Floating in the ICU

When Internal Medicine residents are doing electives -- typically clinical rotations that do not involve night call, they are often circulated through the medical critical care unit for 4-5 nights of the month. We call this floating in the MICU.

That night I was called to the ER to see a 42 year old that was unresponsive to commands and combative. He had been dropped off by an outside facility emergency medical team with scanty information. He had brought in by his colleagues at work. Here is the reconstruction of events.

Joe (not his real name) was working on a roof. He was a roofer. Witnesses say they saw sparks fly from an instrument he was using and they saw fall back. When they went to him (still on the roof), he had a left sided facial droop and right sided weakness. He became disoriented, combative and unresponsive to speech.

When he arrived at our facility, we diagnosed him with a stroke (cerebrovascular accident) and began appropriate treatment. He did not make a complete recovery, although several days later could answer a few simple questions.

Here's the rub. Joe was a healthy guy -- a typical roughneck. He had had some run-ins with the law, worked hard, drank hard and occassionally used amphetamines and marijuana. He was tough as nails and in our emergency room it took 5 of us to hold him down. He did not have any history of high blood pressure. He did not have a high cholesterol or LDL or other signs of atheroschlerosis. In short, there was no predicting that his life was going to change drastically at 42 years.

Much as we know about strokes, this one had no easy explanation. It was a massive infarct of the right middle cerebral artery with subsequent hemorrhage into the ventricle on that side of the brain. Why? How? We will never know. But Joe will never be the same again.

Reminds me of words by Moses in one of the Psalms: "Teach us to number our days that we may gain a heart of wisdom." My take home from this was to use each day wisely and fully, never knowing what tomorrow will bring.

How the giants have fallen...

My brother tells me that in blackjack sometimes, cards come in 'runs' --- a number of deals where the cards are condusive to winning and then sometimes runs where for deal after deal, the cards dealt are a losing lot. Some periods on call, there is a strange similarity between patient cases.

That night, we admitted two tall 16 year olds. One was 6'3", the other was 6'2". Both were high school athletes. One had just qualified for the state championship, jumping his height in the high jump event.

The first one I will call Peter. He had golden curls. He was polite, had no tattooes or piercings. He did not smoke, drink or even have a girlfriend. He had the build of a track and field athlete. He was flown in by helicopter from an outside facility for progressive loss of sensation in his lower extremities. Over the next several weeks, we treated him with steroids, thought we had it beat, discharged him, only to admit him back in worse state.

I still remember the night I was told he was back. I was off that day but Sunday afternoon after church, I went to PICU to see him. There he lay: a 16 year old athlete in a diaper, incontinent of urine, able to open his eyes but not able to speak. He ground his teeth incomprehensively. I cam out of his room and wept secretly in anger and frustration.

The second 16 year old also came to us by helicopter almost within days of the first patient. He too was clean-cut handsome, wholesome male. He had some numbness and tingling in his hands and a lump at the back of his neck. I remember the strange sight at 1:00 am in the morning when 3 specialists -- a neurosurgeon, a pediatric intensivist and a pediatric oncologist, flanked by a couple of residents stood discussing the possibilities.

"I hope he has a lymphoma" someone says.

We all agree, shaking our heads. Then it hit me. Here we were wishing that a previously healthy 16 year old athlete had a form of cancer.

How strange is that?

The reason for our wish was that we had seen the preliminary scans of his spinal cord. The alternative diagnosis was a rhabdomyosarcoma -- a cancer in which often 90% die in 2 years of diagnosis. This patient had some cancer. We were hoping it was the more treatable one with a better prognosis than this.

He had rhabdomyosarcoma.

As the Pediatric Intensive Care Unit resident that month, I was often the one to give specialists involved in his case the news. The pained expression on each face as they heard the news told me they felt as I did. So much for clinical distance.

Both boys are home now. Both endured painful procedures. One has rhabdomyosarcoma and the other may have multiple sclerosis -- an aggressive form at that. They are being treated with the best we have to offer.

O how the giants fell that night. I do not believe I shall ever forget them.

Addendum - written on May 22 2009

Today I received notification that the second patient described above (let's call him Big Ben) died at his home, surrounded by friends and family. He was 18 years old. This week, this was the third death notice we received -- the other patients were younger and died of ALL, having failed bone marrow transplantation. Cancer in children is a horrible disease. I don't know how the Peds Heme/Onc specialists do this!

