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.
Saturday, August 23, 2008
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'
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.
"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.
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.
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.
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.
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?
"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 born...no 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.
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.
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...
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...
Monday, December 31, 2007
Happy 2008 ... from the NICU
It is almost midnight here. Here is the Neonatal Intensive Care Unit, where I have been working for the past month. Tomorrow, I get to drive to Milwaukee to begin a month long rotation in the Pediatric Emergency Department at the Childrens Hospital there. I am on call tonight, so I get to 'ring in the new year' with my little friends. Let me introduce a few of them to you...
There's A -- born at 37 weeks. That makes her full term. Her 19 year mom came into the ER complaining of back pain. What? I'm pregnant? Can't be! A few hours later A was born. She ended up in the Neonatal Unit because her mom had not received any prenatal care and had smoked pot 5 days a week, and drank several times a week during the pregnancy.
A was doing fine until a few weeks ago when she developed an infection beneath her left jaw line. Cultures grew out community-associated MRSA (Methicillin-Resistent Staphylococcus Aureus). It's been rough, but she's doing better.
There are two sets of twins -- both boys. Both were born at about 30 weeks. They are doing quite well. One pair are out of their isolettes in open cribs. I had the pleasure of tying off 6th digits at the base of the pinkies of the other set of twins. They weren't digits really, more like skin stubs.
There's K -- born at 26 weeks at 2 and half pounds. She was one of a set of a twins too. Unfortunately, her sister died on day of life two. Both twins suffered from twin-to-twin transfusion. K has had a rough course, developing a heart disease of unknown origin. That is getting better.
There are lot's more, but these are a few that I have shared life with this past month, and get to bring in the new year with.
Happy New Year, little angels. I pray that the new year is a new lease on life for all of you.
There's A -- born at 37 weeks. That makes her full term. Her 19 year mom came into the ER complaining of back pain. What? I'm pregnant? Can't be! A few hours later A was born. She ended up in the Neonatal Unit because her mom had not received any prenatal care and had smoked pot 5 days a week, and drank several times a week during the pregnancy.
A was doing fine until a few weeks ago when she developed an infection beneath her left jaw line. Cultures grew out community-associated MRSA (Methicillin-Resistent Staphylococcus Aureus). It's been rough, but she's doing better.
There are two sets of twins -- both boys. Both were born at about 30 weeks. They are doing quite well. One pair are out of their isolettes in open cribs. I had the pleasure of tying off 6th digits at the base of the pinkies of the other set of twins. They weren't digits really, more like skin stubs.
There's K -- born at 26 weeks at 2 and half pounds. She was one of a set of a twins too. Unfortunately, her sister died on day of life two. Both twins suffered from twin-to-twin transfusion. K has had a rough course, developing a heart disease of unknown origin. That is getting better.
There are lot's more, but these are a few that I have shared life with this past month, and get to bring in the new year with.
Happy New Year, little angels. I pray that the new year is a new lease on life for all of you.
Sunday, October 28, 2007
HIPAA
Health Insurance Portability and Accountability Act
Blogging and doctoring. Is this allowed? I have researched HIPAA regulations and blogging. As long as I am careful to not disclose any of the 18 Health Information Identifiers, I am okay. Further information can be found at http://casesblog.blogspot.com/2005/07/case-reports-and-hipaa-rules.html. There are a number of resident bloggers out there. Just google resident or medical blog and see.
Physicians have a long tradition of being writers: Abraham Verghese, Oliver Sacks, William Carlos Williams, A. J. Cronin and the list goes on. Physicians tell their stories and since patients make up a big part of their lives, their patients' stories too. Blogging is a new dimension but a continuance of this tradition. If done respecting the dignity and privacy of the patients and with care to avoid divulging health information identifiers, it can become the next torch-bearing media in chronicle-ing our experience with pain, suffering and healing.
Blogging and doctoring. Is this allowed? I have researched HIPAA regulations and blogging. As long as I am careful to not disclose any of the 18 Health Information Identifiers, I am okay. Further information can be found at http://casesblog.blogspot.com/2005/07/case-reports-and-hipaa-rules.html. There are a number of resident bloggers out there. Just google resident or medical blog and see.
Physicians have a long tradition of being writers: Abraham Verghese, Oliver Sacks, William Carlos Williams, A. J. Cronin and the list goes on. Physicians tell their stories and since patients make up a big part of their lives, their patients' stories too. Blogging is a new dimension but a continuance of this tradition. If done respecting the dignity and privacy of the patients and with care to avoid divulging health information identifiers, it can become the next torch-bearing media in chronicle-ing our experience with pain, suffering and healing.
Monday, August 20, 2007
Pronouncing the Dead...
Today I pronounced my first death, as a licensed physician.
I got my license to practice medicine in the state of Wisconsin about a year ago now. Although I am still a resident, as a licensed physician, I get to write and sign some documents I could not do a year ago as an intern.
There are patients who come into the ER or the hospital or the critical care unit whom you barely have time to get to know. They are either dead on arrival, or actively dying and slide down so quickly, no intervention works. When you 'call it' on one of these, there is the despair, frustration, anger, defeat and helplessness that comes with a battle lost.
It is worse when it is a patient you have cared for, for some time. It is even worse when the patient is young and dying of something you cannot identify. My 26 year old male patient died at 4:17 am. He was surrounded by his father, mother, sister and girlfriend of 6 years. Everything we could do had been tried and failed. The family did not wish an autopsy, so he carries the secret of what killed him to the grave with his body.
This is NOT what you train for. It is not why you come to work. It is not the outcome you study, struggle and work for. My grief cannot compare at all with that of the parents of a previously healthy 26 year old son who dies in a few months of unknown causes (he died of multi-organ failure secondary to ARDS (Acute Respiratory Distress Syndrome) but the cause of the ARDS is unknown.
I have no more words.
He died at 4:17 am. The day was one of busiest in the unit: while rounding on our eight patients, very sick ones, another patient arrived who had begun to bleed acutely while in the wards. She was unstable, in a lot of pain and may have been bleeding to death. We barely stabilized her when our beepers went off indicating a 'code blue' -- an elderly gentleman passed out in front of an elevator, had to be shocked back to life, was now intubated and was on the way to the unit. Rounds were over as quickly as we could run them and news of three more patients -- one en route from an outside facility, one in the ER and one being transferred from a floor ward arrived. All sick. No time to grieve, collect one's thoughts or dictate a death summary.
I got home after all this. Before I left, I walked past the CCU bay where my 26 year old patient had been. The bay had been cleaned, the bed re-made. We were crunched for space. Soon, another patient would be in that bay. I left for the day, after a day, night and day of call.
Over a dinner, while keeping sleep-deprived eyes open, I finally get to say my goodbye and grieve a little.
Tomorrow is another day.
I got my license to practice medicine in the state of Wisconsin about a year ago now. Although I am still a resident, as a licensed physician, I get to write and sign some documents I could not do a year ago as an intern.
There are patients who come into the ER or the hospital or the critical care unit whom you barely have time to get to know. They are either dead on arrival, or actively dying and slide down so quickly, no intervention works. When you 'call it' on one of these, there is the despair, frustration, anger, defeat and helplessness that comes with a battle lost.
It is worse when it is a patient you have cared for, for some time. It is even worse when the patient is young and dying of something you cannot identify. My 26 year old male patient died at 4:17 am. He was surrounded by his father, mother, sister and girlfriend of 6 years. Everything we could do had been tried and failed. The family did not wish an autopsy, so he carries the secret of what killed him to the grave with his body.
This is NOT what you train for. It is not why you come to work. It is not the outcome you study, struggle and work for. My grief cannot compare at all with that of the parents of a previously healthy 26 year old son who dies in a few months of unknown causes (he died of multi-organ failure secondary to ARDS (Acute Respiratory Distress Syndrome) but the cause of the ARDS is unknown.
I have no more words.
He died at 4:17 am. The day was one of busiest in the unit: while rounding on our eight patients, very sick ones, another patient arrived who had begun to bleed acutely while in the wards. She was unstable, in a lot of pain and may have been bleeding to death. We barely stabilized her when our beepers went off indicating a 'code blue' -- an elderly gentleman passed out in front of an elevator, had to be shocked back to life, was now intubated and was on the way to the unit. Rounds were over as quickly as we could run them and news of three more patients -- one en route from an outside facility, one in the ER and one being transferred from a floor ward arrived. All sick. No time to grieve, collect one's thoughts or dictate a death summary.
I got home after all this. Before I left, I walked past the CCU bay where my 26 year old patient had been. The bay had been cleaned, the bed re-made. We were crunched for space. Soon, another patient would be in that bay. I left for the day, after a day, night and day of call.
Over a dinner, while keeping sleep-deprived eyes open, I finally get to say my goodbye and grieve a little.
Tomorrow is another day.
Tale of Two Cities...
Charles Dickens' famous book began with these words:
A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.
26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.
In my head, I could almost hear the parellel conversations...
the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"
the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."
Both interventions were tried and failed.
the attending physician: "We will diurese him and keep him on steroids"
the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."
Both interventions were tried and failed.
It went on for some months.
Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?
The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.
In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.
?????
There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.
"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us..."
A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.
26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.
In my head, I could almost hear the parellel conversations...
the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"
the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."
Both interventions were tried and failed.
the attending physician: "We will diurese him and keep him on steroids"
the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."
Both interventions were tried and failed.
It went on for some months.
Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?
The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.
In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.
?????
There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.
Sunday, August 12, 2007
Look into my eyes...
It was a late night admission from the ER. Michael was a 40-something man being admitted for left-sided weakness. By the time he finally decided this was serious and not 'going away' he could not lift his left hand off the bed and his grip strength was down to 1/5 (5/5 being normal).
As we set him up in the medical ICU, starting him on a heparin drip after a head CT, we noted that his blood pressures were through the roof. The radiologist called me back with the results of the CT: he had had an infarct in a region of the brain called the corona radiata. Brain cells were dead. They were never coming back.
Through the course of the night, I sneaked into the room to see how he was doing. The first time around, I found him lying on his side with eyes open. I don't think I shall ever forget the look in those eyes -- fear, frustration, helplessness. He was a mason. When I said something to comfort me, he only replied in a soft voice:
"I should have come in earlier, shouldn't I? I should've come to a doctor before. I should've...."
What do you tell someone who has had a stroke? You cannot promise them that their functions will return. You cannot promise them that their life will be the same again. You cannot promise them anything.
We do what we can, with what knowledge we have. The chips will fall where they may. This gentleman was 1 year younger than me.
As we set him up in the medical ICU, starting him on a heparin drip after a head CT, we noted that his blood pressures were through the roof. The radiologist called me back with the results of the CT: he had had an infarct in a region of the brain called the corona radiata. Brain cells were dead. They were never coming back.
Through the course of the night, I sneaked into the room to see how he was doing. The first time around, I found him lying on his side with eyes open. I don't think I shall ever forget the look in those eyes -- fear, frustration, helplessness. He was a mason. When I said something to comfort me, he only replied in a soft voice:
"I should have come in earlier, shouldn't I? I should've come to a doctor before. I should've...."
What do you tell someone who has had a stroke? You cannot promise them that their functions will return. You cannot promise them that their life will be the same again. You cannot promise them anything.
We do what we can, with what knowledge we have. The chips will fall where they may. This gentleman was 1 year younger than me.
Saturday, August 11, 2007
Enjoying my work
I thought I would post one of the few pictures I have of me in Peds. This little boy has cystic fibrosis. We were out for a walk in the corridor the day before he was going to go home.
The Ward Team in Pediatrics with one of our patients.
