June 30, 2009: this was the last day of work in my residency in Med-Peds.
I began residency on July 13, 2005. Technically, that means I should work until July 12, 2009 to complete the four year program. However, I saved up some vacation time during my last time so that I could end on June 30. During the month of June, I was doing a rotation in Pediatric Hematology-Oncology.
Something special happened on this morning: as I drove into work, I saw a beautiful complete rainbow arc across the sky. It was a complete rainbow from horizon to horizon. One end of it dipped into the horizon just at the location of the Marshfield Clinic. Okay, I'm not going to read anything into this, but it was really cool and special, being my last day of residency and all. :-)
My last day began with Morning Report in Pediatrics. The ward team presented a case of a 4-year old with a rash and fever and we talked about rashes. It was nostalgic to be sitting there as a resident for the last time.
The morning was spent rounding on the 2 Heme-Onc patients we had. I then had an exit quiz in my attending's office. That went well. Interesting how one learns during these rotations. It's like when you look at yourself in a mirror everyday and can't see the changes accomulating daily. Someone else, seeing you after a period sees them immediately. The quiz gave me perspective on my learning in Heme-Onc.
After lunch, I sat down with the program coordinator and went through the exit list. A day before, I had got to hand over my resident's pager. However, since I am staying on here, it was simply replaced by an identical appearing but newer pager. Kind of an anti-climax: I had heard stories of people being so grateful to finally hand off the pager that had 'killed' many a night of sleep. Somehow, I never felt that way. Each page was an invitation to an adventure, a thrill.
Instead of the exit interview being a simple handing over of everything, it was more like a replacing of 'resident' stuff with 'attending' stuff.
The afternoon was not so busy. At 4:30 pm I went to the Pediatric ICU to get report on the patients I would care for during the night -- my last night on call as a resident. There were jokes about how after midnight, I might switch off my pager or simply tell the caller to page the 'resident' instead of me.
My last night on call was wonderful. I ordered pizza for everyone. Instead of wishing for a 'quiet' night, I actually wanted cases. My wish was granted. It was quite busy, with different, interesting admissions and call issues. I admitted a 20-month old female who had had 5 seizures that day. Her parents were both family practice docs. At 3 am in the morning, I did a spinal tap on her. My PICU attending made me a little plaque to wear on my back for the night that said 'After midnight, the bucks stops here!'.
It was poignant to spend my last day in residency on call. When I signed out at 6 am the next morning, I was officially done. The ward team to whom I had signed out were busy sorting out the admissions of the night. Since it was the start of a new month, it was a new team and you could tell they were a little nervous. Everyone had new roles: there was a fresh intern at the table -- his first day in residency; the second resident at the table was now a 'senior' resident -- he was an intern till yesterday, and the Ward Chief was starting his first day as a third and final year Peds resident and Chief Resident at the table. The PICU resident was busy gathering numbers in anticipation of morning rounds. Until yesterday, she too was an intern, and now she was a senior resident and the PICU resident for the month. And me, I was done.
I walked away from a busy floor of activity, everyone trying to step into their new roles, while attempting to provide continuity of care to our precious little patients. Life, as usual, goes on.
Thursday, July 02, 2009
Thursday, June 25, 2009
The retired physician
I was in Wal-Mart the other day, when I saw a curious, elderly gentleman of East Indian descent looking at me. I smiled back. He asked me whether I worked at the Clinic and I said yes.
We started talking.
He had joined the clinic in 1967 and specialized as an anesthesiologist in doing cases in pediatrics and cardiothoracic surgery. Before long, he was reminiscing and talking about old cases. His wife spied us from across a few aisles and came up. She introduced herself.
It became clear that there was some element of senile dementia. From his wife's 'take-charge' attitude (she locked arms with him and began to lead him out where apparently, her sister had the car loaded with their purchases and waiting), it seemed like she was the primary caregiver. As she led/almost pushed him along, I could see the misty look in his eyes, as he was being led off almost mid-sentence....
Curious thing. We'll all get old and senile dementia increases with age. From the stories I heard, this was a successfull and trailblazing anesthesiologist with many 'firsts' in his career. Now he was a retiree who needed looking after.
This reminded me of a more tragic case: I was doing an emergency room rotation that month when the code pager went off early that morning. I ran behind the ER doc as we came to the ward floor. The patient was a retired physician who had come in for an elective prostrate procedure. In the early hours of the morning, his heart had stopped and when the nurses' aide came in to do vitals at about 6 am, he was pulseless with no respirations. We ran the code for about 30 minutes when it became increasingly clear that this frail but hitherto functioning individual was not coming back.
As the ER doc called his wife to give her the bad news, I reflected on the situation. I imagined that this physician had probably done CPR, and ran codes on others before, perhaps even some physicians. Here he was on the other end of that scenario, for the final time. A life spent in medicine and ended in a medical scenario.
As physicians, growing old, becoming senile, being on the receiving end of emergency medical care -- all this seems scary. And yet, it is our future.
We started talking.
He had joined the clinic in 1967 and specialized as an anesthesiologist in doing cases in pediatrics and cardiothoracic surgery. Before long, he was reminiscing and talking about old cases. His wife spied us from across a few aisles and came up. She introduced herself.
It became clear that there was some element of senile dementia. From his wife's 'take-charge' attitude (she locked arms with him and began to lead him out where apparently, her sister had the car loaded with their purchases and waiting), it seemed like she was the primary caregiver. As she led/almost pushed him along, I could see the misty look in his eyes, as he was being led off almost mid-sentence....
Curious thing. We'll all get old and senile dementia increases with age. From the stories I heard, this was a successfull and trailblazing anesthesiologist with many 'firsts' in his career. Now he was a retiree who needed looking after.
This reminded me of a more tragic case: I was doing an emergency room rotation that month when the code pager went off early that morning. I ran behind the ER doc as we came to the ward floor. The patient was a retired physician who had come in for an elective prostrate procedure. In the early hours of the morning, his heart had stopped and when the nurses' aide came in to do vitals at about 6 am, he was pulseless with no respirations. We ran the code for about 30 minutes when it became increasingly clear that this frail but hitherto functioning individual was not coming back.
As the ER doc called his wife to give her the bad news, I reflected on the situation. I imagined that this physician had probably done CPR, and ran codes on others before, perhaps even some physicians. Here he was on the other end of that scenario, for the final time. A life spent in medicine and ended in a medical scenario.
As physicians, growing old, becoming senile, being on the receiving end of emergency medical care -- all this seems scary. And yet, it is our future.
Saturday, June 20, 2009
Graduation week
Every residency has a graduation day. Ours is called Residents & Fellows Recognition Evening. It was the 32nd one in the history of the Marshfield Clinic and Saint Joseph's Hospital. It was heald on Friday, June 12, 2009.To attend this historic landmark event in the life of their loved one, my mother, brother, his wife and son came all the way from Panama. I was excited to have them. I took a week of vacation from June 6 to June 14 to host them here. We spent 5 days in Chicago and 2 in Marshfield. I guess,
knowing how small Marshfield is, I thought they would enjoy Chicago more. It was a special time of togetherness, laughter, food and fun.On June 11, my program director hosted a barbeque at his house in my honor. I was so embarrassed by the attention. Nevertheless, my family were touched by the honor. I received a Chief Resident award from him. My mother wept with joy and feeling. While I am embarrassed by attention and awards, I could not help but feel grateful for the recognition if it brought joy to mother's heart.
