Petersburgh in the former Soviet Union. After completing his medical training, he returned to his country and pursued post-graduate training as a surgeon. He then served in their army as an Army Surgeon. He saw 'action' in the civil war. He subsequently came to the U.S., trained in Internal Medicine in New York state, and is now a board-certified Hospitalist.

Dr. MS studied medicine in her native India. She went on to do post-graduate training in Obstetrics and Gynecology and practiced as an OB/GYN for several years thereafter in India and the Caribbean. She came to the U.S. and started a residency in Pediatrics and is now a fellow in Pediatric Neurology in Boston.

Dr. NG is also from India. After completing medical school and post-graduate training in Dermatology and Venerology, he went to the United Kingdom. He practiced as a House Office there and became certified as a Member of the Royal College of Physicians. He is completing his residency training in Internal Medicine now.

Innumerable others trained in India, Palestine, Austria, Russia, the Ukraine, Sudan as physicians, surgeons, anesthesiologists, Internists, Cardiologists, Ophthalmologists and came to the States to train again, often in other specialties because their specialty would not accept but the rare IMG. Others have served in wars in Bosnia, Kosovo, Darfur and the Congo. Some have studied Russian, Serbian, German and French to be able to study medicine. A few have worked at gas stations and convenience stores while studying for U.S. board exams to get into residency training. Some have done Masters and Doctorates in Public Health, Microbiology and other subjects in order to have a visa to interview and study for entry boards before residency.

When you meet these physicians, you will not hear these stories. There is no sense of entitlement or pride or sacrifice. You will not hear about the number of times they have started from scratch, been discriminated against, been judged or slighted, often by those with much less training and experience than they have. You will only see them try to fit in and do right by their patients, bringing to the doctor-patient encounter a world (pun intended) of experience.

As I have rubbed shoulders with these physicians in training and learned from their cross-training, international exposure to medicine and marveled at their multi-lingual and multi-cultural sensitivity and competency, I cannot help but feel that once again, the United States is gaining the best. The shame and modest reticience I felt in identifying myself as an IMG when I began residency is gone now.

I am an IMG.

Announcing my babies to the world!

Those of you who know me know I rant about bacteriophages. It has been a long four years of dreaming, many weekends and nights of labwork packed into the 'free' time of my residency, and here they are! These are two different species of bacteriophages isolated from the anterior nares of humans, being shown for the FIRST time ever! I believe no-one has ever reported the existence of these cute little fellows in the anterior nares of humans before. Of course, I shall be publishing soon.

Here they are infecting Staphylococci:

I told you I would find them. These are my babies and I am very proud of them. One day, little guys like these -- in some form -- will be the new antibiotics. Many thanks to all the great phage devotees out there who have helped...

Enjoy!

Morning Report Nostalgia

It was 8:05 am and nursing a plastic cup of chocolate chai (a specialty of the Cattails Cafe in the lobby of the Marshfield Clinic) I was one of many bodies sitting in Conference Room G next to the cafetaria in St. Joe's.

The funny thing about the last year of residency is the nostalgia of some of our rituals. While I listened as the presenting senior resident teased up with the case of the day, I looked around the room...

I could see a 3rd year medical student reading out of his red Pocket Medicine -- the eager learner, probably overwhelmed. I remember those days... trying to drink all the water coming out of a fire hose and feeling the panic as gushes of the water of knowledge slipped past me.

Further down the line sat.. or rather snoozed a second year resident in scrubs... no doubt the resident on call the night before -- the night float. The post-call haze is still a familiar sedative to my mind and promises to meet me the day after my next call night and that comes soon enough.

Further down sit some of the third years: one of them is a good friend who is nearing the end of her pregnancy. Just looking at her face reminds me of all the experiences we have shared: nights of call, codes, inservice exams, morning reports, co-presenting at meetings. I shall miss her as she heads off to Nevada for the next year. She has taken a hospitalists job. She has a three year old at home, a second one on the way and a husband working in Vegas.

Around the corner of the horseshoe arrangement of the joined tables sits one of our attendings. He adds questions and reminds us of a couple more diagnoses we should add to our differential as we think through what our mystery patient might have. I remember how intimated I was by him my first year. Now, we joke around. I still admire him but he is more human to me now.

As my eyes round the table, fixing in turn upon each person present -- medical student, intern, second year, third year resident, attending, I cannot help but feel a comfortable sense of family. These are my comrades with whom I have served: nights on call, racing down steps toward a Dr. 6 code, standing in an ER bay examing a patient and sitting tired in the cafetaria wolfing down a quick meal as our pagers go off. A pager goes off. The CCU intern gets up and walks towards the phone at the back of the room, others making room for her.

This is my family and I am misty eyed as I think my days doing this are numbered...

Time Crunch...

Sigh! It's been so long since I've written...
So much has happened...

Well, did I mention that with the beginning of my 4th year, I became the Chief Resident of my program?

During most of this year (academic year) I have agonized over:
1. Should I do a fellowship or look for a job?
2. Where is my place?

After soul-searching, I have abandoned my earlier plan to do an ID fellowship. Not to be arrogant, but with all the education I have, if nothing else, I should be able to learn outside of a structured curriculum. I love all of medicine, so I don't want to do a fellowship and narrow myself down to something. Perhaps what I will end up doing doesn't even come in a fellowship box.

Anyway, with that decision made, I began to look for jobs. I applied to mostly university programs and a couple of private clinics and hospitals with university affiliations. Although I have never dated, I get the feeling that these job hunting interviews were kind of like going out on first dates: everyone is formally dressed and showing off their best side and the whole event is somewhat orchestrated and pre-programmed.

I learned many things about the process and of course, myself in the process: promises are made that are not kept.

What I was looking for in my 'dream' job was the opportunity to:
1. Practice both medicine and pediatrics
2. Do so in an academic environment and,
3. Have the time, resources and opportunity to do research.
4. I was partial to places with existing infra-structure in international work since that is something I know that God has got for me in the future.

After travelling far and wide and having many fun experiences, I found my 'dream' job. It is right here at the Marshfield Clinic!

I am pleased to announce that come July 13 2009, I shall be the newest faculty member of the Marshfield Clinic Med-Peds department. Thank you, thank you.

I am setting up continued research collaboration with Sanjay Shukla's lab and my bacteriophage research. I shall look into getting an academic appointment from UW -- foundations for future research and teaching ventures.

The Suit

Okay, first, I apologize that I haven't written any blog entries in here for a while. So much has happened and is happening...

When I applied to the Marshfield Clinic for residency way back in October-ish, 2005, I was so excited when I received an invitation to interview. I remember packing my little bag and taking a flight from Oklahoma City to Madison. I had already reserved a car to drive from Madison to Marshfield. It was to be a big adventure, as I arrived in the United States and spent my first several months in Oklahoma City. This was my first big trip outside the state, my first residency interview and my first 'road trip'.

When I arrived in Madison, I discovered to my horror that my bag did not make it. I had packed my new suit and dress shoes in there. With a sunken heart, I drove the 2 hours up to Marshfield and was promised that my bag would arrive later that evening and someone would bring it up. My interview was scheduled for 7:30 am the following morning.

To cut a long story short, the bag was finally delivered at 7:30 am the following morning. I had spent a sleepless night on the phone with various cities trying to locate the lost luggage and find a way to get it to Marshfield. I arrived late for my interview in a slightly crumpled suit (no time to iron it out) and red-eyed from a sleepless night.

Of course, as you know from reading my blog, I got the residency position here, despite these difficulties. However, I learned a lesson: always carry your suit with you on the plane.

Well, last Thursday, I was scheduled to attend an interview at my own institution for a job as an Internal Medicine hospitalist (a long story, for another blog entry). I had taken my suit (the same one I had worn to my residency interview) to the cleaners to have the pants let out a bit (okay, so I've gained a little weight in four years).

Schedules being as busy as they are these days (story of my life), I went to the cleaners at 7:30 am on the morning of the interview to collect the pants. There was some snafu and they had not returned from alteration! Deja vu.

I went to the interview in a slightly older suit, sucking my stomach in (pants even tighter than the other one). As I walked, belly sucked in, into the hospital for the interview, I could not help but think how every time I interview at this clinic, there is a suit story. Oh well, another lesson learned...

The interview went fine, by the way.

"...You will die in 3 to 9 months"

I was taking care of a 66 year old female. She had survived cancer of the urethra (the tube through which urine exits the body). The radiation took its toll on her. It scarred her vagina, clitoris and urethral opening. She developed inflammation of a portion of her colon and had to have that portion removed. With all this, the lady that lay in the bed the morning I saw her was bright, cheerful and smiled almost apologetically for the embarrassment of her condition. What brought her to the hospital was not any of the above conditions I described-- she had weathered those and survived. Now she was leaking stool from her vulva. It was an incontinent leak she could not control. It was getting worse. The final in a succession of specialists to see her was a gynecological oncologist. On the phone later he told he had seen a lot of such cases before, having trained at one of the country's leading cancer centers.

His word in the patient's chart were direct and poignant: "This is a terminal condition. In my experience, life expectancy is usually 3 to 9 months." When I walked into the patient's room, she had already her the pronouncement from him. He had been her gynecologist for 15 years and cared enough to tell her the truth without the hemming and hawing less experienced or less caring physicians will indulge in out of their discomfort with the news.

There she lay. She looked at me with eyes reflecting fear, confusion, sadness and searching. Should she seek a second opinion? Did I agree with the assessment? As I gave her my opinion, she told me what an excellent doctor I was. She wasn't being facetious. She meant it. I didn't feel like patting myself on the back or accepting a compliment.

I left the room with respect and admiration for this wonderful woman who could accept news of an imminent death with such grace and fortitude -- much better, I will confess, than the 'excellent doctor'

"Give me some coffee!"

69 year old Mr Jones (I'll call him) is in the medical ICU. He has lung injuries and breathing problems. He is NPO (nil per os -- which means 'nothing by mouth'). His son walked in this morning to see him, holding a cup of coffee in his hands, the aroma filling the room.

"Give me some coffee!" exclaims my patient slurring his speech and breathing hard. Mr. Jones alternates between being lucid and agitated and restless.

"Pa, the doctor said you can't have it." the daughter explains as she signals with her eyes for the son to leave the room with the coffee cup.

I overheard. I am 'the doctor'.

There is something that flinches inside whenever I am reminded that I have denied another human being the basic right to eat and drink by my 'orders' written in the patient's chart. I only have to write 'NPO' and sign my name. It is enough. The power.

Mr. Jones is NPO because he 'failed' the swallow test. When he was offered a little something by mouth in a controlled situation, he aspirated and choked on it. Perhaps he is still too weak, perhaps he suffered injury from the breathing tube that was in his windpipe for several days when he could no longer breath on his own. The NPO is medically justified and re-evaluated at regular intervals.

Still, I flinch.

When have you lived enough?

During that same night, I admitted another nursing home patient for bruising and a history of repeated falls because of syncope -- losing consciousness. Further investigation revealed that he has a bad heart valve. He knew this and had declined repair or replacement of the valve. The poor heart function was causing kidney failure and now disturbing the electric conduction system of his heart. His heart was in danger of going into a fatal rhythm. He could die in his sleep or just walking down the hall, eating or using the bathroom. He was 79 years old and DNR/DNI. While he did not want to have the valve repaired or replaced (the cause of most of his life-threatening troubles), he was not averse to having a defebrillator put it -- a device that would 'shock' his heart back into a rhythm compatible with life if it went into a fatal rhythm.

I tried to explain to him that while this might 'solve' the problem of fainting spells and prevent him from dropping dead suddenly or dying in his sleep, it would do nothing for his failing valve, poor heart function and the resulting kidney damage. In fact, he would worsen and go into heart failure, resulting in fluid building up in his lungs over time and become progressively more short of breath and uncomfortable.

If I had this problem, I would much rather my heart go into a fatal rhythm and kill me instantly rather than my life trickle away with greater discomfort and diminishing quality. Furthermore, as my heart worsened, it would tend to flip into fatal rhythms more often, resulting in me being 'shocked' more often -- doesn't sound good. So my choices would be repair or replace the valve or nothing -- let me die whenever one of those fatal rhythms occur. After explaining this to the patient, he surprised me by saying that my logic sounded clear and that yes, he would like to have the valve replacement surgery.

I guess what surprised me is that this 79 year old gentleman living in a nursing home with no family close by, no wife and not much else wanted to live more and was willing to endure the surgery it would take to make that happen. And then I caught myself. Why was I surprised? I guess I kind of expected him to say that he was 'old' and had lived enough and that he would die someday somehow, so it this was to be way, then so be it. But no.

Of course, I respect his choices and will help him reach his goals, of medically possible. It is a subtle prejudice I need to watch for in myself: deciding when someone has lived enough and should 'throw in the towel'. Who makes that choice: the patient? the physician? the government (who will be paying for all of this in his case since he is on Medicare)? How do you make such a decision? By age? By quality of life? Who determines quality of life? Should we even offer him the surgery just because we can?

I guess we all have to think about the answers.

Who lives and who dies?

I am back in Internal Medicine and on the Wards. The ward month is very busy with call every four days and walking up and down between the different floors of the hospital and the MICU. Still, I love it. Ward medicine gives you a 'captive' patient: he is in the bed and you 'control' his medicines, activity and diet. Compliance is hardly an issue.