Viruses that will save the world
I had a week off from the world of pagers, night call, ER admissions and clinic. I was in Pittsburgh attending the Phage Hunters Workshop (http://www.pitt.edu/~gfh/summerworkshop.html). This workshop is meant for High School Science Teachers, but I went to learn some of the techniques.
There is a group of viruses called bacteriophages. These viruses are specific for bacteria. They do not attack other kinds of cells. Before antibiotics were discovered, they were even used clinically to treat microbial infections.
Think about this. In nature, exists the ultimate enemy of pathogenic bacteria. These bacteriophages (phages, for short) invade, multiple within and destroy these pathogenic bacteria. Of course, just as with antibiotics, bacteria evolve resistance to them. Unlike antibiotics which are static however, phages co-evolve to once again be able to target their hosts. This host-parasite dance continues through time. The phages are ubiquitious. There are a billion of them per cc of lake, river and sea water. We ingest them all the time. They are easily isolated from soil, sewage... anywhere you care to look. They are so easy to isolate and grow, in fact, that middle and high school kids can do it.
The Pittsburgh Bacteriophage Institute holds a Summer Workshop that teaches High School Science Teachers how to 'hunt' for phages in their environment. For several years now, high school students have been isolating and purifying their own phages. They get to name them too.
What excites me about these wonderful little critters is that they may hold the answer to multi-drug resistant superbugs. The Pittsburgh group and collaborators are working on phages against Mycobacterium species -- the group of bacteria that cause the deadly diseases of tuberculosis and leprosy.
My own research (if I can continue to squeeze it into the busy life of a medical resident) is to isolate and purify phages with activity against Staphylococcus aureus. In fact, I declare my life's research ambition to become the world authority on lytic phages of S. aureus. Okay, I'm a dreamer. But I'm not the only one. (Check out the Courses Web site at http://hatfull12.bio.pitt.edu:8080/
Suicide
I HATE suicide!
There is someting sinister, evil and perplexing about suicide that drives me to tears of anger and frustration.
A couple of weeks ago, it was a Monday (and a full moon day) in clinic. I saw a 46 year old man who came in for some minor health issue. I noted that the last provider he saw had started him on a medication for depression, so I decided to ask whether he had noted any difference since taking it.
He shook his head. When I asked about suicidal ideation (thoughts of wanting to kill himself) I was stopped dead (pardon the pun) in my tracks. He replied "Actually, on the way here I thought of throwing myself in front of a semi." This was a middle-aged man with a wife and two kids who wanted to kill himself.
I inquired further. He did not think his life was worth living. His job was a dead end. His marriage was falling apart. He had no desire for sex. We had given him Viagra on a previous visit. He had not used it. Not interested.
Further investigation from the psychiatrist (to whom he was directly referred from my office) revealed that he had a lifetime battle with ichthyosis -- a rare skin condition that causes the skin to appear scaly or reptilian in appearance. His school nickname was 'scales'.
The following day, I saw a young man in clinic with with a weight problem. He too was suicidal. His plan was to turn the fumes from his tailpipe into the car and breathe it in. He too had no reason to live.
That same day, I saw a middle-aged woman who had attempted suicide at the age of 18. She suffered from crippling depression and schizophrenia (the latter adequately controlled on medication). Unfortunately, she lived with a 'partner' who had an autistic 4 year old. I imagined this dysfunctional household: each one's condition exacerbating the other's.
It is horrifying but not uncommon to see that in all three of these patient's families there was a strong history of depression, psychiatric illness and yes, multiple suicides. It is almost as if a demon has these families in his grip, killing one after the other.
The following week in the ICU I took care of a middle-aged woman who sat down at 11:30 pm and drank Anti-freeze till 4:30 am. Yes, she was trying to kill herself. (This is a picture of the actual can from which the patient drank).
There is someting sinister, evil and perplexing about suicide that drives me to tears of anger and frustration.
A couple of weeks ago, it was a Monday (and a full moon day) in clinic. I saw a 46 year old man who came in for some minor health issue. I noted that the last provider he saw had started him on a medication for depression, so I decided to ask whether he had noted any difference since taking it.
He shook his head. When I asked about suicidal ideation (thoughts of wanting to kill himself) I was stopped dead (pardon the pun) in my tracks. He replied "Actually, on the way here I thought of throwing myself in front of a semi." This was a middle-aged man with a wife and two kids who wanted to kill himself.
I inquired further. He did not think his life was worth living. His job was a dead end. His marriage was falling apart. He had no desire for sex. We had given him Viagra on a previous visit. He had not used it. Not interested.
Further investigation from the psychiatrist (to whom he was directly referred from my office) revealed that he had a lifetime battle with ichthyosis -- a rare skin condition that causes the skin to appear scaly or reptilian in appearance. His school nickname was 'scales'.
The following day, I saw a young man in clinic with with a weight problem. He too was suicidal. His plan was to turn the fumes from his tailpipe into the car and breathe it in. He too had no reason to live.
That same day, I saw a middle-aged woman who had attempted suicide at the age of 18. She suffered from crippling depression and schizophrenia (the latter adequately controlled on medication). Unfortunately, she lived with a 'partner' who had an autistic 4 year old. I imagined this dysfunctional household: each one's condition exacerbating the other's.
It is horrifying but not uncommon to see that in all three of these patient's families there was a strong history of depression, psychiatric illness and yes, multiple suicides. It is almost as if a demon has these families in his grip, killing one after the other.
The following week in the ICU I took care of a middle-aged woman who sat down at 11:30 pm and drank Anti-freeze till 4:30 am. Yes, she was trying to kill herself. (This is a picture of the actual can from which the patient drank).Her life was saved by CRRT. The picture shows her getting the treatment.
I remember coming home from work the evening of the day I saw the two suicidal patients in clinic. I finally broke down in my car. Tears of frustration, anger and a feeling of helplessness swept over me.
As a physician I fight disease and sickness all day (and nights on call). We struggle to save broken bodies ravaged by disease. Here were relatively 'healthy' people trying to take their own lives.
The book that has most ilumined the subject of suicide to me is Kay Jamison's Night Falls Fast (http://www.amazon.com/Night-Falls-Fast-Understanding-Suicide/dp/0375401458). As a professor of psychiatry and a lifelong patient with bipolar disorder who has attempted suicide several times herself, she is emininently qualified to comment on the subject. I recommend the book highly.
Sunday, July 29, 2007
Floating in the ICU
When Internal Medicine residents are doing electives -- typically clinical rotations that do not involve night call, they are often circulated through the medical critical care unit for 4-5 nights of the month. We call this floating in the MICU.
That night I was called to the ER to see a 42 year old that was unresponsive to commands and combative. He had been dropped off by an outside facility emergency medical team with scanty information. He had brought in by his colleagues at work. Here is the reconstruction of events.
Joe (not his real name) was working on a roof. He was a roofer. Witnesses say they saw sparks fly from an instrument he was using and they saw fall back. When they went to him (still on the roof), he had a left sided facial droop and right sided weakness. He became disoriented, combative and unresponsive to speech.
When he arrived at our facility, we diagnosed him with a stroke (cerebrovascular accident) and began appropriate treatment. He did not make a complete recovery, although several days later could answer a few simple questions.
Here's the rub. Joe was a healthy guy -- a typical roughneck. He had had some run-ins with the law, worked hard, drank hard and occassionally used amphetamines and marijuana. He was tough as nails and in our emergency room it took 5 of us to hold him down. He did not have any history of high blood pressure. He did not have a high cholesterol or LDL or other signs of atheroschlerosis. In short, there was no predicting that his life was going to change drastically at 42 years.
Much as we know about strokes, this one had no easy explanation. It was a massive infarct of the right middle cerebral artery with subsequent hemorrhage into the ventricle on that side of the brain. Why? How? We will never know. But Joe will never be the same again.
Reminds me of words by Moses in one of the Psalms: "Teach us to number our days that we may gain a heart of wisdom." My take home from this was to use each day wisely and fully, never knowing what tomorrow will bring.
That night I was called to the ER to see a 42 year old that was unresponsive to commands and combative. He had been dropped off by an outside facility emergency medical team with scanty information. He had brought in by his colleagues at work. Here is the reconstruction of events.
Joe (not his real name) was working on a roof. He was a roofer. Witnesses say they saw sparks fly from an instrument he was using and they saw fall back. When they went to him (still on the roof), he had a left sided facial droop and right sided weakness. He became disoriented, combative and unresponsive to speech.
When he arrived at our facility, we diagnosed him with a stroke (cerebrovascular accident) and began appropriate treatment. He did not make a complete recovery, although several days later could answer a few simple questions.
Here's the rub. Joe was a healthy guy -- a typical roughneck. He had had some run-ins with the law, worked hard, drank hard and occassionally used amphetamines and marijuana. He was tough as nails and in our emergency room it took 5 of us to hold him down. He did not have any history of high blood pressure. He did not have a high cholesterol or LDL or other signs of atheroschlerosis. In short, there was no predicting that his life was going to change drastically at 42 years.
Much as we know about strokes, this one had no easy explanation. It was a massive infarct of the right middle cerebral artery with subsequent hemorrhage into the ventricle on that side of the brain. Why? How? We will never know. But Joe will never be the same again.
Reminds me of words by Moses in one of the Psalms: "Teach us to number our days that we may gain a heart of wisdom." My take home from this was to use each day wisely and fully, never knowing what tomorrow will bring.
Friday, June 29, 2007
How the giants have fallen...
My brother tells me that in blackjack sometimes, cards come in 'runs' --- a number of deals where the cards are condusive to winning and then sometimes runs where for deal after deal, the cards dealt are a losing lot. Some periods on call, there is a strange similarity between patient cases.
That night, we admitted two tall 16 year olds. One was 6'3", the other was 6'2". Both were high school athletes. One had just qualified for the state championship, jumping his height in the high jump event.
The first one I will call Peter. He had golden curls. He was polite, had no tattooes or piercings. He did not smoke, drink or even have a girlfriend. He had the build of a track and field athlete. He was flown in by helicopter from an outside facility for progressive loss of sensation in his lower extremities. Over the next several weeks, we treated him with steroids, thought we had it beat, discharged him, only to admit him back in worse state.
I still remember the night I was told he was back. I was off that day but Sunday afternoon after church, I went to PICU to see him. There he lay: a 16 year old athlete in a diaper, incontinent of urine, able to open his eyes but not able to speak. He ground his teeth incomprehensively. I cam out of his room and wept secretly in anger and frustration.
The second 16 year old also came to us by helicopter almost within days of the first patient. He too was clean-cut handsome, wholesome male. He had some numbness and tingling in his hands and a lump at the back of his neck. I remember the strange sight at 1:00 am in the morning when 3 specialists -- a neurosurgeon, a pediatric intensivist and a pediatric oncologist, flanked by a couple of residents stood discussing the possibilities.
"I hope he has a lymphoma" someone says.
We all agree, shaking our heads. Then it hit me. Here we were wishing that a previously healthy 16 year old athlete had a form of cancer.
How strange is that?
The reason for our wish was that we had seen the preliminary scans of his spinal cord. The alternative diagnosis was a rhabdomyosarcoma -- a cancer in which often 90% die in 2 years of diagnosis. This patient had some cancer. We were hoping it was the more treatable one with a better prognosis than this.
He had rhabdomyosarcoma.
As the Pediatric Intensive Care Unit resident that month, I was often the one to give specialists involved in his case the news. The pained expression on each face as they heard the news told me they felt as I did. So much for clinical distance.
Both boys are home now. Both endured painful procedures. One has rhabdomyosarcoma and the other may have multiple sclerosis -- an aggressive form at that. They are being treated with the best we have to offer.