David son of Jesse

A 28 day old male infant presents with a 2 day history of projectile vomiting (emesis reaching a distance of 3 feet). He was not born premature. He is the firstborn. Palpation of his abdomen reveals a small, but palpable 'olive' just right of his midline. To you medical folk out there, diagnosis, please? Want another clue? An upper GI series shows delayed emptying of the stomach and a narrow, stenosed pylorus. Okay, you got it: pyloric stenosis. Found in a 4:1 ratio in males: females and most commonly at the third week of life, this is the most common cause of intestinal obstruction in infants. I admitted a kid with this story to the hospital tonight. I asked what his name was. It was David. As is my practise, I asked the parents name. Dad's name was Jesse. How about that: David, son of Jesse. Mom was the way is not Bathsheeba...

Parents and their responsibility

If you haven't guessed already, I am in Pediatrics these days. In the past few days three clinical experiences have happened that make me want to write this post.

1. Sunday night on call, a 2 year old was brought in with altered mental status (responsive only to painful stimuli), optic nerve atrophy in his left eye and priapism. Turns out that 4 months ago when he had presented with some vision loss in his left eye, an MRI had been done. It revealed a large craniopharygioma in the sellar/suprasellar region of his brain. This is a benign and in his case, cystic tumor. The prognosis was good with surgical resection and radiotherapy. The family, being Amish, told the neurosurgeon that they would think about it. They never came back. Instead, they decided to try a low-sugar diet and some nutritional supplements. Needless to say, this didn't work. The tumor had got larger and now was compressing the aquaduct of silvius in the brain and blocking the flow of CSF resulting in an obstructive hydrocephalus. This is why the toddler wouldn't wake up. That night, we had to intubate him, put a central line and arterial line in his left subclavian and left femoral respectively, put an NG tube and foley catheter in and the neurosurgeon did a bedside craniotomy to place an extraventricular drain. He is scheduled for emergent brain surgery in 4 days. His prognosis is not very good at this point.

His parents, no doubt, felt they were doing the right thing by trying to treat this tumor with diet management, although there is no evidence for this treatment and even the makers of the nutritional supplements they used do not recommend their product as a treatment for brain tumor. Now, their son lies in serious danger of either losing his life, or being permanently blind and/or neurologically impaired the rest of his life.

What do you think of their choice and the consequence to this toddler?

2. The night of call, I spent from about 10:30 pm to 5:45 am working on this single patient. I do not think I sat down for 5 minutes. It was non-stop, hair-raising, nerve-racking action. In the wee hours of the morning, one of our PICU nurses comes in with the story that one of our flight crew nurses who was going through a divorce had killed his children, ages 8 and 4 and then shot himself. Reportedly, he drugged the younger one (a boy) and shot the elder one (the girl) in the head. Apparently, he was going through a messy divorce and stood to lose his kids. We still do not know how he killed his kids. Did he shoot them, like he shot himself? Did he drug them? Did they suffer?

What do you think of this parent's decision?

3. Tuesday morning in clinic, our team's job was to evaluate a little 6 year old for autism. The concern was raised because the child had speech delay, some apparent anxiety and stereotypical behavior -- finger-flicking, head rocking and some repeated movements with her hands. She was a delightful little girl who was brought in by her father. During the interview, we discovered that Mom had been an alcoholic. She would leave this little toddler (at the time) in her rocker rather than let her walk around. Consequence: motor development delay. Mom would get loaded with alcohol and play loud music. She did not interact with the kids. Consequence: anxiety, fear, speech and language delay.

We do not think this little girl has autism. We think she may have re-attachment disorder and anxiety that manifest in the odd, stereotypically behavior, lack of desire to interact with her peers and her various delays.

Thanks, Mom?

In all fairness, most parents do a wonderful job of loving and raising children, making good choices to protect their health, well-being and safety. We can't help our heart-ache when we see the contrary as I did over these last few days.

101

I am in pediatrics these months. However, as a Med/Peds resident I still do clinic one afternoon a week and this last week was Internal Medicine. I looked at my schedule at the date of birth on the sheet: 8/6/05. At first, that didn't seem odd. I had a lot of patients who were less than a year old. Wait! I am in Internal Medicine this afternoon. This can't be right! But it was. My patient was a 101 year old lady.

I went into the room. This was a pleasant lady sitting in a wheelchair (she wasn't disabled). She got around with a walker. When I asked her what health complaints she had, she surprised me by her reply.

"Doctor, I don't have the strength I used to. I fall asleep sitting down for a while."

In my mind, I thought that if that was all the problems I had at 101, I'd take it.

She came to see me because she had been living in a Retirement home and her money had run out. She was going to be on Medicaid and was being moved to a Nursing Home. I felt sad that she was going there. After all, this was a functional, fully cognizant female who was about to move into a home where most of the residents were demented and many dying. What could anyone do?

I finished the encounter and came home shaking my head. 101?

Damned if you do, damed if you don't...

In the last week, we had two codes in Pediatrics. Both involved kids less than 6 months of age.