My first call night of the month, I admitted -- at different times of the night -- two very similar patients. They both came from nursing homes. They were both DNR/DNI. They were both in respiratory distress and unresponsive. One seemed to have a urinary tract infection and the other dehydration and maybe a pneumonia. One was 87 years old and the other 82. With both patients, the management strategy was similar -- treat as sepsis with fluids and broad-spectrum antibiotics and that was what was done.

During the night, one of them died and the other not only lived but 'came to life' -- she woke up and began talking with us, quit lucidly I might add.

We often joke on the wards about 'let's go out there and save some lives!'. I am sure we have something to do with it, but sometimes I wonder how much...

One died and the other lived. We will still do what we do and maybe one day can stratify the risks better to predict the outcome. For now, I still believe God holds life and death in his hands.

She's got the look...

I'm in Allergy this month. I am working with a wonderful Pediatric Allergist. As a resident in training, when you're in a specialty rotation like Allergy, things work a little differently. The Attending physician will send me in to the patient's room to see him or her first. I come out and 'present' the case to him and we then go in together and finish the encounter. During this second phase, I get to watch him interact with the parent and the child patient.

Something I've only noticed this month is the expression on the mom's faces as the doctor asks their child a question and their child answers.

There's the look.

The eyes light up, the face glows with warmth and pride and there's a playful smile on the lips as they almost try to mouth prompt the answers to the child. The roughest most confrontational adult is transformed when their attention switches from you to their child. The child, completely unaware, focuses on the doctor and answers the question. To me, the silent witness, the mom seems completely unaware of the expression on her face. The look.

A different patient room. A different child. A different mom. Ten, sometimes twenty times a day. Always, the same look.

Stories in Medicine: Poem: Waiting...

Stories in Medicine: Poem: Waiting...

Who's the Adult?

It's another night of call in the ICU. I've got to say that I do enjoy being on call for the ICU. Last night, I got called from the ER to admit a 35 year old female who had ingested an unknown quantity of (we think) tylenol. Her blood alcohol level was also sky high. She was stupurous and could not provide any information. Needing information on allergies, medications and other illnesses and hopefully some details on what happened, I asked,

"How did she get here?"

"The ambulance brought her."

"Who called the ambulance?"

"She did."

I looked to see how 'she' was.

'She' was a 12 year old frightened little girl, holding an Easter bunny under her arm.

Apparently, this family moved to Wisconsin from California. They lived in a trailer. Mom didn't have a job and dad worked as a lineman. The little girl tried to answer my questions but clearly, most of the answers were wrong (she thought the anti-depressants were blood pressure medicine). This frightened child saw her mom drink, then ingest a large number of pills, then become stupurous. When her mom wouldn't respond to her, she tried to call 911 on their cell phone. Since she couldn't get a signal, she went over to someone's house, asked permission to use the phone and called 911.

As she bravely tried to answer questions from the nurses, doctors and cops (suicide attempts always bring the cops), she didn't cry, act hysterical or break down. At the end of it all, she looked up at my with wide eyes and asked

"Is my mommy going to be alright?"

It was 1:30 in the morning. Mom was shipped off to my care in the ICU while a cop took the child to a foster home three towns away.

Imagine you are 12 and this is the evening you have had. Dad is nowhere. You are being taken by a policeman to a town far away from where you live at 2:00 in the morning to live with people you have never seen before. She didn't know it, but because of the suicidal intention, Mom would not be discharged from the hospital to home. She would be transferred directly an inpatient psych facility to work out the suicidal ideation. Of course, this was assuming she made it through the night.

As a Med/Peds doc, I see both adults and kids in my practice. Although in this case, the 'adult' was my patient, my heart cried out for the little girl.

Who's the adult in this situation?

It's a boy! No, it's a girl! No, it's a ...I don't know...

Peter is a 7-month old boy. No, wait. Peter is a 7-month old 'boy'. Okay, I'll start differently: Peter was born...no wait. It is very hard to tell a story about someone without mention of their sex: either by use of a pronoun or by implication with the use of a name. Maybe in such cases, we should a name that could belong to a little boy or a little girl. I don't know. Okay, here goes...

A little baby was born and it was evident there were problems. The baby suffered from what is called Eagle-Barrett syndrome: a condition where there is complete or partial absence of the abdominal muscles, problems with the urinary system and in males, the testicles do not descend from the abdomen into the scrotum. In this baby's case, it had a single opening called a urogenital sinus -- a single opening for the urethra and vagina. It's complicated. Although the parents believed the baby to be a boy -- it seemed to have a penile structure and scrotal sac structure, genetic testing showed it to be a female. It had a genotype of XX. Imaging studies (ultrasound) showed the presence of what looked like a premature uterus and the scrotal sac was empty.

In the end, the parents made the decision (based on religious and other non-medical reasons) to raise their child as a boy. And so 'he' is. I got to take care of 'him' in the context of kidney failure and a febrile seizure (another story). I learned a lot from him.

Teenage girl angst

Those of you in residency know this is true: sometimes cases come in groups. Well, last night on call was the night of teenage girl angst. A colleague tells me that it is because it is a cold winter in Wisconsin.

We got a 14 year old girl who stood in front of her friends in a bathroom at school and swallowed a bunch of lithium and prozac tablets, then washed it down with windshield wiper fluid.

A couple of nights ago, we got another 14 year old who had a fight with her parents and swallowed a bunch of tylenol tablets.

Then there's the 14 year old whose weight is 75% below normal -- thin as a rake.

There was also the 13 year old with cut marks on her forearm made with a razor blade. She cut on herself because she was upset and depressed.

The 14 year old who has 'seizures' -- only they aren't.

I remember the teenage years being rough. But I wasn't a girl and so can't identify with the stories I heard:

"my parents don't understand me" "I'm not beautiful" "Life sucks" "they jump to conclusions about me" "I want to be with my friends but my parents won't let me"

Teenage girl angst.

Childrens Hospital, Milwaukee ER

It's been a while since I last wrote in this blog...

I spent January in the Childrens Hospital of Wisconsin in Milwaukee, working in their ER. This is a pediatric ER. What a wonderful experience! The attendings, nurses, care partners, residents and fellows were all very colleageal.

Of course, the stars of the show are always the patients.

During the course of the month, I treated a LOT of upper respiratory tract infections: bronchiolitis, asthma exacerbations, influenza, common cold and such. Then there were gastrointestinal problems -- diarrhea, vomiting, stomach upsets.

Of course, there were unusual things too and those are always interesting...

A 1 year old dared his 4 year old brother to lick a road sign... in the middle of winter. Those of you who live or have lived in cold climates can imagine what happened next. Yup, his tongue stuck to the sign. Although helpful passers-by used water and other 'tricks' to get his tongue loosed, he did sustain a laceration as a piece of his tongue tore open as a flap. Ouch! He initially went to an urgent care facility where some well-meaning soul tried to suture the flap back (after a painful injection of numbing medicine). The stitches didn't hold. Fortunately, the tear was superficial and he was sent home to allow the tongue to heal on its own.

I got to sew lacerations on the scalp, palms, arm and face. I hate to admit it, but I really do enjoy repairing lacerations. I enjoy suturing. With the kind of numbing creams we have these days, it goes much better than I remember from own experience being stapled when I cut my forehead as a child. One kid fell asleep while I sewed a laceration ('lac' in our ER slang) on his face! We had only given him local anesthesia, nothing to put him to asleep. I guess he was just bored.

Not all stories have happy endings. My last day in the ER reminded me of what a city's ER can bring in, all in one day. My colleague saw a 12 year old who came in with a fever. A few blood tests later, we had the grim diagnosis: leukemia. There were teary eyes among several of the staff as a physician went into the room to give the family the bad news they were hearing for the first time. We see so much fever, coughs, colds, stomach aches and such in the ER. Every so often, the diagnosis is as grim as this was.

I saw a 13 year old who complained in front of his brothers, sisters and mom of a sticky discharge from his penis. Well, after I had cleared the room, the rest of the story emerged. Sparing details, he lost his virginity at 12 and had 2 sexual partners at 13. He did not used condoms. We tested him for all sexually transmitted diseases and involved a social worker to uncover more of the story.

I saw a 28 day old baby girl with a fever and drowsiness. Per protocol, we had to rule out meningitis, which meant doing a spinal tap. Both parents hovered nervously near me while I inserted a needle into their little baby girl's spinal column. I think as an intern, I would have asked the attending to do the procedure. But with some experience now, I was able to calmly re-assure them while I sought to obtain the precious spinal fluid that would give us our sample for analysis. Outwardly confident, I did pray that the Lord would give me success the first time round. He did and I was able to get clear spinal fluid without complications. Peds is interesting in that the presence of anxious and nervous family members watching you do delicate procedures brings some pressure to perform. I am grateful for the training and role models I have had that have taught me to do this correctly, confidently and successfully.

On the diversity side of things, I got to impress my attending physician one happy day when we saw a spanish-speaking patient in the morning. I guess it came to her as a surprise that being from India, I could speak spanish. In the evening, the last patient of the day spoke hindi. My attending began to wonder if there was a language I could not speak. To answer a question, I had to call for an interpreter when a Hmong family came next.

I will miss Milwaukee and the Childrens Hospital's ER. A funny thing: by the end of every month, I find myself thinking "this is great! I could do this for the rest of my life. Maybe I should do a fellowship in (fill in the blanks -- NICU, Peds ER...).

So what else did I do in the big city on my time off? I confess: there is no Indian food in Marshfield. I ate Indian food practically every day and thoroughly stuffed my face. The viral gastroenteritis I came home with on my last day when I 'overdid' the 'all you can eat buffer' was a small price to pay...

Happy 2008 ... from the NICU

It is almost midnight here. Here is the Neonatal Intensive Care Unit, where I have been working for the past month. Tomorrow, I get to drive to Milwaukee to begin a month long rotation in the Pediatric Emergency Department at the Childrens Hospital there. I am on call tonight, so I get to 'ring in the new year' with my little friends. Let me introduce a few of them to you...

There's A -- born at 37 weeks. That makes her full term. Her 19 year mom came into the ER complaining of back pain. What? I'm pregnant? Can't be! A few hours later A was born. She ended up in the Neonatal Unit because her mom had not received any prenatal care and had smoked pot 5 days a week, and drank several times a week during the pregnancy.

A was doing fine until a few weeks ago when she developed an infection beneath her left jaw line. Cultures grew out community-associated MRSA (Methicillin-Resistent Staphylococcus Aureus). It's been rough, but she's doing better.

There are two sets of twins -- both boys. Both were born at about 30 weeks. They are doing quite well. One pair are out of their isolettes in open cribs. I had the pleasure of tying off 6th digits at the base of the pinkies of the other set of twins. They weren't digits really, more like skin stubs.

There's K -- born at 26 weeks at 2 and half pounds. She was one of a set of a twins too. Unfortunately, her sister died on day of life two. Both twins suffered from twin-to-twin transfusion. K has had a rough course, developing a heart disease of unknown origin. That is getting better.

There are lot's more, but these are a few that I have shared life with this past month, and get to bring in the new year with.

Happy New Year, little angels. I pray that the new year is a new lease on life for all of you.

HIPAA

Health Insurance Portability and Accountability Act

Blogging and doctoring. Is this allowed? I have researched HIPAA regulations and blogging. As long as I am careful to not disclose any of the 18 Health Information Identifiers, I am okay. Further information can be found at http://casesblog.blogspot.com/2005/07/case-reports-and-hipaa-rules.html. There are a number of resident bloggers out there. Just google resident or medical blog and see.

Physicians have a long tradition of being writers: Abraham Verghese, Oliver Sacks, William Carlos Williams, A. J. Cronin and the list goes on. Physicians tell their stories and since patients make up a big part of their lives, their patients' stories too. Blogging is a new dimension but a continuance of this tradition. If done respecting the dignity and privacy of the patients and with care to avoid divulging health information identifiers, it can become the next torch-bearing media in chronicle-ing our experience with pain, suffering and healing.

Pronouncing the Dead...

Today I pronounced my first death, as a licensed physician.

I got my license to practice medicine in the state of Wisconsin about a year ago now. Although I am still a resident, as a licensed physician, I get to write and sign some documents I could not do a year ago as an intern.

There are patients who come into the ER or the hospital or the critical care unit whom you barely have time to get to know. They are either dead on arrival, or actively dying and slide down so quickly, no intervention works. When you 'call it' on one of these, there is the despair, frustration, anger, defeat and helplessness that comes with a battle lost.

It is worse when it is a patient you have cared for, for some time. It is even worse when the patient is young and dying of something you cannot identify. My 26 year old male patient died at 4:17 am. He was surrounded by his father, mother, sister and girlfriend of 6 years. Everything we could do had been tried and failed. The family did not wish an autopsy, so he carries the secret of what killed him to the grave with his body.

This is NOT what you train for. It is not why you come to work. It is not the outcome you study, struggle and work for. My grief cannot compare at all with that of the parents of a previously healthy 26 year old son who dies in a few months of unknown causes (he died of multi-organ failure secondary to ARDS (Acute Respiratory Distress Syndrome) but the cause of the ARDS is unknown.

I have no more words.

He died at 4:17 am. The day was one of busiest in the unit: while rounding on our eight patients, very sick ones, another patient arrived who had begun to bleed acutely while in the wards. She was unstable, in a lot of pain and may have been bleeding to death. We barely stabilized her when our beepers went off indicating a 'code blue' -- an elderly gentleman passed out in front of an elevator, had to be shocked back to life, was now intubated and was on the way to the unit. Rounds were over as quickly as we could run them and news of three more patients -- one en route from an outside facility, one in the ER and one being transferred from a floor ward arrived. All sick. No time to grieve, collect one's thoughts or dictate a death summary.