I truly believe that all our achievements are not ours alone. As one scientist said, we stand on the shoulders of giants. My family has supported me with much sacrifice and I am indebted to them.
A few weeks earlier, my bacteriophage research won me the Nikolai Award for the best Resident Research of the year.
At the 'graduation' evening, we had a great time. I was touched to see so many of our interns show up to support us on this evening. Belonging to the Med-Peds program, mine was the first name announced in the graduation. I picked up a white envelope to applause and returned to our table. I smiled when I saw what was inside: a red sheet of paper with "You may pick up your certification of completion on the last day of your residency" written on it. The ceremony is over, now get back to work :-)
The last event of the evening was an award given by the transitional year residents to a resident who has contributed the most to their medical education. I was pleasantly and genuinely surprised to win this award. I did not expect it, especially after all the glowing things that the resident said before she announced the winner's name. My family was once again proud and me embarrassed.
I am honestly happy that all the ceremony is over and I can get back to the work I enjoy so much in some measure of anonymity. In truth, when people are sick and hurting, awards seem a little crass. My 'award' is the saving of my patients. I pray for that award daily.
Tuesday, June 02, 2009
Then and Now...
It's June, my final month of residency! Last night was my 4th last call of residency (not that I'm counting or anything...). Things have changed so much since my intern year: I used to have butterflies in my stomach on call nights -- anxious and afraid of what might come up and whether I'd be able to handle it. I was 'afraid' of admissions and codes. Like others on the floor in wards (nurses, aides, unit clerks) I would say "Don't say the 'Q' word (quiet) because we woouldn't want to 'jinx' it and get a lot of admissions, codes or pts in crisis. Now though, I look forward to call night to see what we'll get. I'm not afraid or anxious, although I maintain a healthy respect for the unknown in medicine.
At 3 am I got a call from a 3rd year resident who was on call in the CCU (Critical Care Unit). He had admitted an 80-something year old with severe hypotension. The patient was already on pressors through a peripheral IV and needed a central line. He wondered if I could come and assist. Sleep evaporated and I walked over with a bounce in my step. I was on call for Pediatrics but nothing was happening, so I looked forward to actually doing something that night.
During the first attempt at placing the line, the patient became unresponsive. We called a code, did chest compressions and got him back. The line was placed and an hour later I was back in Peds. In my intern days, this would have pumped me with adrenalin. Not so much last night. It was 'fun'. I know I need to guard against becoming complacent or over-confident. No one knows everything and these are literally life and death situations. But I feel ready for the next step in medicine. I am done with my training at the end of this month and looking forward to the future.
At 3 am I got a call from a 3rd year resident who was on call in the CCU (Critical Care Unit). He had admitted an 80-something year old with severe hypotension. The patient was already on pressors through a peripheral IV and needed a central line. He wondered if I could come and assist. Sleep evaporated and I walked over with a bounce in my step. I was on call for Pediatrics but nothing was happening, so I looked forward to actually doing something that night.
During the first attempt at placing the line, the patient became unresponsive. We called a code, did chest compressions and got him back. The line was placed and an hour later I was back in Peds. In my intern days, this would have pumped me with adrenalin. Not so much last night. It was 'fun'. I know I need to guard against becoming complacent or over-confident. No one knows everything and these are literally life and death situations. But I feel ready for the next step in medicine. I am done with my training at the end of this month and looking forward to the future.
Saturday, May 30, 2009
Foreign body (in more ways than one)
This is a story from a little while back. We admitted a 17 year old female with abdominal pain. As part of the admission tests, we got an abdominal x-ray (a KUB). This is what it looked like:
When we saw the x-ray, we all wondered what those radio-opaque circular objects were. During morning rounds, we stood around the computer screen wondering if she might have inadvertently (or purposely) swallowed something, or were they foreign bodies or calcium crystals or pigments from a tatoo. Finally, since this was a patient I had admitted, I was elected to go into the room and ask her. As diplomatically as I could, I asked our little miss if there was something she might want to tell us. I told her I needed to examine her lower back. She dutifully turned onto her stomach and let me pull me the sheets down. I was all prepared to find a tatoo of some sort on her lower back skin but what I saw stopped me in my tracks and instantly provided the answer to our radiologic dilemma. I turned beet red as I saw a pretty pink thong with artificial gems studded in the pattern of a butterfuly on the triangular piece of thong. My colleagues all had a good laugh at me because I was obviously embarrassed by my finding. We all had an even bigger laugh when the radiologist's official read of the x-ray came back as:
"there are multiple radiopaque densities projected in the central aspect of the lower pelvis, probably at the rectosigmoid junction. I presume that this represents residua from suppository or previously-injected material."
Should we tell him?
Thursday, May 21, 2009
Tortured thoughts....
Perhaps my turn of thoughts is because I am still recovering in some form from a recent illness.
Still...
Last night, I sat at the nurses station on Peds trying to finish some paperwork. From down the hall, I heard the sound of a child wailing and crying. I could not bear it. I asked who this was and was told that this neurodevelopmentally delayed 11 year old cries unconsoleable like this every night. Incredulous, I walked determined down the corridor to see who this patient was and why she cried like this.
LW is 11 years old. She was born to a mother who drank during her pregnancy. After a period of failing to meet developmental milestones and some physical and mental signs of cerebral palsy, she was diagnosed as having a 'chromosome 8 inversion' abnormality and consequent severe cognitive impairment. In my years as a scientist, cheering excitedly and participating in the revolutionary sequencing of DNA and the human genome, I had never envisioned the face I saw last night. There is no way to fix a 'chromosome 8 inversion'. It occurs in every one of the billions of cell in this little girl's body. It is a life sentence. The ramifications and effects are not completely known. Few people have this.
Needless to say, LW is in a foster home. Not many individuals have the emotional and physical resources to care for such children. They are high risk for abuse and neglect. Sitting in her room, watching her wail and cry, frustration and anger burned within me. Why was she crying? How could I stop it? What was I missing?
Her nurse and me checked her daiper, repositioned her, tried to soothe her, turned the tv on and then off, turned the lights on then off, tried everything we could think of. No effect. I tried a mild sedative, then another -- no effect. The crying continued. I sat at her bedside, making eye contact, trying to look into the window of her soul, praying for insight, a connection, a solution. I can only imagine what parents and caregivers must go through, year after year, night after night. I searched the literature on sleep and behavior disorders among those with cerebral palsy and neurodegenerative disorders. I found lots of articles that talk about the toll it takes on caregivers, things tried and failed. I read her medical records and found that this problem had been going on for a while and several solutions were tried unsuccessfully.
This patient came to us with a horrible wound at the back of her head and neck. We are unsure what it is, how it got there and exactly how to make it better. At about 4 am in the morning, I thought I would try giving her something for pain. A little bit of morphine put her into much needed sleep! There was no aha moment. Maybe this was pain. Maybe she was exhausted. Maybe she was just done for the night. Who knows? But she slept.
