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.