I got home after all this. Before I left, I walked past the CCU bay where my 26 year old patient had been. The bay had been cleaned, the bed re-made. We were crunched for space. Soon, another patient would be in that bay. I left for the day, after a day, night and day of call.

Over a dinner, while keeping sleep-deprived eyes open, I finally get to say my goodbye and grieve a little.

Tomorrow is another day.

Tale of Two Cities...

Charles Dickens' famous book began with these words:

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us..."

A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.

26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.

In my head, I could almost hear the parellel conversations...

the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"

the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."

Both interventions were tried and failed.

the attending physician: "We will diurese him and keep him on steroids"

the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."

Both interventions were tried and failed.

It went on for some months.

Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?

The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.

In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.

?????

There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.

Look into my eyes...

It was a late night admission from the ER. Michael was a 40-something man being admitted for left-sided weakness. By the time he finally decided this was serious and not 'going away' he could not lift his left hand off the bed and his grip strength was down to 1/5 (5/5 being normal).

As we set him up in the medical ICU, starting him on a heparin drip after a head CT, we noted that his blood pressures were through the roof. The radiologist called me back with the results of the CT: he had had an infarct in a region of the brain called the corona radiata. Brain cells were dead. They were never coming back.

Through the course of the night, I sneaked into the room to see how he was doing. The first time around, I found him lying on his side with eyes open. I don't think I shall ever forget the look in those eyes -- fear, frustration, helplessness. He was a mason. When I said something to comfort me, he only replied in a soft voice:

"I should have come in earlier, shouldn't I? I should've come to a doctor before. I should've...."

What do you tell someone who has had a stroke? You cannot promise them that their functions will return. You cannot promise them that their life will be the same again. You cannot promise them anything.

We do what we can, with what knowledge we have. The chips will fall where they may. This gentleman was 1 year younger than me.

Enjoying my work

I thought I would post one of the few pictures I have of me in Peds. This little boy has cystic fibrosis. We were out for a walk in the corridor the day before he was going to go home.

The Ward Team in Pediatrics with one of our patients.

Viruses that will save the world

I had a week off from the world of pagers, night call, ER admissions and clinic. I was in Pittsburgh attending the Phage Hunters Workshop (http://www.pitt.edu/~gfh/summerworkshop.html). This workshop is meant for High School Science Teachers, but I went to learn some of the techniques.

There is a group of viruses called bacteriophages. These viruses are specific for bacteria. They do not attack other kinds of cells. Before antibiotics were discovered, they were even used clinically to treat microbial infections.

Think about this. In nature, exists the ultimate enemy of pathogenic bacteria. These bacteriophages (phages, for short) invade, multiple within and destroy these pathogenic bacteria. Of course, just as with antibiotics, bacteria evolve resistance to them. Unlike antibiotics which are static however, phages co-evolve to once again be able to target their hosts. This host-parasite dance continues through time. The phages are ubiquitious. There are a billion of them per cc of lake, river and sea water. We ingest them all the time. They are easily isolated from soil, sewage... anywhere you care to look. They are so easy to isolate and grow, in fact, that middle and high school kids can do it.

The Pittsburgh Bacteriophage Institute holds a Summer Workshop that teaches High School Science Teachers how to 'hunt' for phages in their environment. For several years now, high school students have been isolating and purifying their own phages. They get to name them too.

What excites me about these wonderful little critters is that they may hold the answer to multi-drug resistant superbugs. The Pittsburgh group and collaborators are working on phages against Mycobacterium species -- the group of bacteria that cause the deadly diseases of tuberculosis and leprosy.

My own research (if I can continue to squeeze it into the busy life of a medical resident) is to isolate and purify phages with activity against Staphylococcus aureus. In fact, I declare my life's research ambition to become the world authority on lytic phages of S. aureus. Okay, I'm a dreamer. But I'm not the only one. (Check out the Courses Web site at http://hatfull12.bio.pitt.edu:8080/

Suicide

I HATE suicide!

There is someting sinister, evil and perplexing about suicide that drives me to tears of anger and frustration.

A couple of weeks ago, it was a Monday (and a full moon day) in clinic. I saw a 46 year old man who came in for some minor health issue. I noted that the last provider he saw had started him on a medication for depression, so I decided to ask whether he had noted any difference since taking it.

He shook his head. When I asked about suicidal ideation (thoughts of wanting to kill himself) I was stopped dead (pardon the pun) in my tracks. He replied "Actually, on the way here I thought of throwing myself in front of a semi." This was a middle-aged man with a wife and two kids who wanted to kill himself.

I inquired further. He did not think his life was worth living. His job was a dead end. His marriage was falling apart. He had no desire for sex. We had given him Viagra on a previous visit. He had not used it. Not interested.

Further investigation from the psychiatrist (to whom he was directly referred from my office) revealed that he had a lifetime battle with ichthyosis -- a rare skin condition that causes the skin to appear scaly or reptilian in appearance. His school nickname was 'scales'.

The following day, I saw a young man in clinic with with a weight problem. He too was suicidal. His plan was to turn the fumes from his tailpipe into the car and breathe it in. He too had no reason to live.

That same day, I saw a middle-aged woman who had attempted suicide at the age of 18. She suffered from crippling depression and schizophrenia (the latter adequately controlled on medication). Unfortunately, she lived with a 'partner' who had an autistic 4 year old. I imagined this dysfunctional household: each one's condition exacerbating the other's.

It is horrifying but not uncommon to see that in all three of these patient's families there was a strong history of depression, psychiatric illness and yes, multiple suicides. It is almost as if a demon has these families in his grip, killing one after the other.

The following week in the ICU I took care of a middle-aged woman who sat down at 11:30 pm and drank Anti-freeze till 4:30 am. Yes, she was trying to kill herself. (This is a picture of the actual can from which the patient drank).

Her life was saved by CRRT. The picture shows her getting the treatment.

I remember coming home from work the evening of the day I saw the two suicidal patients in clinic. I finally broke down in my car. Tears of frustration, anger and a feeling of helplessness swept over me.

As a physician I fight disease and sickness all day (and nights on call). We struggle to save broken bodies ravaged by disease. Here were relatively 'healthy' people trying to take their own lives.

The book that has most ilumined the subject of suicide to me is Kay Jamison's Night Falls Fast (http://www.amazon.com/Night-Falls-Fast-Understanding-Suicide/dp/0375401458). As a professor of psychiatry and a lifelong patient with bipolar disorder who has attempted suicide several times herself, she is emininently qualified to comment on the subject. I recommend the book highly.

Floating in the ICU

When Internal Medicine residents are doing electives -- typically clinical rotations that do not involve night call, they are often circulated through the medical critical care unit for 4-5 nights of the month. We call this floating in the MICU.

That night I was called to the ER to see a 42 year old that was unresponsive to commands and combative. He had been dropped off by an outside facility emergency medical team with scanty information. He had brought in by his colleagues at work. Here is the reconstruction of events.

Joe (not his real name) was working on a roof. He was a roofer. Witnesses say they saw sparks fly from an instrument he was using and they saw fall back. When they went to him (still on the roof), he had a left sided facial droop and right sided weakness. He became disoriented, combative and unresponsive to speech.

When he arrived at our facility, we diagnosed him with a stroke (cerebrovascular accident) and began appropriate treatment. He did not make a complete recovery, although several days later could answer a few simple questions.

Here's the rub. Joe was a healthy guy -- a typical roughneck. He had had some run-ins with the law, worked hard, drank hard and occassionally used amphetamines and marijuana. He was tough as nails and in our emergency room it took 5 of us to hold him down. He did not have any history of high blood pressure. He did not have a high cholesterol or LDL or other signs of atheroschlerosis. In short, there was no predicting that his life was going to change drastically at 42 years.

Much as we know about strokes, this one had no easy explanation. It was a massive infarct of the right middle cerebral artery with subsequent hemorrhage into the ventricle on that side of the brain. Why? How? We will never know. But Joe will never be the same again.

Reminds me of words by Moses in one of the Psalms: "Teach us to number our days that we may gain a heart of wisdom." My take home from this was to use each day wisely and fully, never knowing what tomorrow will bring.

How the giants have fallen...

My brother tells me that in blackjack sometimes, cards come in 'runs' --- a number of deals where the cards are condusive to winning and then sometimes runs where for deal after deal, the cards dealt are a losing lot. Some periods on call, there is a strange similarity between patient cases.

That night, we admitted two tall 16 year olds. One was 6'3", the other was 6'2". Both were high school athletes. One had just qualified for the state championship, jumping his height in the high jump event.

The first one I will call Peter. He had golden curls. He was polite, had no tattooes or piercings. He did not smoke, drink or even have a girlfriend. He had the build of a track and field athlete. He was flown in by helicopter from an outside facility for progressive loss of sensation in his lower extremities. Over the next several weeks, we treated him with steroids, thought we had it beat, discharged him, only to admit him back in worse state.

I still remember the night I was told he was back. I was off that day but Sunday afternoon after church, I went to PICU to see him. There he lay: a 16 year old athlete in a diaper, incontinent of urine, able to open his eyes but not able to speak. He ground his teeth incomprehensively. I cam out of his room and wept secretly in anger and frustration.

The second 16 year old also came to us by helicopter almost within days of the first patient. He too was clean-cut handsome, wholesome male. He had some numbness and tingling in his hands and a lump at the back of his neck. I remember the strange sight at 1:00 am in the morning when 3 specialists -- a neurosurgeon, a pediatric intensivist and a pediatric oncologist, flanked by a couple of residents stood discussing the possibilities.

"I hope he has a lymphoma" someone says.

We all agree, shaking our heads. Then it hit me. Here we were wishing that a previously healthy 16 year old athlete had a form of cancer.

How strange is that?

The reason for our wish was that we had seen the preliminary scans of his spinal cord. The alternative diagnosis was a rhabdomyosarcoma -- a cancer in which often 90% die in 2 years of diagnosis. This patient had some cancer. We were hoping it was the more treatable one with a better prognosis than this.

He had rhabdomyosarcoma.

As the Pediatric Intensive Care Unit resident that month, I was often the one to give specialists involved in his case the news. The pained expression on each face as they heard the news told me they felt as I did. So much for clinical distance.

Both boys are home now. Both endured painful procedures. One has rhabdomyosarcoma and the other may have multiple sclerosis -- an aggressive form at that. They are being treated with the best we have to offer.

O how the giants fell that night. I do not believe I shall ever forget them.

Addendum - written on May 22 2009

Today I received notification that the second patient described above (let's call him Big Ben) died at his home, surrounded by friends and family. He was 18 years old. This week, this was the third death notice we received -- the other patients were younger and died of ALL, having failed bone marrow transplantation. Cancer in children is a horrible disease. I don't know how the Peds Heme/Onc specialists do this!

David son of Jesse

A 28 day old male infant presents with a 2 day history of projectile vomiting (emesis reaching a distance of 3 feet). He was not born premature. He is the firstborn. Palpation of his abdomen reveals a small, but palpable 'olive' just right of his midline. To you medical folk out there, diagnosis, please? Want another clue? An upper GI series shows delayed emptying of the stomach and a narrow, stenosed pylorus. Okay, you got it: pyloric stenosis. Found in a 4:1 ratio in males: females and most commonly at the third week of life, this is the most common cause of intestinal obstruction in infants. I admitted a kid with this story to the hospital tonight. I asked what his name was. It was David. As is my practise, I asked the parents name. Dad's name was Jesse. How about that: David, son of Jesse. Mom was the way is not Bathsheeba...

Parents and their responsibility

If you haven't guessed already, I am in Pediatrics these days. In the past few days three clinical experiences have happened that make me want to write this post.

1. Sunday night on call, a 2 year old was brought in with altered mental status (responsive only to painful stimuli), optic nerve atrophy in his left eye and priapism. Turns out that 4 months ago when he had presented with some vision loss in his left eye, an MRI had been done. It revealed a large craniopharygioma in the sellar/suprasellar region of his brain. This is a benign and in his case, cystic tumor. The prognosis was good with surgical resection and radiotherapy. The family, being Amish, told the neurosurgeon that they would think about it. They never came back. Instead, they decided to try a low-sugar diet and some nutritional supplements. Needless to say, this didn't work. The tumor had got larger and now was compressing the aquaduct of silvius in the brain and blocking the flow of CSF resulting in an obstructive hydrocephalus. This is why the toddler wouldn't wake up. That night, we had to intubate him, put a central line and arterial line in his left subclavian and left femoral respectively, put an NG tube and foley catheter in and the neurosurgeon did a bedside craniotomy to place an extraventricular drain. He is scheduled for emergent brain surgery in 4 days. His prognosis is not very good at this point.

His parents, no doubt, felt they were doing the right thing by trying to treat this tumor with diet management, although there is no evidence for this treatment and even the makers of the nutritional supplements they used do not recommend their product as a treatment for brain tumor. Now, their son lies in serious danger of either losing his life, or being permanently blind and/or neurologically impaired the rest of his life.

What do you think of their choice and the consequence to this toddler?

