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?