What does the wailing and crying of someone with 'severe cognitive impairment' mean? Is it pain? Is it just the behavior of a disorganized and disregulated brain that cannot calm itself? The patient cannot communicate verbally and does not appear to follow verbal commands, so who knows? As I sat beside her trying to calm her and soothe her, I felt like I was listening to a scrambled brain cry out. In a dark moment of frustration and despair, I found myself thinking, " why do we prolong such a life? Are we really making any difference with what we do?" Dark, scary thoughts that come not from impatience with the patient, but from a mourning heart and mind that cannot think of an answer to make the suffering better.
We live to fight another day. It is morning again. I hear that she slept for a couple of hours and is up and quieted down... for now. My heart is still in knots. I hear the sound of a scrambled brain in a spastic body crying and I don't know what to do. I am driven to find answers. I love what I do. I am haunted by what I do. I want to be better, smarter, wiser.
Still...
Last night, I sat at the nurses station on Peds trying to finish some paperwork. From down the hall, I heard the sound of a child wailing and crying. I could not bear it. I asked who this was and was told that this neurodevelopmentally delayed 11 year old cries unconsoleable like this every night. Incredulous, I walked determined down the corridor to see who this patient was and why she cried like this.
LW is 11 years old. She was born to a mother who drank during her pregnancy. After a period of failing to meet developmental milestones and some physical and mental signs of cerebral palsy, she was diagnosed as having a 'chromosome 8 inversion' abnormality and consequent severe cognitive impairment. In my years as a scientist, cheering excitedly and participating in the revolutionary sequencing of DNA and the human genome, I had never envisioned the face I saw last night. There is no way to fix a 'chromosome 8 inversion'. It occurs in every one of the billions of cell in this little girl's body. It is a life sentence. The ramifications and effects are not completely known. Few people have this.
Needless to say, LW is in a foster home. Not many individuals have the emotional and physical resources to care for such children. They are high risk for abuse and neglect. Sitting in her room, watching her wail and cry, frustration and anger burned within me. Why was she crying? How could I stop it? What was I missing?
Her nurse and me checked her daiper, repositioned her, tried to soothe her, turned the tv on and then off, turned the lights on then off, tried everything we could think of. No effect. I tried a mild sedative, then another -- no effect. The crying continued. I sat at her bedside, making eye contact, trying to look into the window of her soul, praying for insight, a connection, a solution. I can only imagine what parents and caregivers must go through, year after year, night after night. I searched the literature on sleep and behavior disorders among those with cerebral palsy and neurodegenerative disorders. I found lots of articles that talk about the toll it takes on caregivers, things tried and failed. I read her medical records and found that this problem had been going on for a while and several solutions were tried unsuccessfully.
This patient came to us with a horrible wound at the back of her head and neck. We are unsure what it is, how it got there and exactly how to make it better. At about 4 am in the morning, I thought I would try giving her something for pain. A little bit of morphine put her into much needed sleep! There was no aha moment. Maybe this was pain. Maybe she was exhausted. Maybe she was just done for the night. Who knows? But she slept.
What does the wailing and crying of someone with 'severe cognitive impairment' mean? Is it pain? Is it just the behavior of a disorganized and disregulated brain that cannot calm itself? The patient cannot communicate verbally and does not appear to follow verbal commands, so who knows? As I sat beside her trying to calm her and soothe her, I felt like I was listening to a scrambled brain cry out. In a dark moment of frustration and despair, I found myself thinking, " why do we prolong such a life? Are we really making any difference with what we do?" Dark, scary thoughts that come not from impatience with the patient, but from a mourning heart and mind that cannot think of an answer to make the suffering better.
We live to fight another day. It is morning again. I hear that she slept for a couple of hours and is up and quieted down... for now. My heart is still in knots. I hear the sound of a scrambled brain in a spastic body crying and I don't know what to do. I am driven to find answers. I love what I do. I am haunted by what I do. I want to be better, smarter, wiser.
Sickness
It was Monday, the first day of the work week. I had feeling unwell all weekend and dragged myself into work Monday. After a busy clinic, I was feeling really run down. My nose dripped, my eyes were red and itchy and my body ached. As the night wore on, I found myself getting sicker. Fortunately, it is near the end of the academic year and the intern I was on call with was more than willing, and able to step up to the plate and field most of the calls. Still, as I lay on the couch in the residents' room feeling miserable and useless, I was overcome by guilt at leaving him alone to 'do it all'. I was afraid to go into the Pediatric ICU or the Oncology sections where our sickest patients with the most compromised immune systems lay, lest I infect them with whatever I had.
The next afternoon, after returning home, I felt I was getting worse. I agonized over the decision: should I go in to work or beg off sick. Healthcare workers are a strange breed. When we are sick, we feel guilt and dismay at not showing up for our patients and leaving our overworked and tired colleagues to take up the slack. And yet, who knows more the risks of exposing the sick to more sources of infection from the ones they come to for help and care?
I called in sick. I did present to the Urgent Care and was dutifully swabbed for swine flu, and the two common forms of seasonal flu. Fortunately, I was negative for all three. Fortified by this knowledge, I was able to return to work last night -- no runny nose, a minimum cough and a healing body. Perhaps one of the benefits of working with sickness is the constant exposure and 'education' our immune systems get, and the ability to consequently heal a little faster.
A colleague took my night of call. I shall have to 'pay her back' by taking her call in the future sometime. While I would not let such a good deed unnoticed or want her to gratuitously do my work, I do feel bad that our system does not allow for sickness. Maybe it does, but there is no equitable trade. I'm better and back on the other side of the sick bed, where I belong. By the way, those swabs hurt! OUCH! I guess I know how my patients feel when I order these tests...
The next afternoon, after returning home, I felt I was getting worse. I agonized over the decision: should I go in to work or beg off sick. Healthcare workers are a strange breed. When we are sick, we feel guilt and dismay at not showing up for our patients and leaving our overworked and tired colleagues to take up the slack. And yet, who knows more the risks of exposing the sick to more sources of infection from the ones they come to for help and care?
I called in sick. I did present to the Urgent Care and was dutifully swabbed for swine flu, and the two common forms of seasonal flu. Fortunately, I was negative for all three. Fortified by this knowledge, I was able to return to work last night -- no runny nose, a minimum cough and a healing body. Perhaps one of the benefits of working with sickness is the constant exposure and 'education' our immune systems get, and the ability to consequently heal a little faster.
A colleague took my night of call. I shall have to 'pay her back' by taking her call in the future sometime. While I would not let such a good deed unnoticed or want her to gratuitously do my work, I do feel bad that our system does not allow for sickness. Maybe it does, but there is no equitable trade. I'm better and back on the other side of the sick bed, where I belong. By the way, those swabs hurt! OUCH! I guess I know how my patients feel when I order these tests...
Saturday, May 02, 2009
A strange night of call in Pediatrics - Part 2
We were only getting started.
We received a 6-month old little girl as a transfer from another hospital in a nearby town. While the story was not clear, apparently, her mother and 2 and 3 year old siblings were all dead of gunshots to the head. Her father sat dazed in their home, with the furnace running full and the vents shut off. There was a strong smell of gasoline and natural gas in the home as well as on the baby. Police rescued the little girl and seeing how she smelt of gas -- it came from her breath as well -- arranged for her transfer to us. The transferring physicians wanted her closer to access to a Pediatric ICU if she needed it. Ours is about 50 feet walking distance from our wards. A urine drug screen was positive for sedatives. The little girl was screaming, agitated and wouldn't take a bottle initially.