O how the giants fell that night. I do not believe I shall ever forget them.
Addendum - written on May 22 2009
Today I received notification that the second patient described above (let's call him Big Ben) died at his home, surrounded by friends and family. He was 18 years old. This week, this was the third death notice we received -- the other patients were younger and died of ALL, having failed bone marrow transplantation. Cancer in children is a horrible disease. I don't know how the Peds Heme/Onc specialists do this!
That night, we admitted two tall 16 year olds. One was 6'3", the other was 6'2". Both were high school athletes. One had just qualified for the state championship, jumping his height in the high jump event.
The first one I will call Peter. He had golden curls. He was polite, had no tattooes or piercings. He did not smoke, drink or even have a girlfriend. He had the build of a track and field athlete. He was flown in by helicopter from an outside facility for progressive loss of sensation in his lower extremities. Over the next several weeks, we treated him with steroids, thought we had it beat, discharged him, only to admit him back in worse state.
I still remember the night I was told he was back. I was off that day but Sunday afternoon after church, I went to PICU to see him. There he lay: a 16 year old athlete in a diaper, incontinent of urine, able to open his eyes but not able to speak. He ground his teeth incomprehensively. I cam out of his room and wept secretly in anger and frustration.
The second 16 year old also came to us by helicopter almost within days of the first patient. He too was clean-cut handsome, wholesome male. He had some numbness and tingling in his hands and a lump at the back of his neck. I remember the strange sight at 1:00 am in the morning when 3 specialists -- a neurosurgeon, a pediatric intensivist and a pediatric oncologist, flanked by a couple of residents stood discussing the possibilities.
"I hope he has a lymphoma" someone says.
We all agree, shaking our heads. Then it hit me. Here we were wishing that a previously healthy 16 year old athlete had a form of cancer.
How strange is that?
The reason for our wish was that we had seen the preliminary scans of his spinal cord. The alternative diagnosis was a rhabdomyosarcoma -- a cancer in which often 90% die in 2 years of diagnosis. This patient had some cancer. We were hoping it was the more treatable one with a better prognosis than this.
He had rhabdomyosarcoma.
As the Pediatric Intensive Care Unit resident that month, I was often the one to give specialists involved in his case the news. The pained expression on each face as they heard the news told me they felt as I did. So much for clinical distance.
Both boys are home now. Both endured painful procedures. One has rhabdomyosarcoma and the other may have multiple sclerosis -- an aggressive form at that. They are being treated with the best we have to offer.
O how the giants fell that night. I do not believe I shall ever forget them.
Addendum - written on May 22 2009
Today I received notification that the second patient described above (let's call him Big Ben) died at his home, surrounded by friends and family. He was 18 years old. This week, this was the third death notice we received -- the other patients were younger and died of ALL, having failed bone marrow transplantation. Cancer in children is a horrible disease. I don't know how the Peds Heme/Onc specialists do this!
Thursday, May 10, 2007
David son of Jesse
A 28 day old male infant presents with a 2 day history of projectile vomiting (emesis reaching a distance of 3 feet). He was not born premature. He is the firstborn. Palpation of his abdomen reveals a small, but palpable 'olive' just right of his midline. To you medical folk out there, diagnosis, please? Want another clue? An upper GI series shows delayed emptying of the stomach and a narrow, stenosed pylorus. Okay, you got it: pyloric stenosis. Found in a 4:1 ratio in males: females and most commonly at the third week of life, this is the most common cause of intestinal obstruction in infants. I admitted a kid with this story to the hospital tonight. I asked what his name was. It was David. As is my practise, I asked the parents name. Dad's name was Jesse. How about that: David, son of Jesse. Mom was the way is not Bathsheeba...
Wednesday, April 18, 2007
Parents and their responsibility
If you haven't guessed already, I am in Pediatrics these days. In the past few days three clinical experiences have happened that make me want to write this post.
1. Sunday night on call, a 2 year old was brought in with altered mental status (responsive only to painful stimuli), optic nerve atrophy in his left eye and priapism. Turns out that 4 months ago when he had presented with some vision loss in his left eye, an MRI had been done. It revealed a large craniopharygioma in the sellar/suprasellar region of his brain. This is a benign and in his case, cystic tumor. The prognosis was good with surgical resection and radiotherapy. The family, being Amish, told the neurosurgeon that they would think about it. They never came back. Instead, they decided to try a low-sugar diet and some nutritional supplements. Needless to say, this didn't work. The tumor had got larger and now was compressing the aquaduct of silvius in the brain and blocking the flow of CSF resulting in an obstructive hydrocephalus. This is why the toddler wouldn't wake up. That night, we had to intubate him, put a central line and arterial line in his left subclavian and left femoral respectively, put an NG tube and foley catheter in and the neurosurgeon did a bedside craniotomy to place an extraventricular drain. He is scheduled for emergent brain surgery in 4 days. His prognosis is not very good at this point.
His parents, no doubt, felt they were doing the right thing by trying to treat this tumor with diet management, although there is no evidence for this treatment and even the makers of the nutritional supplements they used do not recommend their product as a treatment for brain tumor. Now, their son lies in serious danger of either losing his life, or being permanently blind and/or neurologically impaired the rest of his life.
What do you think of their choice and the consequence to this toddler?
2. The night of call, I spent from about 10:30 pm to 5:45 am working on this single patient. I do not think I sat down for 5 minutes. It was non-stop, hair-raising, nerve-racking action. In the wee hours of the morning, one of our PICU nurses comes in with the story that one of our flight crew nurses who was going through a divorce had killed his children, ages 8 and 4 and then shot himself. Reportedly, he drugged the younger one (a boy) and shot the elder one (the girl) in the head. Apparently, he was going through a messy divorce and stood to lose his kids. We still do not know how he killed his kids. Did he shoot them, like he shot himself? Did he drug them? Did they suffer?
What do you think of this parent's decision?
3. Tuesday morning in clinic, our team's job was to evaluate a little 6 year old for autism. The concern was raised because the child had speech delay, some apparent anxiety and stereotypical behavior -- finger-flicking, head rocking and some repeated movements with her hands. She was a delightful little girl who was brought in by her father. During the interview, we discovered that Mom had been an alcoholic. She would leave this little toddler (at the time) in her rocker rather than let her walk around. Consequence: motor development delay. Mom would get loaded with alcohol and play loud music. She did not interact with the kids. Consequence: anxiety, fear, speech and language delay.
We do not think this little girl has autism. We think she may have re-attachment disorder and anxiety that manifest in the odd, stereotypically behavior, lack of desire to interact with her peers and her various delays.
Thanks, Mom?
In all fairness, most parents do a wonderful job of loving and raising children, making good choices to protect their health, well-being and safety. We can't help our heart-ache when we see the contrary as I did over these last few days.
1. Sunday night on call, a 2 year old was brought in with altered mental status (responsive only to painful stimuli), optic nerve atrophy in his left eye and priapism. Turns out that 4 months ago when he had presented with some vision loss in his left eye, an MRI had been done. It revealed a large craniopharygioma in the sellar/suprasellar region of his brain. This is a benign and in his case, cystic tumor. The prognosis was good with surgical resection and radiotherapy. The family, being Amish, told the neurosurgeon that they would think about it. They never came back. Instead, they decided to try a low-sugar diet and some nutritional supplements. Needless to say, this didn't work. The tumor had got larger and now was compressing the aquaduct of silvius in the brain and blocking the flow of CSF resulting in an obstructive hydrocephalus. This is why the toddler wouldn't wake up. That night, we had to intubate him, put a central line and arterial line in his left subclavian and left femoral respectively, put an NG tube and foley catheter in and the neurosurgeon did a bedside craniotomy to place an extraventricular drain. He is scheduled for emergent brain surgery in 4 days. His prognosis is not very good at this point.
His parents, no doubt, felt they were doing the right thing by trying to treat this tumor with diet management, although there is no evidence for this treatment and even the makers of the nutritional supplements they used do not recommend their product as a treatment for brain tumor. Now, their son lies in serious danger of either losing his life, or being permanently blind and/or neurologically impaired the rest of his life.
What do you think of their choice and the consequence to this toddler?
2. The night of call, I spent from about 10:30 pm to 5:45 am working on this single patient. I do not think I sat down for 5 minutes. It was non-stop, hair-raising, nerve-racking action. In the wee hours of the morning, one of our PICU nurses comes in with the story that one of our flight crew nurses who was going through a divorce had killed his children, ages 8 and 4 and then shot himself. Reportedly, he drugged the younger one (a boy) and shot the elder one (the girl) in the head. Apparently, he was going through a messy divorce and stood to lose his kids. We still do not know how he killed his kids. Did he shoot them, like he shot himself? Did he drug them? Did they suffer?
What do you think of this parent's decision?
3. Tuesday morning in clinic, our team's job was to evaluate a little 6 year old for autism. The concern was raised because the child had speech delay, some apparent anxiety and stereotypical behavior -- finger-flicking, head rocking and some repeated movements with her hands. She was a delightful little girl who was brought in by her father. During the interview, we discovered that Mom had been an alcoholic. She would leave this little toddler (at the time) in her rocker rather than let her walk around. Consequence: motor development delay. Mom would get loaded with alcohol and play loud music. She did not interact with the kids. Consequence: anxiety, fear, speech and language delay.
We do not think this little girl has autism. We think she may have re-attachment disorder and anxiety that manifest in the odd, stereotypically behavior, lack of desire to interact with her peers and her various delays.
Thanks, Mom?
In all fairness, most parents do a wonderful job of loving and raising children, making good choices to protect their health, well-being and safety. We can't help our heart-ache when we see the contrary as I did over these last few days.
Sunday, April 01, 2007
101
I am in pediatrics these months. However, as a Med/Peds resident I still do clinic one afternoon a week and this last week was Internal Medicine. I looked at my schedule at the date of birth on the sheet: 8/6/05. At first, that didn't seem odd. I had a lot of patients who were less than a year old. Wait! I am in Internal Medicine this afternoon. This can't be right! But it was. My patient was a 101 year old lady.
I went into the room. This was a pleasant lady sitting in a wheelchair (she wasn't disabled). She got around with a walker. When I asked her what health complaints she had, she surprised me by her reply.
"Doctor, I don't have the strength I used to. I fall asleep sitting down for a while."
In my mind, I thought that if that was all the problems I had at 101, I'd take it.
She came to see me because she had been living in a Retirement home and her money had run out. She was going to be on Medicaid and was being moved to a Nursing Home. I felt sad that she was going there. After all, this was a functional, fully cognizant female who was about to move into a home where most of the residents were demented and many dying. What could anyone do?
I finished the encounter and came home shaking my head. 101?
I went into the room. This was a pleasant lady sitting in a wheelchair (she wasn't disabled). She got around with a walker. When I asked her what health complaints she had, she surprised me by her reply.
"Doctor, I don't have the strength I used to. I fall asleep sitting down for a while."
In my mind, I thought that if that was all the problems I had at 101, I'd take it.
She came to see me because she had been living in a Retirement home and her money had run out. She was going to be on Medicaid and was being moved to a Nursing Home. I felt sad that she was going there. After all, this was a functional, fully cognizant female who was about to move into a home where most of the residents were demented and many dying. What could anyone do?
I finished the encounter and came home shaking my head. 101?
Damned if you do, damed if you don't...
In the last week, we had two codes in Pediatrics. Both involved kids less than 6 months of age.
