Saturday, August 23, 2008

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.

Sunday, April 27, 2008

"...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'

Sunday, April 06, 2008

"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.

Wednesday, March 26, 2008

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...

Saturday, March 22, 2008

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?

Saturday, March 01, 2008

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 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.

Tuesday, January 29, 2008

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...