The first one arrived in the ER pulseless and not breathing. We coded him for 25 minutes. He never came around. He was pronounced. There were tears of frustration, grief and shock in the eyes of everyone who walked away from the dead baby. We knew very little about this baby except the couple of sentences the EMT shouted out as we got busy to work on him.

I cannot describe to you how that feels... to do chest compressions on a 3-4 month baby, watching the monitor for signs of life, hearing the litany of a code be chanted behind you "1 more dose of epi now!" "stop compressions, check for pulse!" "continue compressions"

The second code was in the PICU. It was a patient on a ventilator. This was a premature, about 3 month-er that we knew. He stopped breathing (if you can do such a thing while on a breathing machine) when one of his lungs pulled away from the chest wall and collapsed. This led to his heart slowing down and then stopping. He went pulseless.

Peds residents and doctors ran from wherever they were to the PICU and became part of the crowd doing things. I did chest compressions, then needled his right chest wall to relieve the pneumothorax.

I have attended or participated in 4 peds codes so far in my training. This was the first time that the baby lived. Those statistics, dismal as they are, are about right. Not many infants survive codes. Kids do not have the reserve that adults do.

Coming away from this code was different. There was elation, nervous laughter, heady joy -- he lived!

I went back to the wards to resume my duties. I was taking care of a 2 year old admitted for increased secretions from his trach tube. Trach tube? This is a tube attached to the throat to help patients who cannot breathe effectively through their mouths and nostrils. This two-year old lay stiff in bed, with blind eyes open, a thickened pallette and flushed. At 10 months of age, his teenage sister turned away from him in the bath-tub for just a minute to see to another sibling who fell off his bike. In that minute, this little boy drowned. Since the family lived next to a fire station, the crew was over there in record time and he was successfully rescucitated. He lived! This was a code like the one I was just at, in that the patient lived.

Unfortunately, in that short period of time he was down, his brain suffered an irrecoverable injury from being without oxygen. He cannot talk, walk or see. He needs a breathing tube in his throat to breathe effectively. Should he have been saved? Of course! Who can predict what degree of injury and what subsequent recovery is possible? We have no a priori knowlege, so we must rescucitate.

Of course, as I care for him on the wards and wonder about the one we did not save and the one we did, I wonder about these things. What will the outcome be for the one we saved? Will he be like this 2 year old?

I am a christian. I do not swear. But in this case, the phrase "damed if you do, damned if you don't" seems to say it all.

Update on 4/2/2007:
My pager went off in the early hours of the morning. I was off-duty, but I had left my pager on. I looked at the read-out and saw the code message and the room message. Later that morning, the news was confirmed. The 3-monther we had successfuly rescucitated had coded again and this time, did not survive. He died of cardiopulmonary failure that morning.

Save your money....

Toddlers are interesting. This is the age for temper tantrums, the time when toddlers can walk, run and explore. I saw a wonderful little girl in clinic a few days ago. She smiled angelically at me and said nothing. Her 4 year old brother told me the story...

"Mary (not her real name, of course) found money!" She ate it.

Dad and Mom who came along, smiled nervously. We got an x-ray. The one on the left was at this first visit. The one next to it, about 5 days later.

Mom and dad are watching little Mary's poop every day. If the coin does not come out, we may have to go after it endoscopically.

Never a dull moment...

Update:

Several days later, we have a follow-up x-ray:

In a rare show of emotion, the radiologist's report says "Fortunately, she has passed this foreign body."

Unfortunately, the coin was never recovered in the poop. Well, there's good money down the drain... literally. ;-)

Why I became a christian and what it means to me

I was born into a Hindu family. However, I am now a follower of Christ. Is that the same as being a Christian, you ask?

Perhaps not.

I have been asked questions about this often enough. It is important enough to me to want to answer these questions. The answers are an integral part of who I am as a physician, scientist and person.

So here is a link to an article entitled "Why (and how) I became a Christian". I hope and pray that it helps my readers.

http://vijayaswani.blogspot.com/1999/02/why-and-how-i-became-christian.html

Older doctors...

Yesterday, I worked in the orthopedics clinic with a 72-year old physician. He was elected as a fellow in the American College of Orthopedic Surgeons in 1974. Calculating back, he probably went to medical school when I was 1 or 2 years old... and I am 44 year old now. Talk about a lifetime in medicine!

What do you think when you see a 72-year old man still practicing? I was delighted to learn that not only was he sharp, energetic and competent, but he was a pleasure to learn from. It was a great opportunity to learn clinical pearls from someone who has been doing this as long as I have lived.