The first one arrived in the ER pulseless and not breathing. We coded him for 25 minutes. He never came around. He was pronounced. There were tears of frustration, grief and shock in the eyes of everyone who walked away from the dead baby. We knew very little about this baby except the couple of sentences the EMT shouted out as we got busy to work on him.
I cannot describe to you how that feels... to do chest compressions on a 3-4 month baby, watching the monitor for signs of life, hearing the litany of a code be chanted behind you "1 more dose of epi now!" "stop compressions, check for pulse!" "continue compressions"
The second code was in the PICU. It was a patient on a ventilator. This was a premature, about 3 month-er that we knew. He stopped breathing (if you can do such a thing while on a breathing machine) when one of his lungs pulled away from the chest wall and collapsed. This led to his heart slowing down and then stopping. He went pulseless.
Peds residents and doctors ran from wherever they were to the PICU and became part of the crowd doing things. I did chest compressions, then needled his right chest wall to relieve the pneumothorax.
I have attended or participated in 4 peds codes so far in my training. This was the first time that the baby lived. Those statistics, dismal as they are, are about right. Not many infants survive codes. Kids do not have the reserve that adults do.
Coming away from this code was different. There was elation, nervous laughter, heady joy -- he lived!
I went back to the wards to resume my duties. I was taking care of a 2 year old admitted for increased secretions from his trach tube. Trach tube? This is a tube attached to the throat to help patients who cannot breathe effectively through their mouths and nostrils. This two-year old lay stiff in bed, with blind eyes open, a thickened pallette and flushed. At 10 months of age, his teenage sister turned away from him in the bath-tub for just a minute to see to another sibling who fell off his bike. In that minute, this little boy drowned. Since the family lived next to a fire station, the crew was over there in record time and he was successfully rescucitated. He lived! This was a code like the one I was just at, in that the patient lived.
Unfortunately, in that short period of time he was down, his brain suffered an irrecoverable injury from being without oxygen. He cannot talk, walk or see. He needs a breathing tube in his throat to breathe effectively. Should he have been saved? Of course! Who can predict what degree of injury and what subsequent recovery is possible? We have no a priori knowlege, so we must rescucitate.
Of course, as I care for him on the wards and wonder about the one we did not save and the one we did, I wonder about these things. What will the outcome be for the one we saved? Will he be like this 2 year old?
I am a christian. I do not swear. But in this case, the phrase "damed if you do, damned if you don't" seems to say it all.
Update on 4/2/2007:
My pager went off in the early hours of the morning. I was off-duty, but I had left my pager on. I looked at the read-out and saw the code message and the room message. Later that morning, the news was confirmed. The 3-monther we had successfuly rescucitated had coded again and this time, did not survive. He died of cardiopulmonary failure that morning.
The first one arrived in the ER pulseless and not breathing. We coded him for 25 minutes. He never came around. He was pronounced. There were tears of frustration, grief and shock in the eyes of everyone who walked away from the dead baby. We knew very little about this baby except the couple of sentences the EMT shouted out as we got busy to work on him.
I cannot describe to you how that feels... to do chest compressions on a 3-4 month baby, watching the monitor for signs of life, hearing the litany of a code be chanted behind you "1 more dose of epi now!" "stop compressions, check for pulse!" "continue compressions"
The second code was in the PICU. It was a patient on a ventilator. This was a premature, about 3 month-er that we knew. He stopped breathing (if you can do such a thing while on a breathing machine) when one of his lungs pulled away from the chest wall and collapsed. This led to his heart slowing down and then stopping. He went pulseless.
Peds residents and doctors ran from wherever they were to the PICU and became part of the crowd doing things. I did chest compressions, then needled his right chest wall to relieve the pneumothorax.
I have attended or participated in 4 peds codes so far in my training. This was the first time that the baby lived. Those statistics, dismal as they are, are about right. Not many infants survive codes. Kids do not have the reserve that adults do.
Coming away from this code was different. There was elation, nervous laughter, heady joy -- he lived!
I went back to the wards to resume my duties. I was taking care of a 2 year old admitted for increased secretions from his trach tube. Trach tube? This is a tube attached to the throat to help patients who cannot breathe effectively through their mouths and nostrils. This two-year old lay stiff in bed, with blind eyes open, a thickened pallette and flushed. At 10 months of age, his teenage sister turned away from him in the bath-tub for just a minute to see to another sibling who fell off his bike. In that minute, this little boy drowned. Since the family lived next to a fire station, the crew was over there in record time and he was successfully rescucitated. He lived! This was a code like the one I was just at, in that the patient lived.
Unfortunately, in that short period of time he was down, his brain suffered an irrecoverable injury from being without oxygen. He cannot talk, walk or see. He needs a breathing tube in his throat to breathe effectively. Should he have been saved? Of course! Who can predict what degree of injury and what subsequent recovery is possible? We have no a priori knowlege, so we must rescucitate.
Of course, as I care for him on the wards and wonder about the one we did not save and the one we did, I wonder about these things. What will the outcome be for the one we saved? Will he be like this 2 year old?
I am a christian. I do not swear. But in this case, the phrase "damed if you do, damned if you don't" seems to say it all.
Update on 4/2/2007:
My pager went off in the early hours of the morning. I was off-duty, but I had left my pager on. I looked at the read-out and saw the code message and the room message. Later that morning, the news was confirmed. The 3-monther we had successfuly rescucitated had coded again and this time, did not survive. He died of cardiopulmonary failure that morning.
Wednesday, March 28, 2007
Save your money....
Toddlers are interesting. This is the age for temper tantrums, the time when toddlers can walk, run and explore. I saw a wonderful little girl in clinic a few days ago. She smiled angelically at me and said nothing. Her 4 year old brother told me the story...
"Mary (not her real name, of course) found money!" She ate it.
Dad and Mom who came along, smiled nervously. We got an x-ray. The one on the left was at this first visit. The one next to it, about 5 days later.
Mom and dad are watching little Mary's poop every day. If the coin does not come out, we may have to go after it endoscopically.
Never a dull moment...
Update:
Several days later, we have a follow-up x-ray:
In a rare show of emotion, the radiologist's report says "Fortunately, she has passed this foreign body."Unfortunately, the coin was never recovered in the poop. Well, there's good money down the drain... literally. ;-)
Sunday, February 18, 2007
Why I became a christian and what it means to me
I was born into a Hindu family. However, I am now a follower of Christ. Is that the same as being a Christian, you ask?
Perhaps not.
I have been asked questions about this often enough. It is important enough to me to want to answer these questions. The answers are an integral part of who I am as a physician, scientist and person.
So here is a link to an article entitled "Why (and how) I became a Christian". I hope and pray that it helps my readers.
http://vijayaswani.blogspot.com/1999/02/why-and-how-i-became-christian.html
Perhaps not.
I have been asked questions about this often enough. It is important enough to me to want to answer these questions. The answers are an integral part of who I am as a physician, scientist and person.
So here is a link to an article entitled "Why (and how) I became a Christian". I hope and pray that it helps my readers.
http://vijayaswani.blogspot.com/1999/02/why-and-how-i-became-christian.html
Saturday, February 10, 2007
Older doctors...
Yesterday, I worked in the orthopedics clinic with a 72-year old physician. He was elected as a fellow in the American College of Orthopedic Surgeons in 1974. Calculating back, he probably went to medical school when I was 1 or 2 years old... and I am 44 year old now. Talk about a lifetime in medicine!
What do you think when you see a 72-year old man still practicing? I was delighted to learn that not only was he sharp, energetic and competent, but he was a pleasure to learn from. It was a great opportunity to learn clinical pearls from someone who has been doing this as long as I have lived.
This interesting gentleman was a 'retired' orthopedic surgeon. After doing private practice for 7 years and then 30-some years of orthopedic surgery at this clinic, he retired. He bought a 50-ton boat and spent the next 5 years sailing with his wife. When he got tired of that, he decided to come back to medicine, only this time, not to surgery. He sees patients in the orthopedics department, evaluating and medically treating their orthopedic problems. When necessary, he involves his surgical colleagues if his patients need a surgical solution.
I hope that when I am 72, I am as energetic, pleasant and competent as this fine physician. Age is truly no bar in medicine, if one does it right.
What do you think when you see a 72-year old man still practicing? I was delighted to learn that not only was he sharp, energetic and competent, but he was a pleasure to learn from. It was a great opportunity to learn clinical pearls from someone who has been doing this as long as I have lived.
This interesting gentleman was a 'retired' orthopedic surgeon. After doing private practice for 7 years and then 30-some years of orthopedic surgery at this clinic, he retired. He bought a 50-ton boat and spent the next 5 years sailing with his wife. When he got tired of that, he decided to come back to medicine, only this time, not to surgery. He sees patients in the orthopedics department, evaluating and medically treating their orthopedic problems. When necessary, he involves his surgical colleagues if his patients need a surgical solution.
I hope that when I am 72, I am as energetic, pleasant and competent as this fine physician. Age is truly no bar in medicine, if one does it right.
Tuesday, February 06, 2007
Like two ships passing in the night....
It was 3:00 am in the morning on a call day/night. I wonder sometimes if the memorable cases come at that time or if I just happen to remember the cases that come at those hours. Anyway, I had been awake for 24 hours and was fighting sleep. I waswriting some orders for a patient that we had admitted earlier that night. It was the last thing to do before, hopefully, getting some sleep. My pager went off and I rolled my eyes. "Please, not another admission" I thought, hoping that I would get some sleep before the day broke. It was another admission. It was to be a transfer from another hospital. I accepted the patient: a 70-something female with 'pancreatitis'. My mind was already framing the things I would do: bowel rest, IV fluids, should I do some prophylactic antibiotics?
When the patient arrived, I realized this was not going to be 'simple'. (If they transferred from another hospital at 3:00 am in the morning, they usually never were). If it was plain-vanilla pancreatitis, they wouldn't be coming here now, would they? What was I thinking?
Turns out my new admission had metastatic stomach cancer. In addition, she had an elevated Tn I (0.8) and a stable AAA. Oh well. I went to evaluate her. She had severe abdominal pain. Made sense, I thought, she has pancreatitis; only here abdominal pain was diffuse. It wasn't the classic epigastric pain radiating to the back. My sleep dissappeared as I began to feel uncomfortable. Something wasn't right. This wasn't pancreatitis, was it?
After several rounds of fentanyl and then morphine, I began to feel even more uncomfortable. After checking that cardiology didn't want to do anything with her (the Tn I wasn't high enough), I ordered an abdominal CT scan for the morning. It was almost morning anyway.
A nurse casually remarked about the strangeness of the situation: it seemed that my patient's husband was admitted on the opposite side of the corridor on this same floor. He had come in for a heart angiogram and they had discovered severe three-vessel disease. He was on the schedule as the first case for a triple vessel bypass that morning. This couple was not having a good day.
To cut a long story short, by the afternoon of the next day (I was well past 40 hours without sleep by that time and 'wrapping up' to get out of the hospital). the CT results showed that my patient had thrombosed two major arteries in her gut and her gut was almost dead. The vascular surgeons told me that the case was hopeless and that she had less than 12 hours left to live. Ironically, when her gut died, her pain went away and she felt better. That was an ominous sign.
Sleepless and discouraged, I broke the news to tearful daughters and a dumbfounded patient. Her only request of me before we moved her to the palliative care unit (where she would go to die) was that she get to see her husband. The last thing he knew was that he was taking in his wife for some belly pain and vomiting.
By this time, he was in the post-op recovery unit, coming out of anesthesia after his triple bypass. He was dazed, confused and combative (as patients can be coming out of anesthesia). As my patient was wheeled in her bed to our palliative care unit in another building, compassionate nurses and transporters arranged for her to see her husband for the last time. He was not conscious. She wasn't quite all there either. Their daughter told me that in 53 years of marriage they had spent all of 3 nights apart. This night, they passed each other like two ships passing in the night.
