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.