This interesting gentleman was a 'retired' orthopedic surgeon. After doing private practice for 7 years and then 30-some years of orthopedic surgery at this clinic, he retired. He bought a 50-ton boat and spent the next 5 years sailing with his wife. When he got tired of that, he decided to come back to medicine, only this time, not to surgery. He sees patients in the orthopedics department, evaluating and medically treating their orthopedic problems. When necessary, he involves his surgical colleagues if his patients need a surgical solution.

I hope that when I am 72, I am as energetic, pleasant and competent as this fine physician. Age is truly no bar in medicine, if one does it right.

Like two ships passing in the night....

It was 3:00 am in the morning on a call day/night. I wonder sometimes if the memorable cases come at that time or if I just happen to remember the cases that come at those hours. Anyway, I had been awake for 24 hours and was fighting sleep. I waswriting some orders for a patient that we had admitted earlier that night. It was the last thing to do before, hopefully, getting some sleep. My pager went off and I rolled my eyes. "Please, not another admission" I thought, hoping that I would get some sleep before the day broke. It was another admission. It was to be a transfer from another hospital. I accepted the patient: a 70-something female with 'pancreatitis'. My mind was already framing the things I would do: bowel rest, IV fluids, should I do some prophylactic antibiotics?

When the patient arrived, I realized this was not going to be 'simple'. (If they transferred from another hospital at 3:00 am in the morning, they usually never were). If it was plain-vanilla pancreatitis, they wouldn't be coming here now, would they? What was I thinking?

Turns out my new admission had metastatic stomach cancer. In addition, she had an elevated Tn I (0.8) and a stable AAA. Oh well. I went to evaluate her. She had severe abdominal pain. Made sense, I thought, she has pancreatitis; only here abdominal pain was diffuse. It wasn't the classic epigastric pain radiating to the back. My sleep dissappeared as I began to feel uncomfortable. Something wasn't right. This wasn't pancreatitis, was it?

After several rounds of fentanyl and then morphine, I began to feel even more uncomfortable. After checking that cardiology didn't want to do anything with her (the Tn I wasn't high enough), I ordered an abdominal CT scan for the morning. It was almost morning anyway.

A nurse casually remarked about the strangeness of the situation: it seemed that my patient's husband was admitted on the opposite side of the corridor on this same floor. He had come in for a heart angiogram and they had discovered severe three-vessel disease. He was on the schedule as the first case for a triple vessel bypass that morning. This couple was not having a good day.

To cut a long story short, by the afternoon of the next day (I was well past 40 hours without sleep by that time and 'wrapping up' to get out of the hospital). the CT results showed that my patient had thrombosed two major arteries in her gut and her gut was almost dead. The vascular surgeons told me that the case was hopeless and that she had less than 12 hours left to live. Ironically, when her gut died, her pain went away and she felt better. That was an ominous sign.

Sleepless and discouraged, I broke the news to tearful daughters and a dumbfounded patient. Her only request of me before we moved her to the palliative care unit (where she would go to die) was that she get to see her husband. The last thing he knew was that he was taking in his wife for some belly pain and vomiting.

By this time, he was in the post-op recovery unit, coming out of anesthesia after his triple bypass. He was dazed, confused and combative (as patients can be coming out of anesthesia). As my patient was wheeled in her bed to our palliative care unit in another building, compassionate nurses and transporters arranged for her to see her husband for the last time. He was not conscious. She wasn't quite all there either. Their daughter told me that in 53 years of marriage they had spent all of 3 nights apart. This night, they passed each other like two ships passing in the night.

Now I have a confession to make. By the time I took care of all this, I was well past the legally allowed limit for working continously (30 hours for us residents). I was more like in my 45th hour without sleep. I wasn't making clinical decisions. I was saying goodbye to a dying patient and trying to get her to see her husband one last time. I wasn't about to leave a scene of death simply because my 30th hour was up. Doctors can't punch a clock. What would you have done?

Vacation

Now some of you readers out there must think that the lives of residents suck; that they are always depressed or brow-beaten or fighting life and death battles. We-elll, for those of you who think this, I submit the following. This is me sipping a cool drink while listening to the local Mariachi sing in a wonderful beach resort in Panama. (Don't I look happy?)

And there is me pulling my kayak out of the ocean after a wonderful ride.

Ahh! A relaxing vacation... far away from medicine, pagers, call and dictations.

Contrary to rumors, they do let us out of our cages every now and then...

Doctoring in a plane

Hi Everyone!

I am on my way to a much-needed vacation. I shall be visiting my family in sunny Panama (Central America, not Florida). It's been snowing over here. As I have done these past few times I have flown, I have been reading on dealing with medical emergencies on a flight. Have you ever heard the announcement overhead while in flight: "is there a doctor on board?" As a resident, I have wondered how one might prepare for this announcement and whatever follows. I have found four excellent articles. They cover the legal aspects, the most common emergencies one is likely to encounter and what kind of support in terms of personnel, their training and equipment you might have access to. For now, though, I decided to travel with my sphygmomanometer and stethoscope in my hand luggage...