Now I have a confession to make. By the time I took care of all this, I was well past the legally allowed limit for working continously (30 hours for us residents). I was more like in my 45th hour without sleep. I wasn't making clinical decisions. I was saying goodbye to a dying patient and trying to get her to see her husband one last time. I wasn't about to leave a scene of death simply because my 30th hour was up. Doctors can't punch a clock. What would you have done?
When the patient arrived, I realized this was not going to be 'simple'. (If they transferred from another hospital at 3:00 am in the morning, they usually never were). If it was plain-vanilla pancreatitis, they wouldn't be coming here now, would they? What was I thinking?
Turns out my new admission had metastatic stomach cancer. In addition, she had an elevated Tn I (0.8) and a stable AAA. Oh well. I went to evaluate her. She had severe abdominal pain. Made sense, I thought, she has pancreatitis; only here abdominal pain was diffuse. It wasn't the classic epigastric pain radiating to the back. My sleep dissappeared as I began to feel uncomfortable. Something wasn't right. This wasn't pancreatitis, was it?
After several rounds of fentanyl and then morphine, I began to feel even more uncomfortable. After checking that cardiology didn't want to do anything with her (the Tn I wasn't high enough), I ordered an abdominal CT scan for the morning. It was almost morning anyway.
A nurse casually remarked about the strangeness of the situation: it seemed that my patient's husband was admitted on the opposite side of the corridor on this same floor. He had come in for a heart angiogram and they had discovered severe three-vessel disease. He was on the schedule as the first case for a triple vessel bypass that morning. This couple was not having a good day.
To cut a long story short, by the afternoon of the next day (I was well past 40 hours without sleep by that time and 'wrapping up' to get out of the hospital). the CT results showed that my patient had thrombosed two major arteries in her gut and her gut was almost dead. The vascular surgeons told me that the case was hopeless and that she had less than 12 hours left to live. Ironically, when her gut died, her pain went away and she felt better. That was an ominous sign.
Sleepless and discouraged, I broke the news to tearful daughters and a dumbfounded patient. Her only request of me before we moved her to the palliative care unit (where she would go to die) was that she get to see her husband. The last thing he knew was that he was taking in his wife for some belly pain and vomiting.
By this time, he was in the post-op recovery unit, coming out of anesthesia after his triple bypass. He was dazed, confused and combative (as patients can be coming out of anesthesia). As my patient was wheeled in her bed to our palliative care unit in another building, compassionate nurses and transporters arranged for her to see her husband for the last time. He was not conscious. She wasn't quite all there either. Their daughter told me that in 53 years of marriage they had spent all of 3 nights apart. This night, they passed each other like two ships passing in the night.
Now I have a confession to make. By the time I took care of all this, I was well past the legally allowed limit for working continously (30 hours for us residents). I was more like in my 45th hour without sleep. I wasn't making clinical decisions. I was saying goodbye to a dying patient and trying to get her to see her husband one last time. I wasn't about to leave a scene of death simply because my 30th hour was up. Doctors can't punch a clock. What would you have done?
Tuesday, November 28, 2006
Vacation
Now some of you readers out there must think that the lives of residents suck; that they are always depressed or brow-beaten or fighting life and death battles. We-elll, for those of you who think this, I submit the following. 
This is me sipping a cool drink while listening to the local Mariachi sing in a wonderful beach resort in Panama. (Don't I look happy?)
This is me sipping a cool drink while listening to the local Mariachi sing in a wonderful beach resort in Panama. (Don't I look happy?)
And there is me pulling my kayak out of the ocean after a wonderful ride.Ahh! A relaxing vacation... far away from medicine, pagers, call and dictations.
Contrary to rumors, they do let us out of our cages every now and then...
Friday, November 24, 2006
Doctoring in a plane
Hi Everyone!
I am on my way to a much-needed vacation. I shall be visiting my family in sunny Panama (Central America, not Florida). It's been snowing over here. As I have done these past few times I have flown, I have been reading on dealing with medical emergencies on a flight. Have you ever heard the announcement overhead while in flight: "is there a doctor on board?" As a resident, I have wondered how one might prepare for this announcement and whatever follows. I have found four excellent articles. They cover the legal aspects, the most common emergencies one is likely to encounter and what kind of support in terms of personnel, their training and equipment you might have access to. For now, though, I decided to travel with my sphygmomanometer and stethoscope in my hand luggage...
Here are links to the articles:
1. NEJM Article: Responding to medical events during commerical flights. http://content.nejm.org/cgi/reprint/346/14/1067.pdf?ck=nck
2. BMJ ARticle: Is there a doctor on the aircraft? http://www.bmj.com/cgi/reprint/321/7272/1336?ck=nck
3. EMJ Article: Emergencies in the air. http://emj.bmj.com/cgi/reprint/22/9/658
4. BMJ Article: Inflight medical emergencies: An Overview. http://bmj.com/cgi/content/full/321/7272/1338
I am on my way to a much-needed vacation. I shall be visiting my family in sunny Panama (Central America, not Florida). It's been snowing over here. As I have done these past few times I have flown, I have been reading on dealing with medical emergencies on a flight. Have you ever heard the announcement overhead while in flight: "is there a doctor on board?" As a resident, I have wondered how one might prepare for this announcement and whatever follows. I have found four excellent articles. They cover the legal aspects, the most common emergencies one is likely to encounter and what kind of support in terms of personnel, their training and equipment you might have access to. For now, though, I decided to travel with my sphygmomanometer and stethoscope in my hand luggage...
Here are links to the articles:
1. NEJM Article: Responding to medical events during commerical flights. http://content.nejm.org/cgi/reprint/346/14/1067.pdf?ck=nck
2. BMJ ARticle: Is there a doctor on the aircraft? http://www.bmj.com/cgi/reprint/321/7272/1336?ck=nck
3. EMJ Article: Emergencies in the air. http://emj.bmj.com/cgi/reprint/22/9/658
4. BMJ Article: Inflight medical emergencies: An Overview. http://bmj.com/cgi/content/full/321/7272/1338
Monday, November 13, 2006
At 7:00 am he shot himself
At 7:00 am this morning, Auburndale Trauma, age 26 shot himself. He aimed a handgun pointblank at his chest and pulled the trigger.
Well, first of all, Auburndale Trauma is obviously not his real name. In our facility, when a trauma patient arrives that we know almost nothing about, he gets a fictitious name and age. For some cute reason, the tradition is to name the patients after the names of towns in the state, and also for some quaint reason, the patients are always 26 years old.
About 10 days ago, Auburndale was checked into a psychiatric facility with suicidal ideation. He was going through a divorce. He was depressed and wanted to end his life. He was discharged yesterday from that facility.
I am doing a rotation in anesthesia and was in the OR when he was brought in. The thoracic surgeon was good enough to invite me over from my side of the curtain (the one that separates anesthesia from the surgical field). "He's lucky!" He exclaimed. The bullet missed the esophagus, the aorta, the bronchial vein, the perihilar structures. It entered from the left side of his chest and exited from his back. How did it miss the heart?
Then he did a neat trick. After removing the lower lobe of the left lung (which was blown open and useless), he connected his forceps between the entry and exit holes -- the path of the bullet. As the heart beat, every time it entered diastole, it butted against the forceps.
"See?" He's lucky!" He exclaimed again. If this bullet had traversed the left hemithorax when the heart was in diastole, it would have passed right through the ventricle and probably ended his life." He shook his head. "Lucky, I tell you!" He was right in that though. The difference in time is about half a second. Had the bullet arrived half a second later, Auburndale Trauma would have been dead on arrival.
The conversation in the OR was surreal:
"How could he have missed?"
"He flinched when he pulled the trigger."
"He should have aimed into his mouth."
"Or angled left aiming upwards from the xiphoid process."
Auburndale Trauma is not 26. He is in his early thirties. He is getting divorced. He will probably not see his little daughters grow up the way he had thought he would -- as a family. Auburndale Trauma was unhappy enough to end his life. He shot himself in the left chest, no doubt aiming for the heart, to end it all. I do not know if 'lucky' is how I would describe him.
Well, first of all, Auburndale Trauma is obviously not his real name. In our facility, when a trauma patient arrives that we know almost nothing about, he gets a fictitious name and age. For some cute reason, the tradition is to name the patients after the names of towns in the state, and also for some quaint reason, the patients are always 26 years old.
About 10 days ago, Auburndale was checked into a psychiatric facility with suicidal ideation. He was going through a divorce. He was depressed and wanted to end his life. He was discharged yesterday from that facility.
I am doing a rotation in anesthesia and was in the OR when he was brought in. The thoracic surgeon was good enough to invite me over from my side of the curtain (the one that separates anesthesia from the surgical field). "He's lucky!" He exclaimed. The bullet missed the esophagus, the aorta, the bronchial vein, the perihilar structures. It entered from the left side of his chest and exited from his back. How did it miss the heart?
Then he did a neat trick. After removing the lower lobe of the left lung (which was blown open and useless), he connected his forceps between the entry and exit holes -- the path of the bullet. As the heart beat, every time it entered diastole, it butted against the forceps.
"See?" He's lucky!" He exclaimed again. If this bullet had traversed the left hemithorax when the heart was in diastole, it would have passed right through the ventricle and probably ended his life." He shook his head. "Lucky, I tell you!" He was right in that though. The difference in time is about half a second. Had the bullet arrived half a second later, Auburndale Trauma would have been dead on arrival.
The conversation in the OR was surreal:
"How could he have missed?"
"He flinched when he pulled the trigger."
"He should have aimed into his mouth."
"Or angled left aiming upwards from the xiphoid process."
Auburndale Trauma is not 26. He is in his early thirties. He is getting divorced. He will probably not see his little daughters grow up the way he had thought he would -- as a family. Auburndale Trauma was unhappy enough to end his life. He shot himself in the left chest, no doubt aiming for the heart, to end it all. I do not know if 'lucky' is how I would describe him.
Sunday, November 12, 2006
Mahatma Gandhi and medicine...
Yesterday, I watched the movie 'Swades' (can you tell I had the day off :-) ?). In the opening credits, there is a reference to a book called Bapu Kuti by Rajni Bakshi. It is a book about how some of India's journalists, scientists and artists are re-discovering Gandhi. This posed a question in my mind: what did this great man think of medicine?
I recall growing up that my grandmother used to go to a natural cure ashram where the medical practitioners followed Gandhian principles of healthcare. I was too little to remember the details of what they did. Anyway, I got on the 'net and found the book 'Gandhi's Health Guide' by the man himself. What do you think it said?
Well, to those of us from India (and I suspect, to a lot of us from other countries too), Gandhi was a great man. He has been compared to the founders of the world's great religions. However, in regards to his views on medicine, perhaps he was as much a victim of his times and circumstances as many of his contemporaries. I invite you to read extracts from his book at Amazon:
http://www.amazon.com/gp/reader/1580910513/ref=sib_dp_pt/102-6830000-4462505#reader-link
In all fairness, I do believe that had he lived today, he would have acknowleged that physicians and hospitals are necessary and even a blessing to many. After all, not all sickness seems to come from wrongful living.
I recall growing up that my grandmother used to go to a natural cure ashram where the medical practitioners followed Gandhian principles of healthcare. I was too little to remember the details of what they did. Anyway, I got on the 'net and found the book 'Gandhi's Health Guide' by the man himself. What do you think it said?