2. The night of call, I spent from about 10:30 pm to 5:45 am working on this single patient. I do not think I sat down for 5 minutes. It was non-stop, hair-raising, nerve-racking action. In the wee hours of the morning, one of our PICU nurses comes in with the story that one of our flight crew nurses who was going through a divorce had killed his children, ages 8 and 4 and then shot himself. Reportedly, he drugged the younger one (a boy) and shot the elder one (the girl) in the head. Apparently, he was going through a messy divorce and stood to lose his kids. We still do not know how he killed his kids. Did he shoot them, like he shot himself? Did he drug them? Did they suffer?

What do you think of this parent's decision?

3. Tuesday morning in clinic, our team's job was to evaluate a little 6 year old for autism. The concern was raised because the child had speech delay, some apparent anxiety and stereotypical behavior -- finger-flicking, head rocking and some repeated movements with her hands. She was a delightful little girl who was brought in by her father. During the interview, we discovered that Mom had been an alcoholic. She would leave this little toddler (at the time) in her rocker rather than let her walk around. Consequence: motor development delay. Mom would get loaded with alcohol and play loud music. She did not interact with the kids. Consequence: anxiety, fear, speech and language delay.

We do not think this little girl has autism. We think she may have re-attachment disorder and anxiety that manifest in the odd, stereotypically behavior, lack of desire to interact with her peers and her various delays.

Thanks, Mom?

In all fairness, most parents do a wonderful job of loving and raising children, making good choices to protect their health, well-being and safety. We can't help our heart-ache when we see the contrary as I did over these last few days.

101

I am in pediatrics these months. However, as a Med/Peds resident I still do clinic one afternoon a week and this last week was Internal Medicine. I looked at my schedule at the date of birth on the sheet: 8/6/05. At first, that didn't seem odd. I had a lot of patients who were less than a year old. Wait! I am in Internal Medicine this afternoon. This can't be right! But it was. My patient was a 101 year old lady.

I went into the room. This was a pleasant lady sitting in a wheelchair (she wasn't disabled). She got around with a walker. When I asked her what health complaints she had, she surprised me by her reply.

"Doctor, I don't have the strength I used to. I fall asleep sitting down for a while."

In my mind, I thought that if that was all the problems I had at 101, I'd take it.

She came to see me because she had been living in a Retirement home and her money had run out. She was going to be on Medicaid and was being moved to a Nursing Home. I felt sad that she was going there. After all, this was a functional, fully cognizant female who was about to move into a home where most of the residents were demented and many dying. What could anyone do?

I finished the encounter and came home shaking my head. 101?

Damned if you do, damed if you don't...

In the last week, we had two codes in Pediatrics. Both involved kids less than 6 months of age.

The first one arrived in the ER pulseless and not breathing. We coded him for 25 minutes. He never came around. He was pronounced. There were tears of frustration, grief and shock in the eyes of everyone who walked away from the dead baby. We knew very little about this baby except the couple of sentences the EMT shouted out as we got busy to work on him.

I cannot describe to you how that feels... to do chest compressions on a 3-4 month baby, watching the monitor for signs of life, hearing the litany of a code be chanted behind you "1 more dose of epi now!" "stop compressions, check for pulse!" "continue compressions"

The second code was in the PICU. It was a patient on a ventilator. This was a premature, about 3 month-er that we knew. He stopped breathing (if you can do such a thing while on a breathing machine) when one of his lungs pulled away from the chest wall and collapsed. This led to his heart slowing down and then stopping. He went pulseless.

Peds residents and doctors ran from wherever they were to the PICU and became part of the crowd doing things. I did chest compressions, then needled his right chest wall to relieve the pneumothorax.

I have attended or participated in 4 peds codes so far in my training. This was the first time that the baby lived. Those statistics, dismal as they are, are about right. Not many infants survive codes. Kids do not have the reserve that adults do.

Coming away from this code was different. There was elation, nervous laughter, heady joy -- he lived!

I went back to the wards to resume my duties. I was taking care of a 2 year old admitted for increased secretions from his trach tube. Trach tube? This is a tube attached to the throat to help patients who cannot breathe effectively through their mouths and nostrils. This two-year old lay stiff in bed, with blind eyes open, a thickened pallette and flushed. At 10 months of age, his teenage sister turned away from him in the bath-tub for just a minute to see to another sibling who fell off his bike. In that minute, this little boy drowned. Since the family lived next to a fire station, the crew was over there in record time and he was successfully rescucitated. He lived! This was a code like the one I was just at, in that the patient lived.

Unfortunately, in that short period of time he was down, his brain suffered an irrecoverable injury from being without oxygen. He cannot talk, walk or see. He needs a breathing tube in his throat to breathe effectively. Should he have been saved? Of course! Who can predict what degree of injury and what subsequent recovery is possible? We have no a priori knowlege, so we must rescucitate.

Of course, as I care for him on the wards and wonder about the one we did not save and the one we did, I wonder about these things. What will the outcome be for the one we saved? Will he be like this 2 year old?

I am a christian. I do not swear. But in this case, the phrase "damed if you do, damned if you don't" seems to say it all.

Update on 4/2/2007:
My pager went off in the early hours of the morning. I was off-duty, but I had left my pager on. I looked at the read-out and saw the code message and the room message. Later that morning, the news was confirmed. The 3-monther we had successfuly rescucitated had coded again and this time, did not survive. He died of cardiopulmonary failure that morning.

Save your money....

Toddlers are interesting. This is the age for temper tantrums, the time when toddlers can walk, run and explore. I saw a wonderful little girl in clinic a few days ago. She smiled angelically at me and said nothing. Her 4 year old brother told me the story...

"Mary (not her real name, of course) found money!" She ate it.

Dad and Mom who came along, smiled nervously. We got an x-ray. The one on the left was at this first visit. The one next to it, about 5 days later.

Mom and dad are watching little Mary's poop every day. If the coin does not come out, we may have to go after it endoscopically.

Never a dull moment...

Update:

Several days later, we have a follow-up x-ray:

In a rare show of emotion, the radiologist's report says "Fortunately, she has passed this foreign body."

Unfortunately, the coin was never recovered in the poop. Well, there's good money down the drain... literally. ;-)

Why I became a christian and what it means to me

I was born into a Hindu family. However, I am now a follower of Christ. Is that the same as being a Christian, you ask?

Perhaps not.

I have been asked questions about this often enough. It is important enough to me to want to answer these questions. The answers are an integral part of who I am as a physician, scientist and person.

So here is a link to an article entitled "Why (and how) I became a Christian". I hope and pray that it helps my readers.

http://vijayaswani.blogspot.com/1999/02/why-and-how-i-became-christian.html

Older doctors...

Yesterday, I worked in the orthopedics clinic with a 72-year old physician. He was elected as a fellow in the American College of Orthopedic Surgeons in 1974. Calculating back, he probably went to medical school when I was 1 or 2 years old... and I am 44 year old now. Talk about a lifetime in medicine!

What do you think when you see a 72-year old man still practicing? I was delighted to learn that not only was he sharp, energetic and competent, but he was a pleasure to learn from. It was a great opportunity to learn clinical pearls from someone who has been doing this as long as I have lived.

This interesting gentleman was a 'retired' orthopedic surgeon. After doing private practice for 7 years and then 30-some years of orthopedic surgery at this clinic, he retired. He bought a 50-ton boat and spent the next 5 years sailing with his wife. When he got tired of that, he decided to come back to medicine, only this time, not to surgery. He sees patients in the orthopedics department, evaluating and medically treating their orthopedic problems. When necessary, he involves his surgical colleagues if his patients need a surgical solution.

I hope that when I am 72, I am as energetic, pleasant and competent as this fine physician. Age is truly no bar in medicine, if one does it right.

Like two ships passing in the night....

It was 3:00 am in the morning on a call day/night. I wonder sometimes if the memorable cases come at that time or if I just happen to remember the cases that come at those hours. Anyway, I had been awake for 24 hours and was fighting sleep. I waswriting some orders for a patient that we had admitted earlier that night. It was the last thing to do before, hopefully, getting some sleep. My pager went off and I rolled my eyes. "Please, not another admission" I thought, hoping that I would get some sleep before the day broke. It was another admission. It was to be a transfer from another hospital. I accepted the patient: a 70-something female with 'pancreatitis'. My mind was already framing the things I would do: bowel rest, IV fluids, should I do some prophylactic antibiotics?

When the patient arrived, I realized this was not going to be 'simple'. (If they transferred from another hospital at 3:00 am in the morning, they usually never were). If it was plain-vanilla pancreatitis, they wouldn't be coming here now, would they? What was I thinking?

Turns out my new admission had metastatic stomach cancer. In addition, she had an elevated Tn I (0.8) and a stable AAA. Oh well. I went to evaluate her. She had severe abdominal pain. Made sense, I thought, she has pancreatitis; only here abdominal pain was diffuse. It wasn't the classic epigastric pain radiating to the back. My sleep dissappeared as I began to feel uncomfortable. Something wasn't right. This wasn't pancreatitis, was it?

After several rounds of fentanyl and then morphine, I began to feel even more uncomfortable. After checking that cardiology didn't want to do anything with her (the Tn I wasn't high enough), I ordered an abdominal CT scan for the morning. It was almost morning anyway.

A nurse casually remarked about the strangeness of the situation: it seemed that my patient's husband was admitted on the opposite side of the corridor on this same floor. He had come in for a heart angiogram and they had discovered severe three-vessel disease. He was on the schedule as the first case for a triple vessel bypass that morning. This couple was not having a good day.

To cut a long story short, by the afternoon of the next day (I was well past 40 hours without sleep by that time and 'wrapping up' to get out of the hospital). the CT results showed that my patient had thrombosed two major arteries in her gut and her gut was almost dead. The vascular surgeons told me that the case was hopeless and that she had less than 12 hours left to live. Ironically, when her gut died, her pain went away and she felt better. That was an ominous sign.

Sleepless and discouraged, I broke the news to tearful daughters and a dumbfounded patient. Her only request of me before we moved her to the palliative care unit (where she would go to die) was that she get to see her husband. The last thing he knew was that he was taking in his wife for some belly pain and vomiting.

By this time, he was in the post-op recovery unit, coming out of anesthesia after his triple bypass. He was dazed, confused and combative (as patients can be coming out of anesthesia). As my patient was wheeled in her bed to our palliative care unit in another building, compassionate nurses and transporters arranged for her to see her husband for the last time. He was not conscious. She wasn't quite all there either. Their daughter told me that in 53 years of marriage they had spent all of 3 nights apart. This night, they passed each other like two ships passing in the night.

Now I have a confession to make. By the time I took care of all this, I was well past the legally allowed limit for working continously (30 hours for us residents). I was more like in my 45th hour without sleep. I wasn't making clinical decisions. I was saying goodbye to a dying patient and trying to get her to see her husband one last time. I wasn't about to leave a scene of death simply because my 30th hour was up. Doctors can't punch a clock. What would you have done?

Vacation

Now some of you readers out there must think that the lives of residents suck; that they are always depressed or brow-beaten or fighting life and death battles. We-elll, for those of you who think this, I submit the following. This is me sipping a cool drink while listening to the local Mariachi sing in a wonderful beach resort in Panama. (Don't I look happy?)

And there is me pulling my kayak out of the ocean after a wonderful ride.

Ahh! A relaxing vacation... far away from medicine, pagers, call and dictations.

Contrary to rumors, they do let us out of our cages every now and then...

Doctoring in a plane

Hi Everyone!

I am on my way to a much-needed vacation. I shall be visiting my family in sunny Panama (Central America, not Florida). It's been snowing over here. As I have done these past few times I have flown, I have been reading on dealing with medical emergencies on a flight. Have you ever heard the announcement overhead while in flight: "is there a doctor on board?" As a resident, I have wondered how one might prepare for this announcement and whatever follows. I have found four excellent articles. They cover the legal aspects, the most common emergencies one is likely to encounter and what kind of support in terms of personnel, their training and equipment you might have access to. For now, though, I decided to travel with my sphygmomanometer and stethoscope in my hand luggage...

Here are links to the articles:

1. NEJM Article: Responding to medical events during commerical flights. http://content.nejm.org/cgi/reprint/346/14/1067.pdf?ck=nck
2. BMJ ARticle: Is there a doctor on the aircraft? http://www.bmj.com/cgi/reprint/321/7272/1336?ck=nck
3. EMJ Article: Emergencies in the air. http://emj.bmj.com/cgi/reprint/22/9/658
4. BMJ Article: Inflight medical emergencies: An Overview. http://bmj.com/cgi/content/full/321/7272/1338

At 7:00 am he shot himself

At 7:00 am this morning, Auburndale Trauma, age 26 shot himself. He aimed a handgun pointblank at his chest and pulled the trigger.

Well, first of all, Auburndale Trauma is obviously not his real name. In our facility, when a trauma patient arrives that we know almost nothing about, he gets a fictitious name and age. For some cute reason, the tradition is to name the patients after the names of towns in the state, and also for some quaint reason, the patients are always 26 years old.

About 10 days ago, Auburndale was checked into a psychiatric facility with suicidal ideation. He was going through a divorce. He was depressed and wanted to end his life. He was discharged yesterday from that facility.

I am doing a rotation in anesthesia and was in the OR when he was brought in. The thoracic surgeon was good enough to invite me over from my side of the curtain (the one that separates anesthesia from the surgical field). "He's lucky!" He exclaimed. The bullet missed the esophagus, the aorta, the bronchial vein, the perihilar structures. It entered from the left side of his chest and exited from his back. How did it miss the heart?

Then he did a neat trick. After removing the lower lobe of the left lung (which was blown open and useless), he connected his forceps between the entry and exit holes -- the path of the bullet. As the heart beat, every time it entered diastole, it butted against the forceps.

