Trust

I have just read some devastating news. A gastroenterologist known to me professionally has been arrested for fondling his patients while they were under sedation. This is shocking in so many ways. First, there is the betrayal of a sacred trust between a doctor and his or her patient. Second, this man was a very accomplished, scholarly and outstanding citizen, who had even served his country in the Armed Forces. Thirdly, he was a christian, a father who had adopted children from a third world country and one known for compassion and excellence. I have worked in that department and I am not sure how he could be alone with the patient to have indulged in this behavior. There is normally always a nurse, a tech or a family member present. There are always people walking around -- nurses, tech, transport people.

I pray for his family, for his patients -- both the ones who were victims and the ones who are bereft of a good doctor, and lastly for him too. I pray that he finds redemption, repentence and that he seeks for and receives foregiveness and mercy at His Throne of grace.

This is scary stuff. Let each of us examine ourselves and take warning and caution.

The missing urine sample

I worked over Christmas. The day after Christmas a concerned mom brought in a little girl with a fever. I suspected a urinary tract infection as the cause and suggested we get a sample of urine. Since she was not potty-trained, the recommended method for obtaining a noncontaminated sample was to catheterize her. Of course, this is painful and unpleasant, but mom consented, given that it was the best way to be sure this was what was wrong. Two hours after the sample was obtained, I was surprised that a urinalysis result was not back yet. I called the lab and was informed they never received the sample! After several frantic phone calls, the sample was located. It turns out it was not lost. It had been processed both for culture and analysis.

This got me thinking. Snafus happen in every work setting: files get misplaced, entries posted to the wrong account, names mis-spelled, what have you. However, when a sample is obtained at the cost of pain to a little child, it smarts so much if that sample is unretrievable. Clinical information is obtained at the cost of pain and risk to a patient: a lumbar puncture to obtain cerebrospinal fluid, catheterization to obtain a urinary sample, blood draws. I guess everyone thinks their particular work environment is special and I am not exempt from that bias. I'm just glad we found the specimen and could process it correctly. She did have a urinary tract infection and she is being treated. All's well that ends well.

Exhausted!

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

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

Isla Bastimentos and the Ngobe

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

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

Medical missions trip to Bocas del Toro

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


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

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

The phone call

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

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

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

The results came back this morning.

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

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

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

Aloepecia totalis

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

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

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

Is the generalist a relic of the past?

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

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

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

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

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

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

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

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

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

Guilt

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

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

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

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

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

Guilt.

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

Discovering primary care...

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

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

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

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

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

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

Make hay while the sun shines...

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

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

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

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

Paternalism, paternalistic and empathy

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

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

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

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

Okay! (deep breath).

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

What does your doctor mean to you?

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

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

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

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

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

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

Biting your lip...

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

The Boards...

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

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

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

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

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

Results come in 3 months.

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

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

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

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

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

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

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

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

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

Onward and forward to another week...

It's here...

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

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

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

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

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

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

Camp Angel

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

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

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

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

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

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

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

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

Here it is...

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

Physician, heal thyself!

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

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

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

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

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

Can't sleep

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

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

Still.

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

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

The last day of residency

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

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

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

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

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

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

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

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

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

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

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

The retired physician

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

We started talking.

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

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

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

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

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

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

Graduation week

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

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

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

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

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

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

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

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

Then and Now...

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

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

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

Foreign body (in more ways than one)

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

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

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

Should we tell him?

Tortured thoughts....

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

Still...

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

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

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

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

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

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

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

Sickness

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

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

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

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

A strange night of call in Pediatrics - Part 2

We were only getting started.

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

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

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

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

What a night!

A strange night of call in Pediatrics - Part 1

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

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

Okay, time-out.

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

Back to the scene.

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

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

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

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

Brain turns to mush

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

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

What happened?

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

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

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

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

Surfin' USA

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

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

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

There you have it: surfin' USA.

Apology to Plastic Surgeons...

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

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

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

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

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

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

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

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

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

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

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

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

The psychologist who lost his mind

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

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

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

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

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

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

The IMGs

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

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

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

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

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

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

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

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

I am an IMG.

Announcing my babies to the world!

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

Here they are infecting Staphylococci:

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

Enjoy!

Morning Report Nostalgia

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

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

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

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

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

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

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

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

Time Crunch...

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

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

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

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

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

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

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

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

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

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