Here are links to the articles:

1. NEJM Article: Responding to medical events during commerical flights. http://content.nejm.org/cgi/reprint/346/14/1067.pdf?ck=nck
2. BMJ ARticle: Is there a doctor on the aircraft? http://www.bmj.com/cgi/reprint/321/7272/1336?ck=nck
3. EMJ Article: Emergencies in the air. http://emj.bmj.com/cgi/reprint/22/9/658
4. BMJ Article: Inflight medical emergencies: An Overview. http://bmj.com/cgi/content/full/321/7272/1338

At 7:00 am he shot himself

At 7:00 am this morning, Auburndale Trauma, age 26 shot himself. He aimed a handgun pointblank at his chest and pulled the trigger.

Well, first of all, Auburndale Trauma is obviously not his real name. In our facility, when a trauma patient arrives that we know almost nothing about, he gets a fictitious name and age. For some cute reason, the tradition is to name the patients after the names of towns in the state, and also for some quaint reason, the patients are always 26 years old.

About 10 days ago, Auburndale was checked into a psychiatric facility with suicidal ideation. He was going through a divorce. He was depressed and wanted to end his life. He was discharged yesterday from that facility.

I am doing a rotation in anesthesia and was in the OR when he was brought in. The thoracic surgeon was good enough to invite me over from my side of the curtain (the one that separates anesthesia from the surgical field). "He's lucky!" He exclaimed. The bullet missed the esophagus, the aorta, the bronchial vein, the perihilar structures. It entered from the left side of his chest and exited from his back. How did it miss the heart?

Then he did a neat trick. After removing the lower lobe of the left lung (which was blown open and useless), he connected his forceps between the entry and exit holes -- the path of the bullet. As the heart beat, every time it entered diastole, it butted against the forceps.

"See?" He's lucky!" He exclaimed again. If this bullet had traversed the left hemithorax when the heart was in diastole, it would have passed right through the ventricle and probably ended his life." He shook his head. "Lucky, I tell you!" He was right in that though. The difference in time is about half a second. Had the bullet arrived half a second later, Auburndale Trauma would have been dead on arrival.

The conversation in the OR was surreal:

"How could he have missed?"

"He flinched when he pulled the trigger."

"He should have aimed into his mouth."

"Or angled left aiming upwards from the xiphoid process."

Auburndale Trauma is not 26. He is in his early thirties. He is getting divorced. He will probably not see his little daughters grow up the way he had thought he would -- as a family. Auburndale Trauma was unhappy enough to end his life. He shot himself in the left chest, no doubt aiming for the heart, to end it all. I do not know if 'lucky' is how I would describe him.

Mahatma Gandhi and medicine...

Yesterday, I watched the movie 'Swades' (can you tell I had the day off :-) ?). In the opening credits, there is a reference to a book called Bapu Kuti by Rajni Bakshi. It is a book about how some of India's journalists, scientists and artists are re-discovering Gandhi. This posed a question in my mind: what did this great man think of medicine?

I recall growing up that my grandmother used to go to a natural cure ashram where the medical practitioners followed Gandhian principles of healthcare. I was too little to remember the details of what they did. Anyway, I got on the 'net and found the book 'Gandhi's Health Guide' by the man himself. What do you think it said?

Well, to those of us from India (and I suspect, to a lot of us from other countries too), Gandhi was a great man. He has been compared to the founders of the world's great religions. However, in regards to his views on medicine, perhaps he was as much a victim of his times and circumstances as many of his contemporaries. I invite you to read extracts from his book at Amazon:
http://www.amazon.com/gp/reader/1580910513/ref=sib_dp_pt/102-6830000-4462505#reader-link

In all fairness, I do believe that had he lived today, he would have acknowleged that physicians and hospitals are necessary and even a blessing to many. After all, not all sickness seems to come from wrongful living.

I love it when kids cry!

Okay, so the title probably got your attention and you're thinking, what kind of pediatrician is this?!

It snowed quite a bit in our area today. The roads were slippery and a car near an outside town lost control and crashed into another. A semi driving up the same road could not stop in time to avoid the accident and crashed into them both. Our little town does not have many multiple motor vehicle accidents like this. At the hospital, we got news that several adults and chidren were being brought in. We rushed to the ER to await their arrival. The kids came first. There was an 8 year old and a 1 year old.