We activated the CAN (Child Abuse and Neglect) workup.
There was a lull from 1 am to 5 am (no admissions). At 5:45 am we received a little girl with a right eye swollen shut and some steristrips holding lacerated skin together at her right eyebrow. The family had had a picnic in the park the day before and encountered a dog without tags. He seemed friendly enough and came and sat under their picnic table. During the course of the picnic, the family made friends with the dog. Feeling sorry that no owner was in sight and no identifying tags were evident, they called the Humane Society to come and 'rescue' the homeless animal. A Society van was pulling up to the edge of the park. The little girl went to pet the dog goodbye and he bit her on the face, narrowly missing the eye but tearing open the skin of the eyebrow.
The rabies status of the dog is unknown. The girl became sick with a fever several hours later. A bite to the head from a dog of questionable rabies history, now showing signs of systemic illness, fever and increasing swelling and redness closing off the eye is cause for concern. I wrote admit orders and quickly examined the girl before rushing to make the 6:00 am signout to the incoming team.
What a night!
We received a 6-month old little girl as a transfer from another hospital in a nearby town. While the story was not clear, apparently, her mother and 2 and 3 year old siblings were all dead of gunshots to the head. Her father sat dazed in their home, with the furnace running full and the vents shut off. There was a strong smell of gasoline and natural gas in the home as well as on the baby. Police rescued the little girl and seeing how she smelt of gas -- it came from her breath as well -- arranged for her transfer to us. The transferring physicians wanted her closer to access to a Pediatric ICU if she needed it. Ours is about 50 feet walking distance from our wards. A urine drug screen was positive for sedatives. The little girl was screaming, agitated and wouldn't take a bottle initially.
We activated the CAN (Child Abuse and Neglect) workup.
There was a lull from 1 am to 5 am (no admissions). At 5:45 am we received a little girl with a right eye swollen shut and some steristrips holding lacerated skin together at her right eyebrow. The family had had a picnic in the park the day before and encountered a dog without tags. He seemed friendly enough and came and sat under their picnic table. During the course of the picnic, the family made friends with the dog. Feeling sorry that no owner was in sight and no identifying tags were evident, they called the Humane Society to come and 'rescue' the homeless animal. A Society van was pulling up to the edge of the park. The little girl went to pet the dog goodbye and he bit her on the face, narrowly missing the eye but tearing open the skin of the eyebrow.
The rabies status of the dog is unknown. The girl became sick with a fever several hours later. A bite to the head from a dog of questionable rabies history, now showing signs of systemic illness, fever and increasing swelling and redness closing off the eye is cause for concern. I wrote admit orders and quickly examined the girl before rushing to make the 6:00 am signout to the incoming team.
What a night!
A strange night of call in Pediatrics - Part 1
I was Ward Chief in Pediatrics Wards last month. That meant that I did not have any night or weekends call (I know, great, isn't it?). My last day on service, I switched call with a colleague who desperately needed the time off. What a night it would prove to be...
1. We had a young teenager on the service that had transferred out of the Pediatric ICU just that morning. She had been admitted for a suicide attempt (not her first). She had ingested some sedatives and ADHD meds and we were monitoring her for side-effects, with the intention to transfer her to a mental health facility in the morning. She had been 'chaptered' -- meaning that a sheriff's department had activated Chapter 51 of Wisconsin state law: detention against one's will for declaring intent to harm oneself or another. Towards evening, she became irritable, wanting to do things she was not allowed to -- these restrictions being part of a suicide watch. The 'sitter' (person who sits in the room and watches the patient who is on suicide precautions) called for help. The patient had tried to wrap the curtain in the room around her neck and shouted "I want to die!". Nursing responded. Apparently, the patient had a history of explosive rage disorder -- something we were not familiar with. Unfortunately, we were about to find out. She 'lost it' and began screaming at the top of her lungs. She attempted to leave the room. Her nurse attempted to restrain her physically and was bitten, hit and kicked. There was pandemonium. I rushed in.
Okay, time-out.
Medically, here's the situation. She had ingested an amphetamine and a benzodiazapine (to those of you to whom this means anything). We were monitoring for side-effects of the ingestion -- heart arrythmias, respiratory distress, altered mental status. I had to make a decision: am I going to give Haldol (drug that could cause or summated with the previously ingested meds, precipitate a life-threatening cardiac arrythmia) or not?
Back to the scene.
I added my weight (literally) to the bodies trying to physically restrain this large teenage (who weighed more than some of the adults in the room). I made my decision: I called for Haldol and repeated the dose three times, including adding a sedative as well. Since the patient had chewed off her IV, all these meds were given intramuscularly. The needles did not add to the patient's state.
Within minutes, the patient was quietly asleep. No cardiac arrhythmias, no respiratory depression. Just calm. Our nurse was sent to the ER for antibiotics. We were all rattled.
Peds is usually a lovely place to be: there is a little Winnie the Pooh forest, and pictures of doggies, brightly colored beach balls, flowers and toys painted on the walls. Most of our patients are cute, cuddly and make you smile.
Fearful and tearful, mom stood behind the scenes. Grandma stood next to her with fire in her eyes. There would be long conversations with them afterward.
1. We had a young teenager on the service that had transferred out of the Pediatric ICU just that morning. She had been admitted for a suicide attempt (not her first). She had ingested some sedatives and ADHD meds and we were monitoring her for side-effects, with the intention to transfer her to a mental health facility in the morning. She had been 'chaptered' -- meaning that a sheriff's department had activated Chapter 51 of Wisconsin state law: detention against one's will for declaring intent to harm oneself or another. Towards evening, she became irritable, wanting to do things she was not allowed to -- these restrictions being part of a suicide watch. The 'sitter' (person who sits in the room and watches the patient who is on suicide precautions) called for help. The patient had tried to wrap the curtain in the room around her neck and shouted "I want to die!". Nursing responded. Apparently, the patient had a history of explosive rage disorder -- something we were not familiar with. Unfortunately, we were about to find out. She 'lost it' and began screaming at the top of her lungs. She attempted to leave the room. Her nurse attempted to restrain her physically and was bitten, hit and kicked. There was pandemonium. I rushed in.
Okay, time-out.
Medically, here's the situation. She had ingested an amphetamine and a benzodiazapine (to those of you to whom this means anything). We were monitoring for side-effects of the ingestion -- heart arrythmias, respiratory distress, altered mental status. I had to make a decision: am I going to give Haldol (drug that could cause or summated with the previously ingested meds, precipitate a life-threatening cardiac arrythmia) or not?
Back to the scene.
I added my weight (literally) to the bodies trying to physically restrain this large teenage (who weighed more than some of the adults in the room). I made my decision: I called for Haldol and repeated the dose three times, including adding a sedative as well. Since the patient had chewed off her IV, all these meds were given intramuscularly. The needles did not add to the patient's state.
Within minutes, the patient was quietly asleep. No cardiac arrhythmias, no respiratory depression. Just calm. Our nurse was sent to the ER for antibiotics. We were all rattled.