"See?" He's lucky!" He exclaimed again. If this bullet had traversed the left hemithorax when the heart was in diastole, it would have passed right through the ventricle and probably ended his life." He shook his head. "Lucky, I tell you!" He was right in that though. The difference in time is about half a second. Had the bullet arrived half a second later, Auburndale Trauma would have been dead on arrival.

The conversation in the OR was surreal:

"How could he have missed?"

"He flinched when he pulled the trigger."

"He should have aimed into his mouth."

"Or angled left aiming upwards from the xiphoid process."

Auburndale Trauma is not 26. He is in his early thirties. He is getting divorced. He will probably not see his little daughters grow up the way he had thought he would -- as a family. Auburndale Trauma was unhappy enough to end his life. He shot himself in the left chest, no doubt aiming for the heart, to end it all. I do not know if 'lucky' is how I would describe him.

Mahatma Gandhi and medicine...

Yesterday, I watched the movie 'Swades' (can you tell I had the day off :-) ?). In the opening credits, there is a reference to a book called Bapu Kuti by Rajni Bakshi. It is a book about how some of India's journalists, scientists and artists are re-discovering Gandhi. This posed a question in my mind: what did this great man think of medicine?

I recall growing up that my grandmother used to go to a natural cure ashram where the medical practitioners followed Gandhian principles of healthcare. I was too little to remember the details of what they did. Anyway, I got on the 'net and found the book 'Gandhi's Health Guide' by the man himself. What do you think it said?

Well, to those of us from India (and I suspect, to a lot of us from other countries too), Gandhi was a great man. He has been compared to the founders of the world's great religions. However, in regards to his views on medicine, perhaps he was as much a victim of his times and circumstances as many of his contemporaries. I invite you to read extracts from his book at Amazon:
http://www.amazon.com/gp/reader/1580910513/ref=sib_dp_pt/102-6830000-4462505#reader-link

In all fairness, I do believe that had he lived today, he would have acknowleged that physicians and hospitals are necessary and even a blessing to many. After all, not all sickness seems to come from wrongful living.

I love it when kids cry!

Okay, so the title probably got your attention and you're thinking, what kind of pediatrician is this?!

It snowed quite a bit in our area today. The roads were slippery and a car near an outside town lost control and crashed into another. A semi driving up the same road could not stop in time to avoid the accident and crashed into them both. Our little town does not have many multiple motor vehicle accidents like this. At the hospital, we got news that several adults and chidren were being brought in. We rushed to the ER to await their arrival. The kids came first. There was an 8 year old and a 1 year old.

I love it when kids cry. The sounds of both these children crying was a reassuring sound -- it meant they were conscious, alert and that their airway was not compromised. The 1 year old had a head laceration that appeared superficial. The 8 year old had some abdominal pain. While performing the primary survey, one of the nurses asked the crying 8 year old, "where do you live?" Between sniffles and tears, he answered as an 8 year old would: "At my house." In the midst of a tense situation, it brought a flicker of a smile to our faces while we continued with the trauma assessment.

A day and a night in the CCU -- out-of-hospital cardiac arrest

In the evening, we were called from the ER to say that the ambulance was bringing in an "out-of-hospital cardiac arrest". What does that phrase mean to us? To give you an idea, I quote from a review article:

"The circumstances of cardiopulmonary resuscitation (CPR) can affect prognosis after a cardiac arrest in terms of both survival and quality of life. In one study of out of hospital cardiac arrest, 44 percent of patients receiving CPR survived initially, 30 percent were alive at 24 hours, 13 percent at one month, and only 6 percent were alive after 6 months. The duration of CPR significantly correlated with outcome; no patient who required more than 15 minutes of CPR survived more than 6 weeks. (Bereke et al, 1997).

This 70-something lady had spent the day shopping with her daughter, after enjoying a good breakfast. In the evening, she went to visit her husband who was recently transferred to a nursing home because of severe dementia. The two of them were visiting in his room. There was no one else there at the time. What happened next is surmised from the stories of others. The nurse and CNAs at the desk heard the nursing home resident room alarm go off. Apparently, this alarm is triggered to go off when the resident moves his back away from the chair. At first, since they knew his wife was in the room with him at the time, they thought she would help him.

When the alarm did not stop, they went to the room to check up on him. They found him leaned forward in his chair trying to hold up his wife who it appeared, had passed out. They could detect no pulse. The woman was put on the floor and the nurse and CNAs began CPR while someone called for the ambulance. The ambulance techs arrived and hooked up to an AED (Automated External Defibrillator), which advised a shock to the patient. Over the next 40 minutes during which CPR was continued, the patient was shocked again en route to the hospital. By the time she got to the ER, she was intubated, on a ventilator, but her heart was beating on its own. The ER doc was relieved to hand me the chart and the patient as she placed a hand on my shoulder and said "Good luck!"

We moved the patient to the unit (CCU) and got her stabilized. During the course of a very long night, she began to have tonic-clonic seizures. I had the responsibility of talking with the family and explaining the dismal outcome we expected, given this ominous sign of anoxic brain injury.

Last night, I had to have similar conversations with two different sets of families. In both cases, I was telling children of the patients that their mother was not expected to survive, although they were alive at the time. I had to explain that although their heart was beating and the ventilator was helping them breathe, they would never be the same. The patients in both cases were unresponsive. There was a strong possibility of severe injury to the brain from the lack of oxygen in the time it took to rescucitate them.

You know, some nights, after a conversation like that, I am actually grateful if my pager goes off and I can leave to the next emergency where I have to focus on a task at hand and not think about the meaning of the conversation I have just had.

A single event like what happened to this patient can change one's life for ever -- even end it all. And such an event is not predictable, although its occurence may be inevitable in the setting of some kinds of heart disease. Bottom-line: carpe diem -- seize the day!

Addendum, next afternoon:

I visited the CCU to find out how the patient was doing. I was informed that given the poor prognosis and predicted quality of life, the family chose to withdraw support. That meant stopping the ventilator. The patient died shortly after that was done.

A day and a night in the CCU -- "...she's stopped breathing!"

Well, as a Med/Peds resident, I do something different from most of the other residencies. I shift every 4 months between the worlds of Pediatrics and Internal Medicine. With the change in the month, I am back in Internal Medicine again and my patients went from being 7 to 73. Yesterday and last night night, I was on call in the Critical Care Unit. It's been a while since I was there (I think a year has passed) so it took a few moments to get used to things again.

It was a busy night. I got to intubate one patient, and place arterial lines in two others -- one was a femoral and the other a radial.

At about noon, a hospitalist called to say that a 73 year old female patient of hers was found in her room with a heart rate in the 30s and in apneic breathing. She was bringing her to us. As she wheeled her into our section of the unit, her face (the doctor's) was white and she looked frightened. She said "I think she has stopped breathing!" Well, those are the magic words...

I was by her side and feeling for a carotid pulse. There was none. With nurses, and my fellow resident all coming to her side, I began chest compressions while my colleague called out for atropine and epinephrine. Within less than a minute, she was back. Sometimes medicine happens in bursts of a few seconds that make a difference between life and death. I think that besides the adrenaline that we injected into this patient, there was quite a bit in everyone else in the room.

We set up the necessary access lines and blood pressure medications to stabilize her. Unfortunately, she has severe coronary artery disease -- two of the three main blood vessels in her heart (right coronary artery and circumflex) are completely blocked off while the third -- the left anterior descending, is 50% blocked. Because of chronic renal failure, she is not a candidate for a bypass procedure (that is to say she would probably die during the procedure necessary to save her life -- ironic, isn't it?). Although we were able to rescucitate her (get her heart to start beating on its own again and get her to breath), she is in an unresponsive state.

Well, I was quite busy with all this excitement. But there was more. I guess it was to be the night of the 70-somethings.

Can't open my eyes...

Imagine lying in bed, not being able to open your eyes, blink, talk or swallow your spit. Imagine that you have tingling in your arms and legs but no real capacity for coordinated movement. Imagine further that through all this, your hearing is intact, your vision perfect (if someone else will open your eyes for you to be able to see) and there is nothing wrong with your brain. No, this is not a stroke, although it is a nerve disease. Imagine that all this happened after a few days of diarrhea -- the kind of stomach upset that happens when you eat bad food, the kind that happens to all of us.

This is the Miller-Fisher variant of Guillain-Barre syndrome. It is a rare disorder characterized by paralysis of the eye muscles, abnormal muscle coordination and a few other nervous dysfunctions. While the exact cause is not known, it is believed to occur as a sequelae to some viral infections and bacterial infections-- much like Guillain-Barre.

This is the story of a 60-something previously healthy male. (In his room in the CCU, there were pictures on the wall of him with his prize turkey, a deer he had shot and others with his family and friends -- a full and active life). It started with some difficulty talking and swallowing (dysphonia and dysphagia), followed in rapid succession with droopy eyelids. He also reported some tingling in his arms and legs. By the early hours of the following morning, he was unable to spit or swallow. At this point, when he was rushed to an ER, he was intubated and put on a ventilator to support his breathing. By that time, he was unable to shake his head up and down.

When I saw him in the CCU, he had already been in the hospital about a month. His recovery was extremely slow. It is anticipated that he will recover, perhaps completely, within 6 months. Until then, there is not a lot than can be done for him. He could develop secondary infections (he has a tube in his throat and one in his penis). He will get some muscle atropy (since he cannot move his muscles on his own, although he has recovered lower extremity function and some upper extremity function).

See http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher.htm for the NIH's research activity on this horrible condition.

Kawasaki disease

It's 11:17 pm. I was on call last night. We admitted a 7 month old little boy. He was really cute, but irritable. He had presented with a 12 day history of fevers, cracked lips, injected conjunctivae and a passing macular rash. He was transferred to us with suspicions that this could be Kawasaki disease.

We did indeed think this was Kawasaki. Although he did not have all the classic symptomsWe admitted him and got him started on the appropriate treatment: IVIG (Intravenous Immunoglobulin) and high dose aspirin.

Now the bad news.

We knew this could happen. We got an echocardiogram today and he has coronary artery beads that are interpreted to be signs of a coronary artery aneurysm . I am upset and depressed about this. He is 7 months old! While this is a known sequence of Kawasaki, we were hoping that we were in time with treatment.

There is something about a post-call day. You have been on for 30 hours. You are hungry, your stomach probably burns from too much coffee, eating at odd hours, disrupted sleep cycles and who knows what else. You are washed out and running on fumes. To get bad news on a day like that makes it tough.

Something hurts inside. Frustration. Couldn't, can't do anything about this bad finding. Of course, we will 'follow' and react appropriately. Possible future events include thrombosis of the coronary artery. He is 7 months old!! We will probably get a repeat echo in 6 weeks. The anuerysm could either have resolved by then or we could have a giant aneurysm. I am hoping for the best.

I think I hate Kawasaki disease. I hate that we do not know what causes it. What a tease and frustration.

This is one of those days when you wrap your coat about you and press into the cold wind to go on.

Addendum on 12/24/2006:

The follow up echo was done 6 weeks later. The arteries returned to normal. Life is sweet! Merry Christmas!

5 year old versus motor propeller

I am post call today. It was a busy night and by the time I had got home, it was about 3 in the afternoon. I had been in the hospital 33 hours without sleep. Lots had happened. I finally got to send one of our little 5 year olds home today after a 2 month stay in the hospital.

About 2 months ago, he had been boating with his family. He fell into the water and the propeller from the motor slashed into him on the left side, fracturing his scapula, breaking ribs, cutting into his spleen, pancreas, left kidney, small bowel and large bowel. He also had a femur fracture on the same left side.

Shortly after being admitted, his spleen, left kidney and portions of his bowel were removed. During his long hospital stay, he underwent a number of surgical procedures and needed extensive skin grafting to close up the abdominal wound. While the graft didn't exactly take, his abdmomen is healing.

It was emotional to send him out. There were a lot of specialists involved in his care and it was a nightmare to put together his discharge documents -- so many issues to address for follow up and I was afraid something will be missed if I did not document it thoroughly and go over it with the mom. I got to see his abdominal wound today (perhaps for the last time). If you compare it to a normal 5 year old's abdomen, it would be considered almost frankensteinian with suture marks running in different directions and triangular shaped red scar tissue visible medially and laterally. But if you think about where he has reached, it is a beautiful sight. He will need plastic surgery in the future, but for now, he is alive and going home. I shall miss him.

I was proud to be part of his care. I almost feel like I was sending one of my own babies home. He is a medical miracle and an incredibly brave little boy. I wish him well.

Lonely in residency

3.28.2006 12:48 am ...

I just came off call today. It was a long 36 hours stretch at the hospital that was busy with some highs and lows, tense moments and good moments. I came home by 3:30 pm. I was so tired, I think I went to sleep without eating anything. I was scheduled to go to a christian prayer group meeting at 7:00 pm

My eyes opened at 8:30 pm. For a moment I didn't know where or when I was. Then it hit me. I had missed the meeting I was looking forward to going to for a month. Drats! If you don't want to hear me whine, then don't read on...

I feel a sense of frustration. With the life in residency being what it is -- screwed up sleep routines, odd, disjointed times off, it is so difficult to have a life. I got up depressed and frustrated with myself that I have not been able to meet any of these meetings that I wanted to go to.