I love it when kids cry. The sounds of both these children crying was a reassuring sound -- it meant they were conscious, alert and that their airway was not compromised. The 1 year old had a head laceration that appeared superficial. The 8 year old had some abdominal pain. While performing the primary survey, one of the nurses asked the crying 8 year old, "where do you live?" Between sniffles and tears, he answered as an 8 year old would: "At my house." In the midst of a tense situation, it brought a flicker of a smile to our faces while we continued with the trauma assessment.

A day and a night in the CCU -- out-of-hospital cardiac arrest

In the evening, we were called from the ER to say that the ambulance was bringing in an "out-of-hospital cardiac arrest". What does that phrase mean to us? To give you an idea, I quote from a review article:

"The circumstances of cardiopulmonary resuscitation (CPR) can affect prognosis after a cardiac arrest in terms of both survival and quality of life. In one study of out of hospital cardiac arrest, 44 percent of patients receiving CPR survived initially, 30 percent were alive at 24 hours, 13 percent at one month, and only 6 percent were alive after 6 months. The duration of CPR significantly correlated with outcome; no patient who required more than 15 minutes of CPR survived more than 6 weeks. (Bereke et al, 1997).

This 70-something lady had spent the day shopping with her daughter, after enjoying a good breakfast. In the evening, she went to visit her husband who was recently transferred to a nursing home because of severe dementia. The two of them were visiting in his room. There was no one else there at the time. What happened next is surmised from the stories of others. The nurse and CNAs at the desk heard the nursing home resident room alarm go off. Apparently, this alarm is triggered to go off when the resident moves his back away from the chair. At first, since they knew his wife was in the room with him at the time, they thought she would help him.

When the alarm did not stop, they went to the room to check up on him. They found him leaned forward in his chair trying to hold up his wife who it appeared, had passed out. They could detect no pulse. The woman was put on the floor and the nurse and CNAs began CPR while someone called for the ambulance. The ambulance techs arrived and hooked up to an AED (Automated External Defibrillator), which advised a shock to the patient. Over the next 40 minutes during which CPR was continued, the patient was shocked again en route to the hospital. By the time she got to the ER, she was intubated, on a ventilator, but her heart was beating on its own. The ER doc was relieved to hand me the chart and the patient as she placed a hand on my shoulder and said "Good luck!"

We moved the patient to the unit (CCU) and got her stabilized. During the course of a very long night, she began to have tonic-clonic seizures. I had the responsibility of talking with the family and explaining the dismal outcome we expected, given this ominous sign of anoxic brain injury.

Last night, I had to have similar conversations with two different sets of families. In both cases, I was telling children of the patients that their mother was not expected to survive, although they were alive at the time. I had to explain that although their heart was beating and the ventilator was helping them breathe, they would never be the same. The patients in both cases were unresponsive. There was a strong possibility of severe injury to the brain from the lack of oxygen in the time it took to rescucitate them.

You know, some nights, after a conversation like that, I am actually grateful if my pager goes off and I can leave to the next emergency where I have to focus on a task at hand and not think about the meaning of the conversation I have just had.

A single event like what happened to this patient can change one's life for ever -- even end it all. And such an event is not predictable, although its occurence may be inevitable in the setting of some kinds of heart disease. Bottom-line: carpe diem -- seize the day!

Addendum, next afternoon:

I visited the CCU to find out how the patient was doing. I was informed that given the poor prognosis and predicted quality of life, the family chose to withdraw support. That meant stopping the ventilator. The patient died shortly after that was done.

A day and a night in the CCU -- "...she's stopped breathing!"

Well, as a Med/Peds resident, I do something different from most of the other residencies. I shift every 4 months between the worlds of Pediatrics and Internal Medicine. With the change in the month, I am back in Internal Medicine again and my patients went from being 7 to 73. Yesterday and last night night, I was on call in the Critical Care Unit. It's been a while since I was there (I think a year has passed) so it took a few moments to get used to things again.

It was a busy night. I got to intubate one patient, and place arterial lines in two others -- one was a femoral and the other a radial.

At about noon, a hospitalist called to say that a 73 year old female patient of hers was found in her room with a heart rate in the 30s and in apneic breathing. She was bringing her to us. As she wheeled her into our section of the unit, her face (the doctor's) was white and she looked frightened. She said "I think she has stopped breathing!" Well, those are the magic words...

I was by her side and feeling for a carotid pulse. There was none. With nurses, and my fellow resident all coming to her side, I began chest compressions while my colleague called out for atropine and epinephrine. Within less than a minute, she was back. Sometimes medicine happens in bursts of a few seconds that make a difference between life and death. I think that besides the adrenaline that we injected into this patient, there was quite a bit in everyone else in the room.