Peds is usually a lovely place to be: there is a little Winnie the Pooh forest, and pictures of doggies, brightly colored beach balls, flowers and toys painted on the walls. Most of our patients are cute, cuddly and make you smile.
Fearful and tearful, mom stood behind the scenes. Grandma stood next to her with fire in her eyes. There would be long conversations with them afterward.
Saturday, April 11, 2009
Brain turns to mush
The hardest part of Peds to me is when a child suffers an injury or gets a chronic disease that changes their lives forever. A permanent injury or chronic disease is a tragedy to anyone. The sad fact that it happens early in life makes it more tragic.
We have been caring for a previously functional, to most accounts, normal, 6-year old girl. Over the course of a few short weeks, she has transformed from a talkative 1st grader to a hemiplegic (one-sided paralysis), non-verbal body in a bed. Her eyes open and she grunts and cries when you approach her. She does not recognize her parents or grandparents.
What happened?
The truth: we don't know for sure. It has not been for lack of trying to find out. Last week, we went the final mile and did a brain biopsy -- understandably a last resort diagnostic. The neurosurgeon who performed the procedure reported dismally to the family that the consistency of the brain indicated breakdown and the sample he obtained may not have been sufficient.
After considering and rejecting multiple hypothesis, we now believe that this a form of post-influenza encephalitis -- a rare complication of the flu (which she had in early March).
It is our best guess that the changes that have occurred in this little girl are for the most part irreversible. I have no more to say in this case: the rest cannot be put in words.
Walking from room to room on a Pediatric floor in a hospital reminds me of that verse in the Bible: "Weep with those who weep and rejoice with those who rejoice."
We have been caring for a previously functional, to most accounts, normal, 6-year old girl. Over the course of a few short weeks, she has transformed from a talkative 1st grader to a hemiplegic (one-sided paralysis), non-verbal body in a bed. Her eyes open and she grunts and cries when you approach her. She does not recognize her parents or grandparents.
What happened?
The truth: we don't know for sure. It has not been for lack of trying to find out. Last week, we went the final mile and did a brain biopsy -- understandably a last resort diagnostic. The neurosurgeon who performed the procedure reported dismally to the family that the consistency of the brain indicated breakdown and the sample he obtained may not have been sufficient.
After considering and rejecting multiple hypothesis, we now believe that this a form of post-influenza encephalitis -- a rare complication of the flu (which she had in early March).
It is our best guess that the changes that have occurred in this little girl are for the most part irreversible. I have no more to say in this case: the rest cannot be put in words.
Walking from room to room on a Pediatric floor in a hospital reminds me of that verse in the Bible: "Weep with those who weep and rejoice with those who rejoice."
Surfin' USA
Well, I'm back in Pediatrics for the final 4 months of my training. On call this weekend, I learned something new about American culture: car surfing. The trauma code pager went off and announced a 'Level II Peds trauma'. Gathering information from the field reports on this soon-to-arrive patient to our ER, I overheard a dictation describing the 'car surfing accident'.
Car surfing: what's that. A nurse nearby smiled and told me that there was 'car surfing' and 'car skurfing'. Apparently, (according to this local authority, anyway) car surfing is when you stand on the roof of a car while someone else drives. You then put your hands out in the air (allegedly, to steady yourself) to 'surf' the wind. Skurfing is when you're on a skateboard and hold onto a bumper or some other part of a car while it drives.
Back to our trauma. A 17-year old female had climbed onto the roof of the car and getting ready to stand up on it and 'surf'. Unfortunately, her boyfriend started the car in motion a moment too soon to her and she 'wasn't quite ready' and fell off. 'Fortunately', the only injury she suffered was a nondisplaced skull fracture.
There you have it: surfin' USA.
Car surfing: what's that. A nurse nearby smiled and told me that there was 'car surfing' and 'car skurfing'. Apparently, (according to this local authority, anyway) car surfing is when you stand on the roof of a car while someone else drives. You then put your hands out in the air (allegedly, to steady yourself) to 'surf' the wind. Skurfing is when you're on a skateboard and hold onto a bumper or some other part of a car while it drives.
Back to our trauma. A 17-year old female had climbed onto the roof of the car and getting ready to stand up on it and 'surf'. Unfortunately, her boyfriend started the car in motion a moment too soon to her and she 'wasn't quite ready' and fell off. 'Fortunately', the only injury she suffered was a nondisplaced skull fracture.
There you have it: surfin' USA.
Sunday, March 22, 2009
Apology to Plastic Surgeons...
I'm spending a couple of weeks rotating through plastic surgery. Okay, so you're wondering what a primary care doc is doing there? I want to hone my skills to perform office procedures and learn techniques that will help me when I do international medical work.
I confess: I felt a smug moral superiority to plastic surgeons. Sure, they make the big bucks, I believed, but they did so by taking medicine and turning it into a cosmetic shop to indulge the shallow whims and fancies of clients with money to burn. This is what I thought. I thought plastic surgery was all about tummy tucks, breasts (reduction, augmentation), nose jobs and such. And of course, it is about these things... but not all about them.
During the two weeks, I have seen reconstruction of wounds, repair of hand injuries, restoration of dignity and the crown of them all -- the repair of cleft lips. I apologize to plastic surgeons who are artists, creative surgeons and smart and skillful doctors who heal wounds and rebuild beauty and dignity.
I confess: I felt a smug moral superiority to plastic surgeons. Sure, they make the big bucks, I believed, but they did so by taking medicine and turning it into a cosmetic shop to indulge the shallow whims and fancies of clients with money to burn. This is what I thought. I thought plastic surgery was all about tummy tucks, breasts (reduction, augmentation), nose jobs and such. And of course, it is about these things... but not all about them.
During the two weeks, I have seen reconstruction of wounds, repair of hand injuries, restoration of dignity and the crown of them all -- the repair of cleft lips. I apologize to plastic surgeons who are artists, creative surgeons and smart and skillful doctors who heal wounds and rebuild beauty and dignity.
Friday, February 20, 2009
In Memory of Miller Lite and other patients....
Okay. HIPAA forbids me from using names. However, with a name as common as Miller or Smith, I think I may be safe.
During my last 2 months of back-to-back internal medicine wards, our team took care of a wonderful, witty, very sick 70-something male with the name Miller. Mr. Miller had suffered a massive heart attack several months ago that ended up with him getting bypass surgery. Although he pulled through the heart problems okay (sort of), he never really bounced back. By the time he came to us from the nursing home where he was (still) recuperating, he had developed fluids in both lungs and had lost so much weight, he appeared pale and cachectic. With the graveyard humor that hids the pain that is unavoidable as one watches life ebb and patients die, I nicknamed him Miller Lite.
Over the 8 weeks that we were on the wards, Miller Lite from "let's keep fighting" to "I want to die". Miller Lite always had something funny to say to you when you went into his room. He never sounded bitter, critical, frustrated, although sometimes he sounded sad. He had one living child, a daughter he had raised practically by himself. It was touching to go back and forth between daughter and father and hear the exact same admonition:
"Things don't look good, do they. Well, be easy on (insert 'dad' or 'daughter'). I don't want him (her) to suffer!"
I don't think I will ever forget Miller Lite. He died almost within days of being moved from the medicine ward of the hospital to the Palliative Care unit.