Well, to those of us from India (and I suspect, to a lot of us from other countries too), Gandhi was a great man. He has been compared to the founders of the world's great religions. However, in regards to his views on medicine, perhaps he was as much a victim of his times and circumstances as many of his contemporaries. I invite you to read extracts from his book at Amazon:
http://www.amazon.com/gp/reader/1580910513/ref=sib_dp_pt/102-6830000-4462505#reader-link
In all fairness, I do believe that had he lived today, he would have acknowleged that physicians and hospitals are necessary and even a blessing to many. After all, not all sickness seems to come from wrongful living.
Friday, November 10, 2006
I love it when kids cry!
Okay, so the title probably got your attention and you're thinking, what kind of pediatrician is this?!
It snowed quite a bit in our area today. The roads were slippery and a car near an outside town lost control and crashed into another. A semi driving up the same road could not stop in time to avoid the accident and crashed into them both. Our little town does not have many multiple motor vehicle accidents like this. At the hospital, we got news that several adults and chidren were being brought in. We rushed to the ER to await their arrival. The kids came first. There was an 8 year old and a 1 year old.
I love it when kids cry. The sounds of both these children crying was a reassuring sound -- it meant they were conscious, alert and that their airway was not compromised. The 1 year old had a head laceration that appeared superficial. The 8 year old had some abdominal pain. While performing the primary survey, one of the nurses asked the crying 8 year old, "where do you live?" Between sniffles and tears, he answered as an 8 year old would: "At my house." In the midst of a tense situation, it brought a flicker of a smile to our faces while we continued with the trauma assessment.
It snowed quite a bit in our area today. The roads were slippery and a car near an outside town lost control and crashed into another. A semi driving up the same road could not stop in time to avoid the accident and crashed into them both. Our little town does not have many multiple motor vehicle accidents like this. At the hospital, we got news that several adults and chidren were being brought in. We rushed to the ER to await their arrival. The kids came first. There was an 8 year old and a 1 year old.
I love it when kids cry. The sounds of both these children crying was a reassuring sound -- it meant they were conscious, alert and that their airway was not compromised. The 1 year old had a head laceration that appeared superficial. The 8 year old had some abdominal pain. While performing the primary survey, one of the nurses asked the crying 8 year old, "where do you live?" Between sniffles and tears, he answered as an 8 year old would: "At my house." In the midst of a tense situation, it brought a flicker of a smile to our faces while we continued with the trauma assessment.
Sunday, November 05, 2006
A day and a night in the CCU -- out-of-hospital cardiac arrest
In the evening, we were called from the ER to say that the ambulance was bringing in an "out-of-hospital cardiac arrest". What does that phrase mean to us? To give you an idea, I quote from a review article:
"The circumstances of cardiopulmonary resuscitation (CPR) can affect prognosis after a cardiac arrest in terms of both survival and quality of life. In one study of out of hospital cardiac arrest, 44 percent of patients receiving CPR survived initially, 30 percent were alive at 24 hours, 13 percent at one month, and only 6 percent were alive after 6 months. The duration of CPR significantly correlated with outcome; no patient who required more than 15 minutes of CPR survived more than 6 weeks. (Bereke et al, 1997).
This 70-something lady had spent the day shopping with her daughter, after enjoying a good breakfast. In the evening, she went to visit her husband who was recently transferred to a nursing home because of severe dementia. The two of them were visiting in his room. There was no one else there at the time. What happened next is surmised from the stories of others. The nurse and CNAs at the desk heard the nursing home resident room alarm go off. Apparently, this alarm is triggered to go off when the resident moves his back away from the chair. At first, since they knew his wife was in the room with him at the time, they thought she would help him.
When the alarm did not stop, they went to the room to check up on him. They found him leaned forward in his chair trying to hold up his wife who it appeared, had passed out. They could detect no pulse. The woman was put on the floor and the nurse and CNAs began CPR while someone called for the ambulance. The ambulance techs arrived and hooked up to an AED (Automated External Defibrillator), which advised a shock to the patient. Over the next 40 minutes during which CPR was continued, the patient was shocked again en route to the hospital. By the time she got to the ER, she was intubated, on a ventilator, but her heart was beating on its own. The ER doc was relieved to hand me the chart and the patient as she placed a hand on my shoulder and said "Good luck!"
We moved the patient to the unit (CCU) and got her stabilized. During the course of a very long night, she began to have tonic-clonic seizures. I had the responsibility of talking with the family and explaining the dismal outcome we expected, given this ominous sign of anoxic brain injury.
Last night, I had to have similar conversations with two different sets of families. In both cases, I was telling children of the patients that their mother was not expected to survive, although they were alive at the time. I had to explain that although their heart was beating and the ventilator was helping them breathe, they would never be the same. The patients in both cases were unresponsive. There was a strong possibility of severe injury to the brain from the lack of oxygen in the time it took to rescucitate them.
You know, some nights, after a conversation like that, I am actually grateful if my pager goes off and I can leave to the next emergency where I have to focus on a task at hand and not think about the meaning of the conversation I have just had.
A single event like what happened to this patient can change one's life for ever -- even end it all. And such an event is not predictable, although its occurence may be inevitable in the setting of some kinds of heart disease. Bottom-line: carpe diem -- seize the day!
Addendum, next afternoon:
I visited the CCU to find out how the patient was doing. I was informed that given the poor prognosis and predicted quality of life, the family chose to withdraw support. That meant stopping the ventilator. The patient died shortly after that was done.
"The circumstances of cardiopulmonary resuscitation (CPR) can affect prognosis after a cardiac arrest in terms of both survival and quality of life. In one study of out of hospital cardiac arrest, 44 percent of patients receiving CPR survived initially, 30 percent were alive at 24 hours, 13 percent at one month, and only 6 percent were alive after 6 months. The duration of CPR significantly correlated with outcome; no patient who required more than 15 minutes of CPR survived more than 6 weeks. (Bereke et al, 1997).
This 70-something lady had spent the day shopping with her daughter, after enjoying a good breakfast. In the evening, she went to visit her husband who was recently transferred to a nursing home because of severe dementia. The two of them were visiting in his room. There was no one else there at the time. What happened next is surmised from the stories of others. The nurse and CNAs at the desk heard the nursing home resident room alarm go off. Apparently, this alarm is triggered to go off when the resident moves his back away from the chair. At first, since they knew his wife was in the room with him at the time, they thought she would help him.
When the alarm did not stop, they went to the room to check up on him. They found him leaned forward in his chair trying to hold up his wife who it appeared, had passed out. They could detect no pulse. The woman was put on the floor and the nurse and CNAs began CPR while someone called for the ambulance. The ambulance techs arrived and hooked up to an AED (Automated External Defibrillator), which advised a shock to the patient. Over the next 40 minutes during which CPR was continued, the patient was shocked again en route to the hospital. By the time she got to the ER, she was intubated, on a ventilator, but her heart was beating on its own. The ER doc was relieved to hand me the chart and the patient as she placed a hand on my shoulder and said "Good luck!"
We moved the patient to the unit (CCU) and got her stabilized. During the course of a very long night, she began to have tonic-clonic seizures. I had the responsibility of talking with the family and explaining the dismal outcome we expected, given this ominous sign of anoxic brain injury.
Last night, I had to have similar conversations with two different sets of families. In both cases, I was telling children of the patients that their mother was not expected to survive, although they were alive at the time. I had to explain that although their heart was beating and the ventilator was helping them breathe, they would never be the same. The patients in both cases were unresponsive. There was a strong possibility of severe injury to the brain from the lack of oxygen in the time it took to rescucitate them.
You know, some nights, after a conversation like that, I am actually grateful if my pager goes off and I can leave to the next emergency where I have to focus on a task at hand and not think about the meaning of the conversation I have just had.
A single event like what happened to this patient can change one's life for ever -- even end it all. And such an event is not predictable, although its occurence may be inevitable in the setting of some kinds of heart disease. Bottom-line: carpe diem -- seize the day!
Addendum, next afternoon:
I visited the CCU to find out how the patient was doing. I was informed that given the poor prognosis and predicted quality of life, the family chose to withdraw support. That meant stopping the ventilator. The patient died shortly after that was done.
A day and a night in the CCU -- "...she's stopped breathing!"
Well, as a Med/Peds resident, I do something different from most of the other residencies. I shift every 4 months between the worlds of Pediatrics and Internal Medicine. With the change in the month, I am back in Internal Medicine again and my patients went from being 7 to 73. Yesterday and last night night, I was on call in the Critical Care Unit. It's been a while since I was there (I think a year has passed) so it took a few moments to get used to things again.
It was a busy night. I got to intubate one patient, and place arterial lines in two others -- one was a femoral and the other a radial.
At about noon, a hospitalist called to say that a 73 year old female patient of hers was found in her room with a heart rate in the 30s and in apneic breathing. She was bringing her to us. As she wheeled her into our section of the unit, her face (the doctor's) was white and she looked frightened. She said "I think she has stopped breathing!" Well, those are the magic words...
I was by her side and feeling for a carotid pulse. There was none. With nurses, and my fellow resident all coming to her side, I began chest compressions while my colleague called out for atropine and epinephrine. Within less than a minute, she was back. Sometimes medicine happens in bursts of a few seconds that make a difference between life and death. I think that besides the adrenaline that we injected into this patient, there was quite a bit in everyone else in the room.
We set up the necessary access lines and blood pressure medications to stabilize her. Unfortunately, she has severe coronary artery disease -- two of the three main blood vessels in her heart (right coronary artery and circumflex) are completely blocked off while the third -- the left anterior descending, is 50% blocked. Because of chronic renal failure, she is not a candidate for a bypass procedure (that is to say she would probably die during the procedure necessary to save her life -- ironic, isn't it?). Although we were able to rescucitate her (get her heart to start beating on its own again and get her to breath), she is in an unresponsive state.
Well, I was quite busy with all this excitement. But there was more. I guess it was to be the night of the 70-somethings.
It was a busy night. I got to intubate one patient, and place arterial lines in two others -- one was a femoral and the other a radial.
At about noon, a hospitalist called to say that a 73 year old female patient of hers was found in her room with a heart rate in the 30s and in apneic breathing. She was bringing her to us. As she wheeled her into our section of the unit, her face (the doctor's) was white and she looked frightened. She said "I think she has stopped breathing!" Well, those are the magic words...
I was by her side and feeling for a carotid pulse. There was none. With nurses, and my fellow resident all coming to her side, I began chest compressions while my colleague called out for atropine and epinephrine. Within less than a minute, she was back. Sometimes medicine happens in bursts of a few seconds that make a difference between life and death. I think that besides the adrenaline that we injected into this patient, there was quite a bit in everyone else in the room.
We set up the necessary access lines and blood pressure medications to stabilize her. Unfortunately, she has severe coronary artery disease -- two of the three main blood vessels in her heart (right coronary artery and circumflex) are completely blocked off while the third -- the left anterior descending, is 50% blocked. Because of chronic renal failure, she is not a candidate for a bypass procedure (that is to say she would probably die during the procedure necessary to save her life -- ironic, isn't it?). Although we were able to rescucitate her (get her heart to start beating on its own again and get her to breath), she is in an unresponsive state.
Well, I was quite busy with all this excitement. But there was more. I guess it was to be the night of the 70-somethings.
Saturday, November 04, 2006
Can't open my eyes...
Imagine lying in bed, not being able to open your eyes, blink, talk or swallow your spit. Imagine that you have tingling in your arms and legs but no real capacity for coordinated movement. Imagine further that through all this, your hearing is intact, your vision perfect (if someone else will open your eyes for you to be able to see) and there is nothing wrong with your brain. No, this is not a stroke, although it is a nerve disease. Imagine that all this happened after a few days of diarrhea -- the kind of stomach upset that happens when you eat bad food, the kind that happens to all of us.