I called the hospital and found out that one of the kids we had admitted on call -- that we thought had Kawasaki -- has coronary artery anuerysms. It hurts to think of it. I wanted so much to talk to someone about my feelings. But, who? It is 10:30 pm at night. Who could I call at that odd hour?

Residency can be lonely. Because of the hours I do not have much of a social life. Since I do not drink, the bar scene doesn't work for me. I would love to join a class or group or something, but with my call schedule that keeps changing, I don't think I could make the classes. Who would put up with me anyway? They wouldn't see as much of me as they might wish and I might want to call or meet with them at odd hours of morning or night. My days off may come on a week day and I may work 3 weekends straight.

Okay. So I'm post-call and tired. Still...

Poem: Waiting...

I went to a writing group meeting the other day and one of our assignments was to write a poem. The theme was "waiting". Well, I guess I had the ICU on my mind when I wrote this:

Waiting…

The monitor beeped in the background
As the machine took another breath.
Tubes carried food and water,
As the bed bore up life and death.

They came several times a shift:
White coats, green scrubs or plain,
Checked numbers, connections and flow rates;
Today was there weight loss or gain?

“Mr. Jones! Mr. Jones! Mr. Jones!”
called a tired but firm young voice.
Tired eyes above an endotracheal tube
Opened to silence the noise.

The intern left after data gathering,
Leaving a sea of tubes and pumps.
Amidst them, a Mr. Jones closed his eyes
Again to resume the waiting…

Getting a license to practice medicine and a DEA number

9/4/2006 5:28 pm

Some of us have today off, being Labor Day and all. I am enjoying this breather after a heavy month on the Pediatric Wards. Don't get me wrong. I LOVE what I do and like many of you, I aspired for this 'dream life'. No regrets!

I also wanted to share the good news. As of August 2006, I am now a licensed physician. It is customary to put in an application at the end of internship for a license from the state where you are. This is not a training permit, but the real thing -- the license you will (if you continue to renew it) have for the rest of your working life. Well, after due process -- without any hitches, I was given a license.

After getting the license, I was able to apply for a DEA number. This is the number the Federal Government assigns to health professionals writing prescriptions for narcotics. The Drug Enforcement Agency uses this number to track licensed health professionals' prescription activity. Incidentally, most pharmacies will not fill ANY prescription written by you without this number, even if you are licensed. (Go figure!).


I understand that there are not many states that will issue a license to a foreign medical graduate after only one year of post-graduate training. I guess I am fortunate to be in one of those states.

End of Internship year

Well, it is July 4, 2006. I am post-call and although tired, felt like browsing the forum and thought it would be nice to record some thoughts on completing the internship year. Perhaps those of you in a similar position might want to share your stories too.

What a year it has been! Well, first off, as a Med-Peds resident, I should qualify my experience. In med-peds, unlike categorical residencies, internship lasts 14 months instead of the usual 12. This is because we are doing two residencies and need to fulfill criteria for completion of core curricula in each. That means that although I am now a PGY2, I am still an intern for another 4 months (this one included). I also have the rather odd position of being a senior in medicine and still an intern in pediatrics.

The exciting event on the horizon for all of us is getting our licenses! This happens once your program submits a document to the state medical board to say that you have completed one year of post-graduate training. All the rest of my paperwork is done and I should expect the license in about 2 weeks to a month. At that point, I will be able to sign prescriptions for all things except narcotics. That latter privilege comes after I get an assigned DEA number. I need the state license first. It is interesting that there is no 'other' license issued to you at the end of residency. This is it. Of course, being licensed in one state means you can only practice in that state. Some states have reciprocity agreements and grant licenses easier if you are licensed in one of the states they have an agreement with. (I haven't investigated that much; having a license is plenty good enough for me for now).

It is interesting how I feel a little changed through this first year. I am a little (just a little) more sure of myself in the hospital and clinics. At least things are more familiar (I know where the cafetaria and rest rooms are) and I feel that I can usually do a few things rather than stand around biting my nails when things get scary. I am particularly proud of my ability to put in central lines (the subclavian is my favorite) and in my program, I have something of reputation for that.

To those of you who know me, I still draw biochemical graffiti on blank blackboards, greenboards or whiteboards whenever I see one. The program and residents tolerate me in that regard. You know, I think you really don't really how much has changed until you look into the eyes of the new interns and see their dazed look or they ask you questions and somehow (miraculously) you know the answers. Being a senior is kind of scary because while the intern does the H & P, you decide the management plan. Somehow though, I am not afraid of that responsibility and feel up to the challenge.

The USMLE exams are now a distant memory and are only relived whenever the intraining exams come around (which for peds is in a week).

Internship -- Critical Care

Hi guys!

I just came through spending a month in critical care medicine, and I think I've found my true love. At first, I was nervous in the CCU (Critical Care Unit). Everyone looked so fragile and on the edge of life (most of them just don't look like that, they are!). I was afraid to do anything -- a physical exam, ask questions or anything. By the end of the month though, I have lost that fear. I feel like I know a little more of what to do there. I got a chance to intubate a couple of people, participate in several code blues (cardiac and/or respiratory failure) and was part of several death-and-life dramas. There were many cool experiences.

And oh by the way, all you guys who gave me grief for spending so much time on the Henderson-Hasselbalch equation in biochemistry, just wait till you see how useful it is in critical care and how much you will use your knowledge of blood gases. More on that later...

Vijay

Marshfield Clinic magazine article

During my internship year, one unexpected surprise was a visit from a 'reporter'. This person worked for an inhouse publication called The Scope -- a publication put out by our institute's division of education. I was told that they wanted to interview the new residents to find out how things were going.

The only time I could find to do this was one afternoon, post-call. So, after a particularly busy night and morning, before I went home, I met the interviewer and answered some questions. The result is this article. I guess it is part of posterity now.

From the trenches of internship

11/13/2005

I am doing a Med-Peds residency at the Marshfield Clinic & St. Joseph's Hospital in WI. This was my first weekend off in 6 weeks. I actually got both Sat and Sun off -- didn't have to go to the hospital, didn't have to answer pages. Unbelievable!

I just wanted to say that residency is great but can tax you physically. I had to make a poster presentation at the American Society of Human Genetics last month. I was up all night preparing the poster. The next night, I was up all night on call. The following day, I was post-call and snoring loudly in the plane from Marshfield to Salt Lake City. I presented my paper the following day. The next morning, I was on the plane back and on call the following night.

Having said all this, I would not trade it for the world. I am living a dream. I am learning and doing a great deal and loving every minute of it. There are poignant experiences that burn into one's memory: like doing chest compressions on an 8 month old female infant who did not survive the code. I had been up all night and the child was flown in by copter in the morning, pulseless and not breathing. I don't think I shall forget that experience.

To all you medical students out there, doing USMLEs, attending classes and looking forward with trepidation to residency: hang in there; learn the best you can; make the knowledge yours -- not just short term memory for a test. You will need it! But it's worth it in the end. During residency, no one cares where you went to medical school, what grades you got in path or physio or whatever, or what scores you got in the USMLE. Everyone comes to know what you do and don't know by the way you function on the wards and in the clinic. It's the knowledge that's really yours that shows then.

Passing the last USMLE exam -- Step 3

I received good news over this 4th of July weekend and wanted to share it with you. In order to qualify for an H1-B visa, my residency program required me to take the USMLE Step3 before they could offer me a contract. It was scary thinking of doing step 3 before beginning residency. Did you know that while the pass rate for steps 1 & 2 for foreign medical graduates is in the 80s, the pass rate for FMGs for step 3 is only 56%? I wonder why. I have read horror stories on the web of folks who got 98 and 99 in steps 1 and 2 and then failed step 3. So I was nervous.

Anyway, I found out on Saturday that I have passed Step 3 with a significant margin. I want to encourage all of you out there from MUA and Saba that our schools do deliver the goods. I am proof of that. Keep working hard and you will match in the specialty you want and hopefully, where you want too.

Vijay

Good NEJM articles on becoming a doctor

In the last two issues of the New England Journal of Medicine, there have been some excellent articles regarding becoming a doctor...1. Abraham Verghese's The Calling talks about how he came to choose medicine as a career and the importance of literature in developing as a physician (if you were my student, you can guess why I liked this one).2. Dr. Treadway's The First Day describes the experience of learning to take a good history and conduct a good physical examination and how learning these skills go hand in hand with developing compassion for patients.3. Sobel (a fourth year medical student) writes about the language of medicine one learns while a clinical clerk -- its great reading for learning to give the short presentation of your patient on rounds, to an attending or a consulting physician.4. Dr. Goldfinger (no, I do not think he is a proctologist) writes a humerous but pointed piece about the use of medical jargon and acronyms in medicine -- especially in students' presentations.

Match Results 3/18/2005

This is a quickie...

I remember the moment I found out where I was to spend the next four years of my life doing residency. I was working in a lab at the NIH. It was 3/15/2005 -- Match Day. I had been logging on to the Match website every few moments waiting for my news. It finally came! I had matched in Med/Peds in the Marshfield Clinic in WI. I remember going down and stepping outside the building. It was a cold morning. I called my mother in Panama and gave her the news. I posted a message on our school's clinical experiences web site that read:

Congrats to all of you out there that matched this year! I've heard from a few folk with their good news. As for me, I matched in the Internal Medicine/Pediatrics program at the Marshfield Clinic in Marshfield, WI. I am thrilled that I got the specialty of my choice. I am also thrilled that I got into the Marshfield Clinic -- a national center for genomic medicine as well as a major place with lots of fellowships and residencies.

I am sure we all share the same feelings of gratefulness to our schools' faculty and administration for all their support and help through the years that led to this day.

First Call Night in Ob/Gyn

March 14, 2004 8:35 pm

It’s the first call night. It’s been an interesting day. I came in at 5:00 am and found the night resident. He told me to hop to it! I had to have notes written on all the post-partum patients before the morning resident was to come in. Of course, I had already begun and he was pleased to know that I had the notes all done. We had a lady come in. She was not quite in labor but the fetal monitor showed that the baby’s heart rate was decelerating. In a flash, we were all in the OR and the morning resident, to whom we had not even had a chance to say ‘Good Morning’ was doing the C section.

Things slowed down a bit after that. Outpatient got interesting. A Vietnamese couple came in. The woman was having some back and abdominal pain. This was her second pregnancy. She was only 20. I did an H & P on her. As we monitored her, it appeared she was in the beginnings of labor. The attending physician was contacted over the phone. He instructed us to admit her. We did. I began writing labor notes on her, monitoring her progress over the next couple of hours. I was called to outpatient to look at another patient. About 25 minutes later, as I walked back to the nurses’ station opposite the L & D rooms, I noticed activity in my patient’s room – the Vietnamese lady. I rushed in to find that the baby had been delivered, by the nurse. Things changed so fast that not even the resident could get there from the call room a few doors down the hall. I watched as he sutured a tear in her vagina. Babies can come so fast!

It’s a couple of hours later. I just checked in on the patient again. She is sitting up in bed, her husband beside her. Their little baby girl is in a warmed crib. They are eating sandwiches and watching ‘Men in Black’ on television – just another evening. Imagine that! It was a pretty picture.

Last Friday was not so pretty. We were in outpatient and saw a 33 year-old G3P0. She had got pregnant after 10 years, after having lost her previous two pregnancies at 9 weeks – one a placenta previa and the other a miscarriage. She came in, this time at 9 weeks complaining of bright red bloody discharge. We checked her and she was rushed for a stat ultrasound, where it was determined that her fetus was no longer viable. Of course, she was very tearful. We admitted her to the unit and in a couple of hours took her into the OR for a D & C. It was kind of ironic. The D & C was being done by a 3rd year Ob/Gyn resident who was pregnant herself. A female medical student who was in call and myself, who stayed behind to watch this procedure were in the OR with her. When the anesthetic began to wear off in the OR after the operation and as we wheeled her into recovery, she sobbed uncontrollably “You took my baby. My baby’s dead. I want my baby. Why did this happen to me?” I had spoken to her for some time, comforting her before the D & C. She cried, believing that she might never get pregnant again.

As I stood in the OR recovery room trying to pacify her as she sobbed inconsolably, I thought of that verse from the Bible “Rachel weeping for her children and refusing to be comforted, because they are no more.” Who says OB is always a happy specialty?

First day in Ob/Gyn core rotation

3/9/2004 9:41 pm

Well, Psych is over and I was excited about getting started in ob/gyn. I was apprehensive about this rotation because: (1) I am a male and have limited exposure to female problems (no jokes, please!), (2) I do not have any children and have never witnessed a live birth and (3) I have not been around infants and small children a lot.

I arrived my first day at 5:30 am. Our scheduled time of reporting in was 6:00 am. However, I always find it useful to arrive in time to meet the night shift of nurses and get a heads up on what's cooking. We had one first-time mother (grava 1: Para: 1) ready to give birth. Since she had been there since midnight, it was decided to induce contractions with oxytocin (Pitocin). By about 6:30 am, the resident decided to induce artifical rupture of membranes (AROM). pardon the comparison but seeing the meconium-stained amniotic fluid flow out of the vagina was like watching Linda Blair vomit the green stuff in the movie 'The Exorcist'. By about 8:00 am, the baby's heart rate began to fall into the 80s. Interesting that for fetuses, normal HR is 120 to 160. Anything below 120 is considered bradycardia. Interesting contrast with adults where normal HR is 60 - 120 and anything above 120 is considered tachycardia. Anyway, after trying various things -- adjusting the position of the mother, discontinuing the oxytocin drip, a decision was made to do a C-section. Since this was my first day in the unit and I had never scrubbed in for surgery before, I was assigned the role of watching another medical student scrub in and told to observe everything she would do during the procedure.