We set up the necessary access lines and blood pressure medications to stabilize her. Unfortunately, she has severe coronary artery disease -- two of the three main blood vessels in her heart (right coronary artery and circumflex) are completely blocked off while the third -- the left anterior descending, is 50% blocked. Because of chronic renal failure, she is not a candidate for a bypass procedure (that is to say she would probably die during the procedure necessary to save her life -- ironic, isn't it?). Although we were able to rescucitate her (get her heart to start beating on its own again and get her to breath), she is in an unresponsive state.

Well, I was quite busy with all this excitement. But there was more. I guess it was to be the night of the 70-somethings.

Can't open my eyes...

Imagine lying in bed, not being able to open your eyes, blink, talk or swallow your spit. Imagine that you have tingling in your arms and legs but no real capacity for coordinated movement. Imagine further that through all this, your hearing is intact, your vision perfect (if someone else will open your eyes for you to be able to see) and there is nothing wrong with your brain. No, this is not a stroke, although it is a nerve disease. Imagine that all this happened after a few days of diarrhea -- the kind of stomach upset that happens when you eat bad food, the kind that happens to all of us.

This is the Miller-Fisher variant of Guillain-Barre syndrome. It is a rare disorder characterized by paralysis of the eye muscles, abnormal muscle coordination and a few other nervous dysfunctions. While the exact cause is not known, it is believed to occur as a sequelae to some viral infections and bacterial infections-- much like Guillain-Barre.

This is the story of a 60-something previously healthy male. (In his room in the CCU, there were pictures on the wall of him with his prize turkey, a deer he had shot and others with his family and friends -- a full and active life). It started with some difficulty talking and swallowing (dysphonia and dysphagia), followed in rapid succession with droopy eyelids. He also reported some tingling in his arms and legs. By the early hours of the following morning, he was unable to spit or swallow. At this point, when he was rushed to an ER, he was intubated and put on a ventilator to support his breathing. By that time, he was unable to shake his head up and down.

When I saw him in the CCU, he had already been in the hospital about a month. His recovery was extremely slow. It is anticipated that he will recover, perhaps completely, within 6 months. Until then, there is not a lot than can be done for him. He could develop secondary infections (he has a tube in his throat and one in his penis). He will get some muscle atropy (since he cannot move his muscles on his own, although he has recovered lower extremity function and some upper extremity function).

See http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher.htm for the NIH's research activity on this horrible condition.

Kawasaki disease

It's 11:17 pm. I was on call last night. We admitted a 7 month old little boy. He was really cute, but irritable. He had presented with a 12 day history of fevers, cracked lips, injected conjunctivae and a passing macular rash. He was transferred to us with suspicions that this could be Kawasaki disease.

We did indeed think this was Kawasaki. Although he did not have all the classic symptomsWe admitted him and got him started on the appropriate treatment: IVIG (Intravenous Immunoglobulin) and high dose aspirin.

Now the bad news.

We knew this could happen. We got an echocardiogram today and he has coronary artery beads that are interpreted to be signs of a coronary artery aneurysm . I am upset and depressed about this. He is 7 months old! While this is a known sequence of Kawasaki, we were hoping that we were in time with treatment.

There is something about a post-call day. You have been on for 30 hours. You are hungry, your stomach probably burns from too much coffee, eating at odd hours, disrupted sleep cycles and who knows what else. You are washed out and running on fumes. To get bad news on a day like that makes it tough.

Something hurts inside. Frustration. Couldn't, can't do anything about this bad finding. Of course, we will 'follow' and react appropriately. Possible future events include thrombosis of the coronary artery. He is 7 months old!! We will probably get a repeat echo in 6 weeks. The anuerysm could either have resolved by then or we could have a giant aneurysm. I am hoping for the best.

I think I hate Kawasaki disease. I hate that we do not know what causes it. What a tease and frustration.

This is one of those days when you wrap your coat about you and press into the cold wind to go on.

Addendum on 12/24/2006:

The follow up echo was done 6 weeks later. The arteries returned to normal. Life is sweet! Merry Christmas!

5 year old versus motor propeller

I am post call today. It was a busy night and by the time I had got home, it was about 3 in the afternoon. I had been in the hospital 33 hours without sleep. Lots had happened. I finally got to send one of our little 5 year olds home today after a 2 month stay in the hospital.

About 2 months ago, he had been boating with his family. He fell into the water and the propeller from the motor slashed into him on the left side, fracturing his scapula, breaking ribs, cutting into his spleen, pancreas, left kidney, small bowel and large bowel. He also had a femur fracture on the same left side.

Shortly after being admitted, his spleen, left kidney and portions of his bowel were removed. During his long hospital stay, he underwent a number of surgical procedures and needed extensive skin grafting to close up the abdominal wound. While the graft didn't exactly take, his abdmomen is healing.