This is the Miller-Fisher variant of Guillain-Barre syndrome. It is a rare disorder characterized by paralysis of the eye muscles, abnormal muscle coordination and a few other nervous dysfunctions. While the exact cause is not known, it is believed to occur as a sequelae to some viral infections and bacterial infections-- much like Guillain-Barre.
This is the story of a 60-something previously healthy male. (In his room in the CCU, there were pictures on the wall of him with his prize turkey, a deer he had shot and others with his family and friends -- a full and active life). It started with some difficulty talking and swallowing (dysphonia and dysphagia), followed in rapid succession with droopy eyelids. He also reported some tingling in his arms and legs. By the early hours of the following morning, he was unable to spit or swallow. At this point, when he was rushed to an ER, he was intubated and put on a ventilator to support his breathing. By that time, he was unable to shake his head up and down.
When I saw him in the CCU, he had already been in the hospital about a month. His recovery was extremely slow. It is anticipated that he will recover, perhaps completely, within 6 months. Until then, there is not a lot than can be done for him. He could develop secondary infections (he has a tube in his throat and one in his penis). He will get some muscle atropy (since he cannot move his muscles on his own, although he has recovered lower extremity function and some upper extremity function).
See http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher.htm for the NIH's research activity on this horrible condition.
This is the Miller-Fisher variant of Guillain-Barre syndrome. It is a rare disorder characterized by paralysis of the eye muscles, abnormal muscle coordination and a few other nervous dysfunctions. While the exact cause is not known, it is believed to occur as a sequelae to some viral infections and bacterial infections-- much like Guillain-Barre.
This is the story of a 60-something previously healthy male. (In his room in the CCU, there were pictures on the wall of him with his prize turkey, a deer he had shot and others with his family and friends -- a full and active life). It started with some difficulty talking and swallowing (dysphonia and dysphagia), followed in rapid succession with droopy eyelids. He also reported some tingling in his arms and legs. By the early hours of the following morning, he was unable to spit or swallow. At this point, when he was rushed to an ER, he was intubated and put on a ventilator to support his breathing. By that time, he was unable to shake his head up and down.
When I saw him in the CCU, he had already been in the hospital about a month. His recovery was extremely slow. It is anticipated that he will recover, perhaps completely, within 6 months. Until then, there is not a lot than can be done for him. He could develop secondary infections (he has a tube in his throat and one in his penis). He will get some muscle atropy (since he cannot move his muscles on his own, although he has recovered lower extremity function and some upper extremity function).
See http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher.htm for the NIH's research activity on this horrible condition.
Saturday, October 28, 2006
Kawasaki disease
It's 11:17 pm. I was on call last night. We admitted a 7 month old little boy. He was really cute, but irritable. He had presented with a 12 day history of fevers, cracked lips, injected conjunctivae and a passing macular rash. He was transferred to us with suspicions that this could be Kawasaki disease.
We did indeed think this was Kawasaki. Although he did not have all the classic symptomsWe admitted him and got him started on the appropriate treatment: IVIG (Intravenous Immunoglobulin) and high dose aspirin.
Now the bad news.
We knew this could happen. We got an echocardiogram today and he has coronary artery beads that are interpreted to be signs of a coronary artery aneurysm . I am upset and depressed about this. He is 7 months old! While this is a known sequence of Kawasaki, we were hoping that we were in time with treatment.
There is something about a post-call day. You have been on for 30 hours. You are hungry, your stomach probably burns from too much coffee, eating at odd hours, disrupted sleep cycles and who knows what else. You are washed out and running on fumes. To get bad news on a day like that makes it tough.
Something hurts inside. Frustration. Couldn't, can't do anything about this bad finding. Of course, we will 'follow' and react appropriately. Possible future events include thrombosis of the coronary artery. He is 7 months old!! We will probably get a repeat echo in 6 weeks. The anuerysm could either have resolved by then or we could have a giant aneurysm. I am hoping for the best.
I think I hate Kawasaki disease. I hate that we do not know what causes it. What a tease and frustration.
This is one of those days when you wrap your coat about you and press into the cold wind to go on.
Addendum on 12/24/2006:
The follow up echo was done 6 weeks later. The arteries returned to normal. Life is sweet! Merry Christmas!
We did indeed think this was Kawasaki. Although he did not have all the classic symptomsWe admitted him and got him started on the appropriate treatment: IVIG (Intravenous Immunoglobulin) and high dose aspirin.
Now the bad news.
We knew this could happen. We got an echocardiogram today and he has coronary artery beads that are interpreted to be signs of a coronary artery aneurysm . I am upset and depressed about this. He is 7 months old! While this is a known sequence of Kawasaki, we were hoping that we were in time with treatment.
There is something about a post-call day. You have been on for 30 hours. You are hungry, your stomach probably burns from too much coffee, eating at odd hours, disrupted sleep cycles and who knows what else. You are washed out and running on fumes. To get bad news on a day like that makes it tough.
Something hurts inside. Frustration. Couldn't, can't do anything about this bad finding. Of course, we will 'follow' and react appropriately. Possible future events include thrombosis of the coronary artery. He is 7 months old!! We will probably get a repeat echo in 6 weeks. The anuerysm could either have resolved by then or we could have a giant aneurysm. I am hoping for the best.
I think I hate Kawasaki disease. I hate that we do not know what causes it. What a tease and frustration.
This is one of those days when you wrap your coat about you and press into the cold wind to go on.
Addendum on 12/24/2006:
The follow up echo was done 6 weeks later. The arteries returned to normal. Life is sweet! Merry Christmas!
Friday, October 27, 2006
5 year old versus motor propeller
I am post call today. It was a busy night and by the time I had got home, it was about 3 in the afternoon. I had been in the hospital 33 hours without sleep. Lots had happened. I finally got to send one of our little 5 year olds home today after a 2 month stay in the hospital.
About 2 months ago, he had been boating with his family. He fell into the water and the propeller from the motor slashed into him on the left side, fracturing his scapula, breaking ribs, cutting into his spleen, pancreas, left kidney, small bowel and large bowel. He also had a femur fracture on the same left side.
Shortly after being admitted, his spleen, left kidney and portions of his bowel were removed. During his long hospital stay, he underwent a number of surgical procedures and needed extensive skin grafting to close up the abdominal wound. While the graft didn't exactly take, his abdmomen is healing.
It was emotional to send him out. There were a lot of specialists involved in his care and it was a nightmare to put together his discharge documents -- so many issues to address for follow up and I was afraid something will be missed if I did not document it thoroughly and go over it with the mom. I got to see his abdominal wound today (perhaps for the last time). If you compare it to a normal 5 year old's abdomen, it would be considered almost frankensteinian with suture marks running in different directions and triangular shaped red scar tissue visible medially and laterally. But if you think about where he has reached, it is a beautiful sight. He will need plastic surgery in the future, but for now, he is alive and going home. I shall miss him.
I was proud to be part of his care. I almost feel like I was sending one of my own babies home. He is a medical miracle and an incredibly brave little boy. I wish him well.
About 2 months ago, he had been boating with his family. He fell into the water and the propeller from the motor slashed into him on the left side, fracturing his scapula, breaking ribs, cutting into his spleen, pancreas, left kidney, small bowel and large bowel. He also had a femur fracture on the same left side.
Shortly after being admitted, his spleen, left kidney and portions of his bowel were removed. During his long hospital stay, he underwent a number of surgical procedures and needed extensive skin grafting to close up the abdominal wound. While the graft didn't exactly take, his abdmomen is healing.
It was emotional to send him out. There were a lot of specialists involved in his care and it was a nightmare to put together his discharge documents -- so many issues to address for follow up and I was afraid something will be missed if I did not document it thoroughly and go over it with the mom. I got to see his abdominal wound today (perhaps for the last time). If you compare it to a normal 5 year old's abdomen, it would be considered almost frankensteinian with suture marks running in different directions and triangular shaped red scar tissue visible medially and laterally. But if you think about where he has reached, it is a beautiful sight. He will need plastic surgery in the future, but for now, he is alive and going home. I shall miss him.
I was proud to be part of his care. I almost feel like I was sending one of my own babies home. He is a medical miracle and an incredibly brave little boy. I wish him well.
Lonely in residency
3.28.2006 12:48 am ...
I just came off call today. It was a long 36 hours stretch at the hospital that was busy with some highs and lows, tense moments and good moments. I came home by 3:30 pm. I was so tired, I think I went to sleep without eating anything. I was scheduled to go to a christian prayer group meeting at 7:00 pm
My eyes opened at 8:30 pm. For a moment I didn't know where or when I was. Then it hit me. I had missed the meeting I was looking forward to going to for a month. Drats! If you don't want to hear me whine, then don't read on...
I feel a sense of frustration. With the life in residency being what it is -- screwed up sleep routines, odd, disjointed times off, it is so difficult to have a life. I got up depressed and frustrated with myself that I have not been able to meet any of these meetings that I wanted to go to.
I called the hospital and found out that one of the kids we had admitted on call -- that we thought had Kawasaki -- has coronary artery anuerysms. It hurts to think of it. I wanted so much to talk to someone about my feelings. But, who? It is 10:30 pm at night. Who could I call at that odd hour?
Residency can be lonely. Because of the hours I do not have much of a social life. Since I do not drink, the bar scene doesn't work for me. I would love to join a class or group or something, but with my call schedule that keeps changing, I don't think I could make the classes. Who would put up with me anyway? They wouldn't see as much of me as they might wish and I might want to call or meet with them at odd hours of morning or night. My days off may come on a week day and I may work 3 weekends straight.
Okay. So I'm post-call and tired. Still...
I just came off call today. It was a long 36 hours stretch at the hospital that was busy with some highs and lows, tense moments and good moments. I came home by 3:30 pm. I was so tired, I think I went to sleep without eating anything. I was scheduled to go to a christian prayer group meeting at 7:00 pm
My eyes opened at 8:30 pm. For a moment I didn't know where or when I was. Then it hit me. I had missed the meeting I was looking forward to going to for a month. Drats! If you don't want to hear me whine, then don't read on...
I feel a sense of frustration. With the life in residency being what it is -- screwed up sleep routines, odd, disjointed times off, it is so difficult to have a life. I got up depressed and frustrated with myself that I have not been able to meet any of these meetings that I wanted to go to.
I called the hospital and found out that one of the kids we had admitted on call -- that we thought had Kawasaki -- has coronary artery anuerysms. It hurts to think of it. I wanted so much to talk to someone about my feelings. But, who? It is 10:30 pm at night. Who could I call at that odd hour?
Residency can be lonely. Because of the hours I do not have much of a social life. Since I do not drink, the bar scene doesn't work for me. I would love to join a class or group or something, but with my call schedule that keeps changing, I don't think I could make the classes. Who would put up with me anyway? They wouldn't see as much of me as they might wish and I might want to call or meet with them at odd hours of morning or night. My days off may come on a week day and I may work 3 weekends straight.
Okay. So I'm post-call and tired. Still...
Wednesday, October 11, 2006
Poem: Waiting...
I went to a writing group meeting the other day and one of our assignments was to write a poem. The theme was "waiting". Well, I guess I had the ICU on my mind when I wrote this:
Waiting…
The monitor beeped in the background
As the machine took another breath.
Tubes carried food and water,
As the bed bore up life and death.
They came several times a shift:
White coats, green scrubs or plain,
Checked numbers, connections and flow rates;
Today was there weight loss or gain?