It reminds me of another patient that died. Ms Mindy was a 50-something female with cognitive delay with a moppy disposition who had endured multiple abdominal surgeries and wasn't recovering. I was a third year medical student and it was my first surgery rotation. I was married at the time and once wistfully remarked to my attending after countless days in the hospital:
"I think I know more about when Ms Mindy last passed gas or had a bowel movement than I know about how things are with my wife or my family." We both laughed and then there was the awkward silence that comes after a sad truism has been uttered.
Taking care of patients is emotional business (this clinical distance is a myth) and with the long hours and years of training of medicine, is it any surprise that a number of your emotive experiences and memories become those of your patients?
During my last 2 months of back-to-back internal medicine wards, our team took care of a wonderful, witty, very sick 70-something male with the name Miller. Mr. Miller had suffered a massive heart attack several months ago that ended up with him getting bypass surgery. Although he pulled through the heart problems okay (sort of), he never really bounced back. By the time he came to us from the nursing home where he was (still) recuperating, he had developed fluids in both lungs and had lost so much weight, he appeared pale and cachectic. With the graveyard humor that hids the pain that is unavoidable as one watches life ebb and patients die, I nicknamed him Miller Lite.
Over the 8 weeks that we were on the wards, Miller Lite from "let's keep fighting" to "I want to die". Miller Lite always had something funny to say to you when you went into his room. He never sounded bitter, critical, frustrated, although sometimes he sounded sad. He had one living child, a daughter he had raised practically by himself. It was touching to go back and forth between daughter and father and hear the exact same admonition:
"Things don't look good, do they. Well, be easy on (insert 'dad' or 'daughter'). I don't want him (her) to suffer!"
I don't think I will ever forget Miller Lite. He died almost within days of being moved from the medicine ward of the hospital to the Palliative Care unit.
It reminds me of another patient that died. Ms Mindy was a 50-something female with cognitive delay with a moppy disposition who had endured multiple abdominal surgeries and wasn't recovering. I was a third year medical student and it was my first surgery rotation. I was married at the time and once wistfully remarked to my attending after countless days in the hospital:
"I think I know more about when Ms Mindy last passed gas or had a bowel movement than I know about how things are with my wife or my family." We both laughed and then there was the awkward silence that comes after a sad truism has been uttered.
Taking care of patients is emotional business (this clinical distance is a myth) and with the long hours and years of training of medicine, is it any surprise that a number of your emotive experiences and memories become those of your patients?
The psychologist who lost his mind
I am spending the month in neurology. I got to spend a day working with a specialist in dementia. We saw a 73 year old male for a follow-up appointment. This gentleman was a Ph.D. psychologist by profession. It was moving to be a part of this encounter.
"Mr. J, I am sorry to inform you that I will not be able to support your application to the Department of Transportation to let you drive."
"That's... I can... why...."
Mr. J, I understand how frustrating this must be for you. You've probably had patients with Alzheimer's and might remember what this disease does..."
"I used to be.... I know! I... Alzheimer's... not fair..." and after a painful pause, 'frustating!
There is an irony in this encounter. The psychologist who measured the slipping away of memory is now in the 'driver's seat' of the very condition that will take him...literally... out of the driver's seat.
"Mr. J, I am sorry to inform you that I will not be able to support your application to the Department of Transportation to let you drive."
"That's... I can... why...."
Mr. J, I understand how frustrating this must be for you. You've probably had patients with Alzheimer's and might remember what this disease does..."
"I used to be.... I know! I... Alzheimer's... not fair..." and after a painful pause, 'frustating!
There is an irony in this encounter. The psychologist who measured the slipping away of memory is now in the 'driver's seat' of the very condition that will take him...literally... out of the driver's seat.
Friday, February 06, 2009
The IMGs
IMG stands for International Medical Graduate. In the U.S. medical system, it used to identify a physician who went to medical school outside the United States. A subset of this group is sometimes identified as FMGs (Foreign Medical Graduate) -- to distinguish 'Americans' who studied outside the United States from foreign nationals who did their medical training elsewhere (often their home country) and who have come to the United States to pursue residency and perhaps fellowship training and perhaps to stay on and practice in the U.S.
I am an IMG. In the eyes of some, IMGs are viewed as somehow being inferior in their training and abilities to practice medicine in the U.S. As I finish residency training, I want to highlight a few of the IMGs I know...
Dr. RD is from Sri Lanka. He went to medical school in St. Petersburgh in the former Soviet Union. After completing his medical training, he returned to his country and pursued post-graduate training as a surgeon. He then served in their army as an Army Surgeon. He saw 'action' in the civil war. He subsequently came to the U.S., trained in Internal Medicine in New York state, and is now a board-certified Hospitalist.
Dr. MS studied medicine in her native India. She went on to do post-graduate training in Obstetrics and Gynecology and practiced as an OB/GYN for several years thereafter in India and the Caribbean. She came to the U.S. and started a residency in Pediatrics and is now a fellow in Pediatric Neurology in Boston.
Dr. NG is also from India. After completing medical school and post-graduate training in Dermatology and Venerology, he went to the United Kingdom. He practiced as a House Office there and became certified as a Member of the Royal College of Physicians. He is completing his residency training in Internal Medicine now.
Innumerable others trained in India, Palestine, Austria, Russia, the Ukraine, Sudan as physicians, surgeons, anesthesiologists, Internists, Cardiologists, Ophthalmologists and came to the States to train again, often in other specialties because their specialty would not accept but the rare IMG. Others have served in wars in Bosnia, Kosovo, Darfur and the Congo. Some have studied Russian, Serbian, German and French to be able to study medicine. A few have worked at gas stations and convenience stores while studying for U.S. board exams to get into residency training. Some have done Masters and Doctorates in Public Health, Microbiology and other subjects in order to have a visa to interview and study for entry boards before residency.
When you meet these physicians, you will not hear these stories. There is no sense of entitlement or pride or sacrifice. You will not hear about the number of times they have started from scratch, been discriminated against, been judged or slighted, often by those with much less training and experience than they have. You will only see them try to fit in and do right by their patients, bringing to the doctor-patient encounter a world (pun intended) of experience.
As I have rubbed shoulders with these physicians in training and learned from their cross-training, international exposure to medicine and marveled at their multi-lingual and multi-cultural sensitivity and competency, I cannot help but feel that once again, the United States is gaining the best. The shame and modest reticience I felt in identifying myself as an IMG when I began residency is gone now.
I am an IMG.
I am an IMG. In the eyes of some, IMGs are viewed as somehow being inferior in their training and abilities to practice medicine in the U.S. As I finish residency training, I want to highlight a few of the IMGs I know...
Dr. RD is from Sri Lanka. He went to medical school in St. Petersburgh in the former Soviet Union. After completing his medical training, he returned to his country and pursued post-graduate training as a surgeon. He then served in their army as an Army Surgeon. He saw 'action' in the civil war. He subsequently came to the U.S., trained in Internal Medicine in New York state, and is now a board-certified Hospitalist.
Dr. MS studied medicine in her native India. She went on to do post-graduate training in Obstetrics and Gynecology and practiced as an OB/GYN for several years thereafter in India and the Caribbean. She came to the U.S. and started a residency in Pediatrics and is now a fellow in Pediatric Neurology in Boston.