The C-section was great. It was everything I had read and seeing the baby be drawn out of the opened uterus was the coolest thing I have seen yet. The resident did all the work, while the attending just helped. I had a great view and could see everything clearly.

We went to lunch afterwards and I had a pizza with lots of tomato sauce (I know, pretty sick of me, no?). The rest of the day was kind of slow. I developed either the beginnings of a cold or an allergic rhinitis and was sneezing all day. That was not so good. My first call is Sunday. It seems that in this unit, medical students are really encouraged to participate in delivering babies, procedures and the like. I am excited and looking forward to every day here.

Shock Therapy

It was my last day in psych and I got to see some interesting stuff. A patient in the unit who suffers from severe depression was found to be a suitable candidate for ECT. A nursing student (an ex-Vetinarian) and myself (an ex-Biochemistry) accompanied her from the unit to the Main Hospital where ECTs are done on the 5th floor. We chatted with the patient. She was nervous, even though this was the second ECT treatment she had received. Once in the room, an anaesthetist proceeded to administer Pentothal and succinylcholine and robinol. In addition, since she was being treated with benzodiazapines for her depression, Romazicon was also administered to lower her seizure threshold. She was administered 50 sec of 80 mA at 220 ohms resistance, which translates to about 176 volts. The entire procedure was followed on a monitor (to watch heart rate and blood pressure) and an EEG to follow the seizure activity. Because of the muscle relaxant, the patient did not 'jump off the bed' when the shock was administered. Furthermore, the major region of the shock was the temporal lobes bilaterally.

The patient regained consciousness soon afterwards in the OR holding room. She did not remember who the nursing student and myself were due to loss of short term memory. Overall, the procedure was nothing spectacular to watch. ECT is administered in a much more humane way these days with appropriate anaesthesia and limiting the major electric disturbance to the region intended. It is still a treatment modality of choice in certain refractory depression and even mania cases.

I talked to God today

Mentally Retarded and Emotionally Disturbed Children.

Today I got to spend several hours sitting in a class for ‘low-functioning’ mentally retarded and emotionally disturbed children. There were about 6 children in the class. One was a 12-year-old with Fragile X syndrome, another a 14-year-old with an IQ of about 60, a couple of girls – 9 and 11 with autism and mild MR with emotional disturbance respectively and a conduct disorder MR child (age 12). The level of the class was about that of a kindergarten class. Basically, the kids worked on tracing the lines in coloring pictures. They went over some flash cards of common signs (such as danger, poison, pedestrian crossings, etc.).

It was discouraging to hear that the two girls were raped as toddlers, one by her father (now in prison) and the other by several men at different times. Apparently, sexual abuse of the mentally retarded tends to be more common than of normal children.

It was interesting to interact with children suffering from disorders that I had only studied about in medical genetics and other courses. I had interesting discussions with their therapists and teachers regarding the goals for the children and the methods of communication. Most of these children have difficulties describing their feelings. Picture books and clever techniques are used. I felt a sense of admiration for the teachers and therapists that work with these lowest level of functioning children. Often the goal is simply to get the child to follow staff directions, to raise self-esteem and to help the child achieve the level of independence of function he or she is capable of, e.g. dressing themselves, toilet hygiene, anger management, etc.

In the afternoon, I got to talk to ‘God’. This was a 50-odd year old male who for the past 11 years has had the delusion that he is God. He does, however, also know that ‘here’, he is identified by the name that is on his official records. When he was brought in, he was paranoid, believing his neighbors and his wife and his doctors wanted to kill him. During the mental status exam, when I asked him to interpret the proverb, "People in glass houses should not throw stones" he laughed and told me "yeah, that's stupid, because the glass would fall on me!" He has since overcome this belief somewhat. He still maintains that his neighbors are trying to get him but he is content to ‘what goes around come around’. He no longer seems to manifest any homicidal tendencies. What is this person’s baseline function? What would be our goal for the inpatient treatment he is receiving? Today, he was due to appear in court. He told me he was going to tell the judge that he was ready to go home. Do we have any hope of convincing him that he is not God? Or should be just release him back into his situation when he is no longer a threat to self and others? I had some interesting discussions with his therapists and psychiatrist on these matters.

Child Psychiatry

Well, this past week, I have working in the childrens' psychiatric unit. At first, I was apprehensive since I have not been around kids a lot. I wondered if I would be able to relate to them and help them. The apprehension was soon replaced with a kind of sadness as kids matter-of-factly told me their stories. We had one kid who was admitted to the unit because he had thrown a chair at a teacher (in the US, you can forcibly admitted to a psych unit -- EOD -- emergency ordered detention -- if you are considered a harm to yourself or others; this kid fit the latter requirement). It turns out that he has a lot of problems, losing his temper and getting into fights with other kids and adults. The only person he does not fight with is his mother. When I asked him about his dad, he told me his dad was in prison. He last saw him 3 years ago and last spoke to him a year ago. I asked him if he missed his dad. He shrugged his shoulders and said that "a little", then added that he hadn't got to know him really well, since he had been in prison before and was only out for a short while before he was back in again. His problem: depression. Well, I think I would be depressed too! We are giving him anti-depressants and teaching him 'anger management' skills. Another kid has been hallucinating since the age of two! He hears whispers around him at all times, sees snakes and imagines his entire past. The prognosis for him is not good. He is a loveable, if somewhat hard to manage kid, but one who has developed the symptoms of schizophrenia very, very early. Of course, there are several mental illnesses in his family: schizophrenia, bipolar disorder and depression. That can't help. There are lots of stories to tell. Every child is a story, most of them not happy ones. I mean, how do handle hearing a 9 year-old girl tell you that she wants to kill herself because she bear to go on living? She even had a plan -- to slit her wrists. Interestingly, in this particular case, we could not find a precipitating stressor for the depression. Of course, there is a family history of depression, though none of suicide. There were many interesting cases.
I really came to love the staff who work there. They love the kids and discipline them too. The kids know that they discipline in love, so they love them back (that is, those kids that are capable of loving; we have some kids with attachment disorder, who do not know how to do that).
This coming week is my last week in psych. After that, I begin ob/gyn. That should be 'fun'. I have never seen a live birth before, so working in the L & D (Labor & Delivery) unit should be lots of fun. I also look forward to gynecology -- everything from routine pap smears and pelvic exams to surgery).

The Charles Manson Fan Club of 1

I just had to talk about this session this afternoon. The patient is a 20-something caucasian female, slightly obese, dressed in a T-shirt and jeans. She sat with a grimace on her face and pulled at her shirt sleeves, looking somewhat uncomfortable, somewhat anxious, somewhat depressed. The session blew my mind away. She talked about being a fan of Charles Manson. She sent death threats to another psychiatrist who hospitalized her over Christmas for suicidal ideation. She said to relieve stress she was thinking of doing something different... like smashing someone's head with a sledgehammer. Her therapist recommended she try smashing a watermelon first -- you know, just for practise and to see what she would have to deal with afterwords. She did. She set up the watermelon in her kitchen and smashed it with a sledgehammer. Somehow, this convinced her to abandon her plan because she says she's been cleaning out watermelon seeds and pieces from all over her kitchen for weeks now. Instead, she thought she might try jumping from a high point. I thought she meant bungee jumping, but further elaboration revealed she meant without a cord or a parachute. I surmised this when she said "the jump would be fun, but hitting the ground would hurt." Incidently, she brought in something she had sketched. It was a pencil sketch potrait of herself, drawn as Mona Lisa sitting in a bathrobe on a torn sofa. The Mona Lisa looked liked a photograph. I thought she must have been drawing it from a picture. She casually mentioned she had drawn this from memory. Of course, how much of this was shock value and how much of this was psychosis? Apparently, her body is like railroad tracks from the self-mutilation. Laugh if you will, but look behind you when you're walking home alone at night...

In the morning, I got a wish I had for some time. I was really interested in seeing dementia -- vascular, Alzheimer's infectious disease-induced... Well, I spent the morning in the geriatric psych ward. Fortunately (or unfortunately), I had been on call with my attending covering all the patients there both Saturday and Sunday, so this morning when I went to see them again, but this time with an internal medicine doc, I felt like I was meeting old friends. One of them -- a troubled 60-something year old female of mixed caucasian-indian descent came up to me and hugged me and woulnd't let me go. This, in the middle of the lunch room at lunch time. Whether from the meds she was on or from previous activities, her voice was heavily slurred and words came out agonizingly slowly. As she held me close, she announced to me and to all present, "Doctor, will you kill me please?" Then in a little louder voice, "Please doctor, kill me!" Finally, screaming while hugging me tighter, "Kill me, Doctor!" Okay. So I think I've seen enough dementia. There was one really cool thing though. Over the weekend we had seen this sweet little old lady with crippling parkinson's. Today when I saw her, she kept sticking her tongue out at me in a tic-like fashion. It took me a few seconds when I realized what I was looking at...tardive dyskinesia. And finally, there was the retired psychiatric Charge Nurse who over the course of her 40 years of service has probably trained half the psychiatrists in the state we're in. My attending spoke respectfully to her and told me later that she taught him and helped him a lot when he was an intern 20-odd years ago. Her memory has gone to pieces, but as is often the case in such dementia, when he quizzed her on some old psychiatric drug pharmacology, she spit out the answer even before I could hazard a guess. I'm enjoying the psych rotation... in a strange kind of way. Now when I walk in the mall, I see people differently...

More later...

The woman with no hair anywhere

I met an interesting pt during one of my weeks of rotation in psych. She appeared to be a pleasant Caucasian female. Moderately obese in either her late 30s or early 40s Some years ago, she was disgnosed with panic disorder with agoraphobia she was admitted to our inpt. facility here and received treatment. She is much better now. She recently gave birth. She has children from a previous marrage. Her ex-husband -a cocaine addict is having Paranoia and hallucinations.

When this woman had panic attacks, she was put on Paxel. Apparently. A rare side effect of this group of drugs ( the ssris) can be aloepecia totalis the complete loss of all hair. Sae has no hair anywhere! she has approached the makers of the drug for compensation but so far has got none. she was telling us how expensive wigs are to maintain if one wears them all the time as she is forced to do. She was an interesting person, telling us of her ongoing interests in sports. She takes care of a house of children and occassionaIly a psychotic ex -husband.

She was also reporting on another interesting side-effect of ssris. Vivid dreams and nightmares. Apparently. These are due to serotonergic activity.
I thought the unfortunate side-effect of aloepecia totalis was interesting and unfortunate, especially for a young female.

The Psychotic who predicted her death

This is the story of a dear patient. Sne was a cauc. Female in her early forties who was found orthe floor of her home in feces and filth. She was malnourished.when we interviewed her,she was actively hallucinating. She saw bugs, heard voices. In got to do the complete psychiatric interview on her. She was very interesting. A few days ago, in the early morning, she was found pulseless and not breathing. A code blue was called. PEA was identified and the appropriate procedure initiated. Forty minutes later, a pulse and respiration was re- established. We do not know how long she was down for. since the last person to see her active was a phleblotomist who came to draw blood @ 4:10am in the morning.

She was intubated and transferred to the icu as I write this. Will she make it? She told a nurse yesterday that today she would die. Depending on how long she was down, her brain has been deprived of O2 for a good while. Did she attempt suicide? If so, how? She told another med student yesterday that there were 2 people in the roomM with her (hallucinations). Did 'they' kill her?

Iain writing this update a few days later. The pt. is dead. She died in the evening after we all left the hospital. From the time she wss transferred to the lCU she never regained consciousness. We determined that she was breathing a little on her own, but otherwise there wss minimal brain function. We had her on 8 ug of dopamine to keep he BP up. Towards the end of last week, it was agreed upon by family and her attending doctors that she was never going to regain consc. Her pupils were fixed and dilated and she showed only primitive reflexes. Her relatives asked that we disconnect all machines. Her attending physician felt that this would be too aggressive and active a move. Instead, heopted to keepthe ventilator on. Towards yesterday evening the pt. began to develop a climbing fever. Nothing was given for it. This was the acute Cause of her demise.

This case was interesting because of the rapid turn of events, the psychosis and in the end, our inability to elicit a favorable outcome for her. It was a tragic story. I believe that everyone acted appropriately. However, none of us who participated in the case came away happy. We lose some battles in spite of everything.

Juvenile sex offenders

Thursday, February 05, 2004 Juvenile Sex Offenders – a first experience

It was an interesting day. I was scheduled to spend the day with Dr. B – a psychiatrist in the Adolescent Unit. I met him at 8:15 am in the unit on the 3rd floor and sat in on the treatment plan meeting. During this meeting, the psychiatrist, therapists and case manager (along with medical students, nursing students and a few other odds and ends) sit in and discuss the progress and plan of each resident. Before the session, I accompanied Dr. Bell to do an H & P on a patient admitted the night before. She was a 14 year old girl. She was admitted for feeling suicidal. I learned that she had been raped by her step-grandfather. She had marks on her wrists from where she has cut and mutilated herself in the past. During the treatment meeting, there were may interesting cases. There is a lot of history of abandonment, neglect, drug abuse and poor parenting. There are also a lot of examples of physical and sexual abuse. The unit we were in was the acute unit: where patients are admitted for short periods of time – upto a couple of weeks. This is in contrast to the unit on the 4th floor, where patients spend 6 months to a year. These are patients with no where else to go – they have been thrown out of practically everywhere else.