“Mr. Jones! Mr. Jones! Mr. Jones!”
called a tired but firm young voice.
Tired eyes above an endotracheal tube
Opened to silence the noise.
The intern left after data gathering,
Leaving a sea of tubes and pumps.
Amidst them, a Mr. Jones closed his eyes
Again to resume the waiting…
Waiting…
The monitor beeped in the background
As the machine took another breath.
Tubes carried food and water,
As the bed bore up life and death.
They came several times a shift:
White coats, green scrubs or plain,
Checked numbers, connections and flow rates;
Today was there weight loss or gain?
“Mr. Jones! Mr. Jones! Mr. Jones!”
called a tired but firm young voice.
Tired eyes above an endotracheal tube
Opened to silence the noise.
The intern left after data gathering,
Leaving a sea of tubes and pumps.
Amidst them, a Mr. Jones closed his eyes
Again to resume the waiting…
Sunday, September 10, 2006
Getting a license to practice medicine and a DEA number
9/4/2006 5:28 pm
Some of us have today off, being Labor Day and all. I am enjoying this breather after a heavy month on the Pediatric Wards. Don't get me wrong. I LOVE what I do and like many of you, I aspired for this 'dream life'. No regrets!
I also wanted to share the good news. As of August 2006, I am now a licensed physician. It is customary to put in an application at the end of internship for a license from the state where you are. This is not a training permit, but the real thing -- the license you will (if you continue to renew it) have for the rest of your working life. Well, after due process -- without any hitches, I was given a license.
After getting the license, I was able to apply for a DEA number. This is the number the Federal Government assigns to health professionals writing prescriptions for narcotics. The Drug Enforcement Agency uses this number to track licensed health professionals' prescription activity. Incidentally, most pharmacies will not fill ANY prescription written by you without this number, even if you are licensed. (Go figure!).
I understand that there are not many states that will issue a license to a foreign medical graduate after only one year of post-graduate training. I guess I am fortunate to be in one of those states.
Some of us have today off, being Labor Day and all. I am enjoying this breather after a heavy month on the Pediatric Wards. Don't get me wrong. I LOVE what I do and like many of you, I aspired for this 'dream life'. No regrets!
I also wanted to share the good news. As of August 2006, I am now a licensed physician. It is customary to put in an application at the end of internship for a license from the state where you are. This is not a training permit, but the real thing -- the license you will (if you continue to renew it) have for the rest of your working life. Well, after due process -- without any hitches, I was given a license.
After getting the license, I was able to apply for a DEA number. This is the number the Federal Government assigns to health professionals writing prescriptions for narcotics. The Drug Enforcement Agency uses this number to track licensed health professionals' prescription activity. Incidentally, most pharmacies will not fill ANY prescription written by you without this number, even if you are licensed. (Go figure!).
I understand that there are not many states that will issue a license to a foreign medical graduate after only one year of post-graduate training. I guess I am fortunate to be in one of those states.
Wednesday, July 05, 2006
End of Internship year
Well, it is July 4, 2006. I am post-call and although tired, felt like browsing the forum and thought it would be nice to record some thoughts on completing the internship year. Perhaps those of you in a similar position might want to share your stories too.
What a year it has been! Well, first off, as a Med-Peds resident, I should qualify my experience. In med-peds, unlike categorical residencies, internship lasts 14 months instead of the usual 12. This is because we are doing two residencies and need to fulfill criteria for completion of core curricula in each. That means that although I am now a PGY2, I am still an intern for another 4 months (this one included). I also have the rather odd position of being a senior in medicine and still an intern in pediatrics.
The exciting event on the horizon for all of us is getting our licenses! This happens once your program submits a document to the state medical board to say that you have completed one year of post-graduate training. All the rest of my paperwork is done and I should expect the license in about 2 weeks to a month. At that point, I will be able to sign prescriptions for all things except narcotics. That latter privilege comes after I get an assigned DEA number. I need the state license first. It is interesting that there is no 'other' license issued to you at the end of residency. This is it. Of course, being licensed in one state means you can only practice in that state. Some states have reciprocity agreements and grant licenses easier if you are licensed in one of the states they have an agreement with. (I haven't investigated that much; having a license is plenty good enough for me for now).
It is interesting how I feel a little changed through this first year. I am a little (just a little) more sure of myself in the hospital and clinics. At least things are more familiar (I know where the cafetaria and rest rooms are) and I feel that I can usually do a few things rather than stand around biting my nails when things get scary. I am particularly proud of my ability to put in central lines (the subclavian is my favorite) and in my program, I have something of reputation for that.
To those of you who know me, I still draw biochemical graffiti on blank blackboards, greenboards or whiteboards whenever I see one. The program and residents tolerate me in that regard. You know, I think you really don't really how much has changed until you look into the eyes of the new interns and see their dazed look or they ask you questions and somehow (miraculously) you know the answers. Being a senior is kind of scary because while the intern does the H & P, you decide the management plan. Somehow though, I am not afraid of that responsibility and feel up to the challenge.
The USMLE exams are now a distant memory and are only relived whenever the intraining exams come around (which for peds is in a week).
What a year it has been! Well, first off, as a Med-Peds resident, I should qualify my experience. In med-peds, unlike categorical residencies, internship lasts 14 months instead of the usual 12. This is because we are doing two residencies and need to fulfill criteria for completion of core curricula in each. That means that although I am now a PGY2, I am still an intern for another 4 months (this one included). I also have the rather odd position of being a senior in medicine and still an intern in pediatrics.
The exciting event on the horizon for all of us is getting our licenses! This happens once your program submits a document to the state medical board to say that you have completed one year of post-graduate training. All the rest of my paperwork is done and I should expect the license in about 2 weeks to a month. At that point, I will be able to sign prescriptions for all things except narcotics. That latter privilege comes after I get an assigned DEA number. I need the state license first. It is interesting that there is no 'other' license issued to you at the end of residency. This is it. Of course, being licensed in one state means you can only practice in that state. Some states have reciprocity agreements and grant licenses easier if you are licensed in one of the states they have an agreement with. (I haven't investigated that much; having a license is plenty good enough for me for now).
It is interesting how I feel a little changed through this first year. I am a little (just a little) more sure of myself in the hospital and clinics. At least things are more familiar (I know where the cafetaria and rest rooms are) and I feel that I can usually do a few things rather than stand around biting my nails when things get scary. I am particularly proud of my ability to put in central lines (the subclavian is my favorite) and in my program, I have something of reputation for that.
To those of you who know me, I still draw biochemical graffiti on blank blackboards, greenboards or whiteboards whenever I see one. The program and residents tolerate me in that regard. You know, I think you really don't really how much has changed until you look into the eyes of the new interns and see their dazed look or they ask you questions and somehow (miraculously) you know the answers. Being a senior is kind of scary because while the intern does the H & P, you decide the management plan. Somehow though, I am not afraid of that responsibility and feel up to the challenge.
The USMLE exams are now a distant memory and are only relived whenever the intraining exams come around (which for peds is in a week).
Sunday, May 28, 2006
Internship -- Critical Care
Hi guys!
I just came through spending a month in critical care medicine, and I think I've found my true love. At first, I was nervous in the CCU (Critical Care Unit). Everyone looked so fragile and on the edge of life (most of them just don't look like that, they are!). I was afraid to do anything -- a physical exam, ask questions or anything. By the end of the month though, I have lost that fear. I feel like I know a little more of what to do there. I got a chance to intubate a couple of people, participate in several code blues (cardiac and/or respiratory failure) and was part of several death-and-life dramas. There were many cool experiences.
And oh by the way, all you guys who gave me grief for spending so much time on the Henderson-Hasselbalch equation in biochemistry, just wait till you see how useful it is in critical care and how much you will use your knowledge of blood gases. More on that later...
Vijay
I just came through spending a month in critical care medicine, and I think I've found my true love. At first, I was nervous in the CCU (Critical Care Unit). Everyone looked so fragile and on the edge of life (most of them just don't look like that, they are!). I was afraid to do anything -- a physical exam, ask questions or anything. By the end of the month though, I have lost that fear. I feel like I know a little more of what to do there. I got a chance to intubate a couple of people, participate in several code blues (cardiac and/or respiratory failure) and was part of several death-and-life dramas. There were many cool experiences.
And oh by the way, all you guys who gave me grief for spending so much time on the Henderson-Hasselbalch equation in biochemistry, just wait till you see how useful it is in critical care and how much you will use your knowledge of blood gases. More on that later...
Vijay
Monday, January 30, 2006
Marshfield Clinic magazine article
During my internship year, one unexpected surprise was a visit from a 'reporter'. This person worked for an inhouse publication called The Scope -- a publication put out by our institute's division of education. I was told that they wanted to interview the new residents to find out how things were going.
The only time I could find to do this was one afternoon, post-call. So, after a particularly busy night and morning, before I went home, I met the interviewer and answered some questions. The result is this article. I guess it is part of posterity now.
Monday, November 14, 2005
From the trenches of internship
11/13/2005
I am doing a Med-Peds residency at the Marshfield Clinic & St. Joseph's Hospital in WI. This was my first weekend off in 6 weeks. I actually got both Sat and Sun off -- didn't have to go to the hospital, didn't have to answer pages. Unbelievable!
I just wanted to say that residency is great but can tax you physically. I had to make a poster presentation at the American Society of Human Genetics last month. I was up all night preparing the poster. The next night, I was up all night on call. The following day, I was post-call and snoring loudly in the plane from Marshfield to Salt Lake City. I presented my paper the following day. The next morning, I was on the plane back and on call the following night.
Having said all this, I would not trade it for the world. I am living a dream. I am learning and doing a great deal and loving every minute of it. There are poignant experiences that burn into one's memory: like doing chest compressions on an 8 month old female infant who did not survive the code. I had been up all night and the child was flown in by copter in the morning, pulseless and not breathing. I don't think I shall forget that experience.
To all you medical students out there, doing USMLEs, attending classes and looking forward with trepidation to residency: hang in there; learn the best you can; make the knowledge yours -- not just short term memory for a test. You will need it! But it's worth it in the end. During residency, no one cares where you went to medical school, what grades you got in path or physio or whatever, or what scores you got in the USMLE. Everyone comes to know what you do and don't know by the way you function on the wards and in the clinic. It's the knowledge that's really yours that shows then.
I am doing a Med-Peds residency at the Marshfield Clinic & St. Joseph's Hospital in WI. This was my first weekend off in 6 weeks. I actually got both Sat and Sun off -- didn't have to go to the hospital, didn't have to answer pages. Unbelievable!
I just wanted to say that residency is great but can tax you physically. I had to make a poster presentation at the American Society of Human Genetics last month. I was up all night preparing the poster. The next night, I was up all night on call. The following day, I was post-call and snoring loudly in the plane from Marshfield to Salt Lake City. I presented my paper the following day. The next morning, I was on the plane back and on call the following night.
Having said all this, I would not trade it for the world. I am living a dream. I am learning and doing a great deal and loving every minute of it. There are poignant experiences that burn into one's memory: like doing chest compressions on an 8 month old female infant who did not survive the code. I had been up all night and the child was flown in by copter in the morning, pulseless and not breathing. I don't think I shall forget that experience.
To all you medical students out there, doing USMLEs, attending classes and looking forward with trepidation to residency: hang in there; learn the best you can; make the knowledge yours -- not just short term memory for a test. You will need it! But it's worth it in the end. During residency, no one cares where you went to medical school, what grades you got in path or physio or whatever, or what scores you got in the USMLE. Everyone comes to know what you do and don't know by the way you function on the wards and in the clinic. It's the knowledge that's really yours that shows then.
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