Dr. NG is also from India. After completing medical school and post-graduate training in Dermatology and Venerology, he went to the United Kingdom. He practiced as a House Office there and became certified as a Member of the Royal College of Physicians. He is completing his residency training in Internal Medicine now.
Innumerable others trained in India, Palestine, Austria, Russia, the Ukraine, Sudan as physicians, surgeons, anesthesiologists, Internists, Cardiologists, Ophthalmologists and came to the States to train again, often in other specialties because their specialty would not accept but the rare IMG. Others have served in wars in Bosnia, Kosovo, Darfur and the Congo. Some have studied Russian, Serbian, German and French to be able to study medicine. A few have worked at gas stations and convenience stores while studying for U.S. board exams to get into residency training. Some have done Masters and Doctorates in Public Health, Microbiology and other subjects in order to have a visa to interview and study for entry boards before residency.
When you meet these physicians, you will not hear these stories. There is no sense of entitlement or pride or sacrifice. You will not hear about the number of times they have started from scratch, been discriminated against, been judged or slighted, often by those with much less training and experience than they have. You will only see them try to fit in and do right by their patients, bringing to the doctor-patient encounter a world (pun intended) of experience.
As I have rubbed shoulders with these physicians in training and learned from their cross-training, international exposure to medicine and marveled at their multi-lingual and multi-cultural sensitivity and competency, I cannot help but feel that once again, the United States is gaining the best. The shame and modest reticience I felt in identifying myself as an IMG when I began residency is gone now.
I am an IMG.
Thursday, February 05, 2009
Announcing my babies to the world!
Those of you who know me know I rant about bacteriophages. It has been a long four years of dreaming, many weekends and nights of labwork packed into the 'free' time of my residency, and here they are! These are two different species of bacteriophages isolated from the anterior nares of humans, being shown for the FIRST time ever! I believe no-one has ever reported the existence of these cute little fellows in the anterior nares of humans before. Of course, I shall be publishing soon.
Here they are infecting Staphylococci:
I told you I would find them. These are my babies and I am very proud of them. One day, little guys like these -- in some form -- will be the new antibiotics. Many thanks to all the great phage devotees out there who have helped...Enjoy!
Morning Report Nostalgia
It was 8:05 am and nursing a plastic cup of chocolate chai (a specialty of the Cattails Cafe in the lobby of the Marshfield Clinic) I was one of many bodies sitting in Conference Room G next to the cafetaria in St. Joe's.
The funny thing about the last year of residency is the nostalgia of some of our rituals. While I listened as the presenting senior resident teased up with the case of the day, I looked around the room...
I could see a 3rd year medical student reading out of his red Pocket Medicine -- the eager learner, probably overwhelmed. I remember those days... trying to drink all the water coming out of a fire hose and feeling the panic as gushes of the water of knowledge slipped past me.
Further down the line sat.. or rather snoozed a second year resident in scrubs... no doubt the resident on call the night before -- the night float. The post-call haze is still a familiar sedative to my mind and promises to meet me the day after my next call night and that comes soon enough.
Further down sit some of the third years: one of them is a good friend who is nearing the end of her pregnancy. Just looking at her face reminds me of all the experiences we have shared: nights of call, codes, inservice exams, morning reports, co-presenting at meetings. I shall miss her as she heads off to Nevada for the next year. She has taken a hospitalists job. She has a three year old at home, a second one on the way and a husband working in Vegas.
Around the corner of the horseshoe arrangement of the joined tables sits one of our attendings. He adds questions and reminds us of a couple more diagnoses we should add to our differential as we think through what our mystery patient might have. I remember how intimated I was by him my first year. Now, we joke around. I still admire him but he is more human to me now.
As my eyes round the table, fixing in turn upon each person present -- medical student, intern, second year, third year resident, attending, I cannot help but feel a comfortable sense of family. These are my comrades with whom I have served: nights on call, racing down steps toward a Dr. 6 code, standing in an ER bay examing a patient and sitting tired in the cafetaria wolfing down a quick meal as our pagers go off. A pager goes off. The CCU intern gets up and walks towards the phone at the back of the room, others making room for her.
This is my family and I am misty eyed as I think my days doing this are numbered...
The funny thing about the last year of residency is the nostalgia of some of our rituals. While I listened as the presenting senior resident teased up with the case of the day, I looked around the room...
I could see a 3rd year medical student reading out of his red Pocket Medicine -- the eager learner, probably overwhelmed. I remember those days... trying to drink all the water coming out of a fire hose and feeling the panic as gushes of the water of knowledge slipped past me.
Further down the line sat.. or rather snoozed a second year resident in scrubs... no doubt the resident on call the night before -- the night float. The post-call haze is still a familiar sedative to my mind and promises to meet me the day after my next call night and that comes soon enough.
Further down sit some of the third years: one of them is a good friend who is nearing the end of her pregnancy. Just looking at her face reminds me of all the experiences we have shared: nights of call, codes, inservice exams, morning reports, co-presenting at meetings. I shall miss her as she heads off to Nevada for the next year. She has taken a hospitalists job. She has a three year old at home, a second one on the way and a husband working in Vegas.
Around the corner of the horseshoe arrangement of the joined tables sits one of our attendings. He adds questions and reminds us of a couple more diagnoses we should add to our differential as we think through what our mystery patient might have. I remember how intimated I was by him my first year. Now, we joke around. I still admire him but he is more human to me now.
As my eyes round the table, fixing in turn upon each person present -- medical student, intern, second year, third year resident, attending, I cannot help but feel a comfortable sense of family. These are my comrades with whom I have served: nights on call, racing down steps toward a Dr. 6 code, standing in an ER bay examing a patient and sitting tired in the cafetaria wolfing down a quick meal as our pagers go off. A pager goes off. The CCU intern gets up and walks towards the phone at the back of the room, others making room for her.
This is my family and I am misty eyed as I think my days doing this are numbered...
Time Crunch...
Sigh! It's been so long since I've written...
So much has happened...
Well, did I mention that with the beginning of my 4th year, I became the Chief Resident of my program?
During most of this year (academic year) I have agonized over:
1. Should I do a fellowship or look for a job?
2. Where is my place?
After soul-searching, I have abandoned my earlier plan to do an ID fellowship. Not to be arrogant, but with all the education I have, if nothing else, I should be able to learn outside of a structured curriculum. I love all of medicine, so I don't want to do a fellowship and narrow myself down to something. Perhaps what I will end up doing doesn't even come in a fellowship box.
Anyway, with that decision made, I began to look for jobs. I applied to mostly university programs and a couple of private clinics and hospitals with university affiliations. Although I have never dated, I get the feeling that these job hunting interviews were kind of like going out on first dates: everyone is formally dressed and showing off their best side and the whole event is somewhat orchestrated and pre-programmed.
I learned many things about the process and of course, myself in the process: promises are made that are not kept.
What I was looking for in my 'dream' job was the opportunity to:
1. Practice both medicine and pediatrics
2. Do so in an academic environment and,
3. Have the time, resources and opportunity to do research.
4. I was partial to places with existing infra-structure in international work since that is something I know that God has got for me in the future.
After travelling far and wide and having many fun experiences, I found my 'dream' job. It is right here at the Marshfield Clinic!