After the meeting, I went to the hospital to go psychiatric interviews on two consults for Dr. C (my attending). The first one was a 50 year old Black woman admitted for CHF, hypothyroidism, DM2 and gouty arthritis. She was cooperative and described being institutionalized when she was 11 years old because of physical abuse by an alcoholic mother. She was kept in various institutions until she was 17. The second patient was a contrast. He was a 46 year old white male with a relatively high level of functioning. He felt the human race was nothing but “technologically advanced cockroaches.” He was suspicious and declined to participate in the interview. I managed to get some information about him. He reports being allergic to Thorazine – “causes muscles all over my body to lock up”. He has been institutionalized and used drugs in high school. I wrote up the reports and took them over to Dr. C who by that time had returned from his talk in another city. He felt that the male patient must have been a late onset schizophrenia in view of his high level of functioning and intelligence. He explained that perhaps his animosity to the questions and his decline to participate in the interview was because of a sense of shame and feeling that people treat him differently because of his illness. When I asked him about suicide ideation, the patient had said “I’ve been asked that question so many times and I think it is a personal matter.” He denied homicidal ideation. And admitted to having been given Thorazine for the first time in a state psychiatric facility, I found out later. We also chatted about astronomy and Mars, since the patient expressed interests in those areas. I promised him a magazine on Mars.

In the afternoon, I drove in the snow and rain over to the other campus of our Bahavior Medicine facility on 59th street. This is the facility where the geriatric and juvenile sex offenders units are located. I spend the afternoon reviewing charts and reading about juvenile sex offenders. The first chart I read was the case of a 14 year old boy who had raped his 8 year old half-brother in a foster home. He had had anal intercourse with him. Later, to prevent the child from telling on him, he had suggested to him that he poison the entire household. When that didn’t take, he stole his foster father’s gun and gave it to the boy and suggested that he shoot himself and end his life. The boy eventually told someone and the patient was taken into custody and brought to this facility. His own history is interesting. He is the product of an incestrous relationship between his mother and his maternal grandfather. He was eventually taken away from his mother because of her abuse. He was physically and sexually abused by her boyfriends and male relatives. The stories of most of the boys in the facility – ages 13 to 17 were similar with elements of abuse and neglect. Interestingly, many of them sexually abuse boys 5 years younger than themselves in the same age and in the same way as they themselves were abused. I then sat in on treatment plan meetings, in which the boys were brought in one by one to a meeting with the therapist, the psychiatrist and the Charge Nurse. Besides myself, a social work student who works at the facility doing her practicum were also present.

Rather than be disgusted and feel hatred towards these boys, I felt a morbid curiosity. It is creditable that the state does not just lock them up and throw away the key. After all, they have committed heinous crimes and are in such small numbers that one might not want to invest resources in ‘fixing’ them. As a Christian, I struggle with the finality with which specialists and experts pronounce judgment on the future of these and other pediatric patients saying they are marred for life. The Bible teaches that one can be completely made anew.

I love what I do...

Competency

February 5, 2004 Competency

Today’s learning experience in psychiatry can be summed up in one word: competency. We were consulted on two patients. We were asked to determine whether they were competent enough to make medical decisions.

This pt. is an 88 year-old black female who has suffered 2 strokes in 2003. In Jan .2004, Home Health called EMSA and asked them to take the patient to the Emergency Room because herb lood pressure was elevated. More importantly. Her speech was slurred. This pt. had been living on her own all this time, by herself, with someone coming in to help her with groceries

The pt was admitted to our hospital a week earlier. Psychiatry was called to assess the competency of the pstient. I found her in her bed talking to an empty room. When I asked her any questions, she would answer but then she would keep talking.

Finally, I asked her if she knew why she was in the hospital. She said she knew she had a stroke. She emphatically communicated to me she did not want to go to a Nursing home. She wanted to go home, she said. When I asked her why she had refused to take injections. She got a bit agitated. She said that her doctor thought she was crazy. He was trying to give her medicine like Haldol for being crazy, but she was not crazy. She said she wanted to gone home.

Question: Is this woman competent? If we decide she is incompetent to make decisions, then we must release her to home. If on the other hand we decide she is incompetent She will be forcibly administered Haldol. What are we to do?

This case raises the question of whether an elderly person who is not choosing well is necessarily incompetent. She may not necessarily be choosing wisely. She also may not be the smartest kid on the block. However, all of us perhaps know some cantankerous old folks, fiercely independent who live life on their own terms. When do we infringe upon their autonomy?

I learned from my attending that one asks several questions, such as

Do you understand your illness, that you are sick and in need of treatment?

Can you understand the treatment options, their associated risks and benefits and what they mean?

Can the patient hold the information needed to make a medical decision in their minds in an orderly and rational fashion?

If the answer to any of these questions are ‘no’, then the patient is deemed non-competent to make their own medical decisions. It is, of course, highly subjective

Our second competency case was a 46 year old Caucasian male. He appeared highly intelligent but somewhat bizarre in behavior. He spoke with stilted speech and during the course of the interview would go from being friendly to clamming up and withdrawing from giving more information. When asked about medical issues, he answered, “I think it is personal” and would volunteer no more information. He used the same words and answer to several subsequent questions (preservation). If we changed the topic and asked about something else, he would answer in short sentences. If we talked about sports or astronomy (his interest), he would thaw out, but only a little. Lately, he had been refusing medications. When asked about it, he denied he had done so. My attending found him non-competent to make medical decisions.<

Both the above patients lost their autonomy in the hospital setting and would now have little or no choice in their medications, perhaps need to be restrained if they became uncooperative. I shall keep following the case to see if their consciousness resolves and they regain their competence

A case worker for the first case told me that if a person is found non-competent, then a state body called Adult Protection Services comes in to protect them from themselves. They may be placed in a group or nursing home. The philosophical ramifications of today’s experience were immense and gave me a lot to think about.

Drug reps and Pharmaceutical dinners

Wednesday, February 04, 2004 The world of drug reps and drug company sponsored dinners

I am learning that drug reps can be a great source of information. However, one has to learn how to ‘exploit’ this resource just right. I am not talking about exploiting them literally. I am referring to learning and getting as much knowledge as I can for the benefit of my patients. I had an interesting experience this afternoon. The rep from Zoloft came over. Since my attending was busy, I talked to her for a bit. She gave me a brochure that showed a study comparing weight gains with Zoloft compared to Paxil. The graphs showed that patients on Zoloft had a much lower weight gain than patients on Paxil. Okay; A hour or so later, the Paxil rep showed up. She spied the Zoloft literature on the table and asked me about it. I shared the results of the study with her and asked her about the weight gain issue. Well, she produced another full-color brochure with a different study comparing the effect of patients taking Paxil to placebo. Her study showed that patients on Paxil actually had less weight gain than patients on placebo. It was an interesting contradiction – the two studies showing opposite findings. The next day, the rep from Wellbutrin came over. She had some things to say about Zoloft and Paxil and compared them to Wellbutrin. I think that if one listens critically, one can learn quite a bit from the comparative assessment. Finally, I asked my attending what he thought about these drugs and what his experience was using them. All this coupled with reading the relevant chapters in Blueprints in Psychiatry made for a good pharmacology learning experience. Moral of the story: learning to critically evaluate facts, studies and such and drawing the best conclusions.

Today I also got to go to my first drug-company sponsored dinner talk. It was held at a fine restaurant in Bricktown. I arrived at the restaurant to find about 20 people. I sat with an elder Indian couple – husband a general surgeon and wife a psychiatrist at the VA. The speaker was an asst. professor from USC, LA. He spoke about the use of Risperdone in bipolar disorder. The talk was in PowerPoint and interesting. He made disclosure that he was a consultant and speaker for several drug companies. The food was great – lobster brisque, cold water lobster tail, cheesecake, pasta. I loved it. After the talk, we all went our separate ways. I kind of enjoyed being a medical student/future doctor this evening. One wonders about the ethics of such things. Surely, the good treatment and food softens one up a bit to the drug reps and the companies and products they represent. It probably doesn't hurt either that most of the reps are pretty, well-groomed (well nourished and in no apparent distress, but I digress) and seem to flirt and flatter a little as they deal with us. Maybe that's just marketing...

First week in Psychiatry

1/31/2004 2:38 pm

I finished my Internal Medicine on a Friday and began my psych rotation on Monday, Jan 26, 2004. The first day, I was asked to report to my preceptor, Dr. C at 8:00 am in the morning. This itself was a big difference from IM where we used to report at 6:30 am. Dr. C is the head of a department of Behavioral Medicine. The first day was kind of unstructured. He took me around to the Children's Inpatient unit, the Adolescent Inpatient unit and the Adult Inpatient units. We also got a glance at a special unit for mentally retarded children. I basically got to spend the day in the lounge outside his office. He could not let me in while he interviewed some patients as my presence would affect the dynamics of the interview.

The Department of Behavioral Medicine has several programs/units:
Child Psychiatry
Adolescent Psychiatry
Adult Inpatient Units
A special unit for children and adolescents with mild to severe mental retardation
A Chemical Dependancy Unit and
An outpatient facility that runs intensive throughout-the-day psychotherapy, psych-education programs.

In the afternoon I got to sit in on the outpatient day therapy sessions. They were in groups and the topic being discussed was dealing with grief.

During the rest of the week, I spent a couple of days at the Chemical Dependancy program attending the day sessions -- almost all of the therapy is done in groups in this unit, and studying the drug protocols in the charts. For alcohol dependency/abuse, the detox protocols consisted mainly of Librium and Clonidine. I was surprised to learn that Clonidine is used. I was told by a psychiatrist in that unit that alcoholics will often exhibit sympathetic respnses during their detox -- higher blood pressures, perspiration, tremors, and that Clonidine helps with this.

Since my days were so slow and I was not spent yet, I volunteered to join the staff that man the ER in the 3:00 pm to 11:00 pm shift. Apparently, that is when they get most of their admissions to the psych unit. I was amazed and appalled at how many people come in with suicidal ideation and even a plan. Amazingly, almost all of the people I saw in the first week there were females in the ages ranging from 13 to 25. One evening, after 4 such "I want to kill myself" cases in a row, I was somewhat encouraged when the fifth person I interviewed, a 31 year old Caucasian male said "I hear voices". I asked "What are the voices saying to you?" The answer: "The voices are telling me to kill myself. Here we go again...

I like working the ER because I am getting to see some florid pathology and I get to practise my ability to do the mental status exam and come up with the appropriate DSM-IV diagnosis.

More First week in Psychiatry

1/31/2004 2:29 pm

I spent a couple of afternoons during my first week sitting in on Treatment Team meetings. This is when the Treatment team consisting of the psychiatrist, case managers, psychotherapist and charge nurses present updates on each case to the psychiatrist. A plan is formulated in terms of time to be spent on the unit, med changes, therapy changes, etc.

I was absolutely thrown offbalance by the horrible stories I heard in the Treatment Team meeting of the Children's Unit. I was told stories of drug-addict parents, abandoned children, physically and sexually abused children (one child was sexually abused by her grandfather from the age of 6 months to 4 years of age) and drug babies -- children affected by their mothers having taken drugs or alcohol or both during the pregnancy, or of mothers using damaging medication while breast-feeding their kids.

One 2 year old was found on the streets by police, wandering by himself. When asked what his name was, he said "Motherfucker." He'd probably been called that so many times, he actually thought it was his name!
I have been learning about attachment disorders. I was so moved that I went out and bought a couple of books about it to learn more.
On a more practical note, stuff in the basic sciences that relate to this rotation are:
DSM-IV criteria for diagnosis, Mental Status Exam, The psychiatric interview, and mechanism of action of all the drugs -- antipyschotics, anti-depressents particularly.
More later...

Advice to the third year med student doing psychiatry

I finished 6 weeks of my psychiatry core rotation last week. It is Sunday as I write this and tomorrow I shall begin a rotation in ob/gyn. I wanted to sum up the rotation.

It was interesting that in this hospital, I was told not to wear my white coat and that I would probably not need my stethoscope, although I was to keep both items close by (in the car) in case I needed to a physical exam. Throughout the rotation, the procedures I learned were: the complete psychiatric interview, writing a progress note on inpatients, writing a consult note for hospital patients on whom we were called in for a psych consult, the Mental Status Exam, the Mini-Mental Status exam, contributing an evaluation to furnish materiel for a psychiatric evalulation of competency.

I got to spend time in: outpatient group and individual sessions with both the psychiatrist and therapists, medicine management meetings, inpatient adult, adolescent, childrens' and mentally retarded children with emotional problems facilities. I also got to visit geriatric psychiatric facilities and a special facility for juvenile sex offenders. I got to see take-downs, face-to-face evalulations, ECTs and pts. in various stages of mania, psychosis, depression.

I thoroughly enjoyed the rotation. My only peeve was that things were pretty slow and some days, there was precious little to do. I like to be busy and some days I wasn't very.

Recommendations for books and things: I highly recommend the Blueprints for Psychiatry 3rd edition. It has additional materiel and questions not found in the previous editions. For the PDA, I highly recommend the Washington Manual Psychiatry Survival Guide. This is a new program from Skyscape. It is EXCELLENT. It has discussion articles on each of the major disorders, an abbreviated DSM-IV, a drug formulary and full examples of every kind of note I needed. Buy it. It will not be a waste and you will not have to carry any other book or PDA program in your pocket.

I am looking forward to the next rotation...