I am pleased to announce that come July 13 2009, I shall be the newest faculty member of the Marshfield Clinic Med-Peds department. Thank you, thank you.
I am setting up continued research collaboration with Sanjay Shukla's lab and my bacteriophage research. I shall look into getting an academic appointment from UW -- foundations for future research and teaching ventures.
So much has happened...
Well, did I mention that with the beginning of my 4th year, I became the Chief Resident of my program?
During most of this year (academic year) I have agonized over:
1. Should I do a fellowship or look for a job?
2. Where is my place?
After soul-searching, I have abandoned my earlier plan to do an ID fellowship. Not to be arrogant, but with all the education I have, if nothing else, I should be able to learn outside of a structured curriculum. I love all of medicine, so I don't want to do a fellowship and narrow myself down to something. Perhaps what I will end up doing doesn't even come in a fellowship box.
Anyway, with that decision made, I began to look for jobs. I applied to mostly university programs and a couple of private clinics and hospitals with university affiliations. Although I have never dated, I get the feeling that these job hunting interviews were kind of like going out on first dates: everyone is formally dressed and showing off their best side and the whole event is somewhat orchestrated and pre-programmed.
I learned many things about the process and of course, myself in the process: promises are made that are not kept.
What I was looking for in my 'dream' job was the opportunity to:
1. Practice both medicine and pediatrics
2. Do so in an academic environment and,
3. Have the time, resources and opportunity to do research.
4. I was partial to places with existing infra-structure in international work since that is something I know that God has got for me in the future.
After travelling far and wide and having many fun experiences, I found my 'dream' job. It is right here at the Marshfield Clinic!
I am pleased to announce that come July 13 2009, I shall be the newest faculty member of the Marshfield Clinic Med-Peds department. Thank you, thank you.
I am setting up continued research collaboration with Sanjay Shukla's lab and my bacteriophage research. I shall look into getting an academic appointment from UW -- foundations for future research and teaching ventures.
Saturday, August 23, 2008
The Suit
Okay, first, I apologize that I haven't written any blog entries in here for a while. So much has happened and is happening...
When I applied to the Marshfield Clinic for residency way back in October-ish, 2005, I was so excited when I received an invitation to interview. I remember packing my little bag and taking a flight from Oklahoma City to Madison. I had already reserved a car to drive from Madison to Marshfield. It was to be a big adventure, as I arrived in the United States and spent my first several months in Oklahoma City. This was my first big trip outside the state, my first residency interview and my first 'road trip'.
When I arrived in Madison, I discovered to my horror that my bag did not make it. I had packed my new suit and dress shoes in there. With a sunken heart, I drove the 2 hours up to Marshfield and was promised that my bag would arrive later that evening and someone would bring it up. My interview was scheduled for 7:30 am the following morning.
To cut a long story short, the bag was finally delivered at 7:30 am the following morning. I had spent a sleepless night on the phone with various cities trying to locate the lost luggage and find a way to get it to Marshfield. I arrived late for my interview in a slightly crumpled suit (no time to iron it out) and red-eyed from a sleepless night.
Of course, as you know from reading my blog, I got the residency position here, despite these difficulties. However, I learned a lesson: always carry your suit with you on the plane.
Well, last Thursday, I was scheduled to attend an interview at my own institution for a job as an Internal Medicine hospitalist (a long story, for another blog entry). I had taken my suit (the same one I had worn to my residency interview) to the cleaners to have the pants let out a bit (okay, so I've gained a little weight in four years).
Schedules being as busy as they are these days (story of my life), I went to the cleaners at 7:30 am on the morning of the interview to collect the pants. There was some snafu and they had not returned from alteration! Deja vu.
I went to the interview in a slightly older suit, sucking my stomach in (pants even tighter than the other one). As I walked, belly sucked in, into the hospital for the interview, I could not help but think how every time I interview at this clinic, there is a suit story. Oh well, another lesson learned...
The interview went fine, by the way.
When I applied to the Marshfield Clinic for residency way back in October-ish, 2005, I was so excited when I received an invitation to interview. I remember packing my little bag and taking a flight from Oklahoma City to Madison. I had already reserved a car to drive from Madison to Marshfield. It was to be a big adventure, as I arrived in the United States and spent my first several months in Oklahoma City. This was my first big trip outside the state, my first residency interview and my first 'road trip'.
When I arrived in Madison, I discovered to my horror that my bag did not make it. I had packed my new suit and dress shoes in there. With a sunken heart, I drove the 2 hours up to Marshfield and was promised that my bag would arrive later that evening and someone would bring it up. My interview was scheduled for 7:30 am the following morning.
To cut a long story short, the bag was finally delivered at 7:30 am the following morning. I had spent a sleepless night on the phone with various cities trying to locate the lost luggage and find a way to get it to Marshfield. I arrived late for my interview in a slightly crumpled suit (no time to iron it out) and red-eyed from a sleepless night.
Of course, as you know from reading my blog, I got the residency position here, despite these difficulties. However, I learned a lesson: always carry your suit with you on the plane.
Well, last Thursday, I was scheduled to attend an interview at my own institution for a job as an Internal Medicine hospitalist (a long story, for another blog entry). I had taken my suit (the same one I had worn to my residency interview) to the cleaners to have the pants let out a bit (okay, so I've gained a little weight in four years).
Schedules being as busy as they are these days (story of my life), I went to the cleaners at 7:30 am on the morning of the interview to collect the pants. There was some snafu and they had not returned from alteration! Deja vu.
I went to the interview in a slightly older suit, sucking my stomach in (pants even tighter than the other one). As I walked, belly sucked in, into the hospital for the interview, I could not help but think how every time I interview at this clinic, there is a suit story. Oh well, another lesson learned...
The interview went fine, by the way.
Sunday, April 27, 2008
"...You will die in 3 to 9 months"
I was taking care of a 66 year old female. She had survived cancer of the urethra (the tube through which urine exits the body). The radiation took its toll on her. It scarred her vagina, clitoris and urethral opening. She developed inflammation of a portion of her colon and had to have that portion removed. With all this, the lady that lay in the bed the morning I saw her was bright, cheerful and smiled almost apologetically for the embarrassment of her condition. What brought her to the hospital was not any of the above conditions I described-- she had weathered those and survived. Now she was leaking stool from her vulva. It was an incontinent leak she could not control. It was getting worse. The final in a succession of specialists to see her was a gynecological oncologist. On the phone later he told he had seen a lot of such cases before, having trained at one of the country's leading cancer centers.
His word in the patient's chart were direct and poignant: "This is a terminal condition. In my experience, life expectancy is usually 3 to 9 months." When I walked into the patient's room, she had already her the pronouncement from him. He had been her gynecologist for 15 years and cared enough to tell her the truth without the hemming and hawing less experienced or less caring physicians will indulge in out of their discomfort with the news.
There she lay. She looked at me with eyes reflecting fear, confusion, sadness and searching. Should she seek a second opinion? Did I agree with the assessment? As I gave her my opinion, she told me what an excellent doctor I was. She wasn't being facetious. She meant it. I didn't feel like patting myself on the back or accepting a compliment.
I left the room with respect and admiration for this wonderful woman who could accept news of an imminent death with such grace and fortitude -- much better, I will confess, than the 'excellent doctor'
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?
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