It was emotional to send him out. There were a lot of specialists involved in his care and it was a nightmare to put together his discharge documents -- so many issues to address for follow up and I was afraid something will be missed if I did not document it thoroughly and go over it with the mom. I got to see his abdominal wound today (perhaps for the last time). If you compare it to a normal 5 year old's abdomen, it would be considered almost frankensteinian with suture marks running in different directions and triangular shaped red scar tissue visible medially and laterally. But if you think about where he has reached, it is a beautiful sight. He will need plastic surgery in the future, but for now, he is alive and going home. I shall miss him.

I was proud to be part of his care. I almost feel like I was sending one of my own babies home. He is a medical miracle and an incredibly brave little boy. I wish him well.

Lonely in residency

3.28.2006 12:48 am ...

I just came off call today. It was a long 36 hours stretch at the hospital that was busy with some highs and lows, tense moments and good moments. I came home by 3:30 pm. I was so tired, I think I went to sleep without eating anything. I was scheduled to go to a christian prayer group meeting at 7:00 pm

My eyes opened at 8:30 pm. For a moment I didn't know where or when I was. Then it hit me. I had missed the meeting I was looking forward to going to for a month. Drats! If you don't want to hear me whine, then don't read on...

I feel a sense of frustration. With the life in residency being what it is -- screwed up sleep routines, odd, disjointed times off, it is so difficult to have a life. I got up depressed and frustrated with myself that I have not been able to meet any of these meetings that I wanted to go to.

I called the hospital and found out that one of the kids we had admitted on call -- that we thought had Kawasaki -- has coronary artery anuerysms. It hurts to think of it. I wanted so much to talk to someone about my feelings. But, who? It is 10:30 pm at night. Who could I call at that odd hour?

Residency can be lonely. Because of the hours I do not have much of a social life. Since I do not drink, the bar scene doesn't work for me. I would love to join a class or group or something, but with my call schedule that keeps changing, I don't think I could make the classes. Who would put up with me anyway? They wouldn't see as much of me as they might wish and I might want to call or meet with them at odd hours of morning or night. My days off may come on a week day and I may work 3 weekends straight.

Okay. So I'm post-call and tired. Still...

Poem: Waiting...

I went to a writing group meeting the other day and one of our assignments was to write a poem. The theme was "waiting". Well, I guess I had the ICU on my mind when I wrote this:

Waiting…

The monitor beeped in the background
As the machine took another breath.
Tubes carried food and water,
As the bed bore up life and death.

They came several times a shift:
White coats, green scrubs or plain,
Checked numbers, connections and flow rates;
Today was there weight loss or gain?

“Mr. Jones! Mr. Jones! Mr. Jones!”
called a tired but firm young voice.
Tired eyes above an endotracheal tube
Opened to silence the noise.

The intern left after data gathering,
Leaving a sea of tubes and pumps.
Amidst them, a Mr. Jones closed his eyes
Again to resume the waiting…

Getting a license to practice medicine and a DEA number

9/4/2006 5:28 pm

Some of us have today off, being Labor Day and all. I am enjoying this breather after a heavy month on the Pediatric Wards. Don't get me wrong. I LOVE what I do and like many of you, I aspired for this 'dream life'. No regrets!

I also wanted to share the good news. As of August 2006, I am now a licensed physician. It is customary to put in an application at the end of internship for a license from the state where you are. This is not a training permit, but the real thing -- the license you will (if you continue to renew it) have for the rest of your working life. Well, after due process -- without any hitches, I was given a license.

After getting the license, I was able to apply for a DEA number. This is the number the Federal Government assigns to health professionals writing prescriptions for narcotics. The Drug Enforcement Agency uses this number to track licensed health professionals' prescription activity. Incidentally, most pharmacies will not fill ANY prescription written by you without this number, even if you are licensed. (Go figure!).


I understand that there are not many states that will issue a license to a foreign medical graduate after only one year of post-graduate training. I guess I am fortunate to be in one of those states.

End of Internship year

Well, it is July 4, 2006. I am post-call and although tired, felt like browsing the forum and thought it would be nice to record some thoughts on completing the internship year. Perhaps those of you in a similar position might want to share your stories too.

What a year it has been! Well, first off, as a Med-Peds resident, I should qualify my experience. In med-peds, unlike categorical residencies, internship lasts 14 months instead of the usual 12. This is because we are doing two residencies and need to fulfill criteria for completion of core curricula in each. That means that although I am now a PGY2, I am still an intern for another 4 months (this one included). I also have the rather odd position of being a senior in medicine and still an intern in pediatrics.

The exciting event on the horizon for all of us is getting our licenses! This happens once your program submits a document to the state medical board to say that you have completed one year of post-graduate training. All the rest of my paperwork is done and I should expect the license in about 2 weeks to a month. At that point, I will be able to sign prescriptions for all things except narcotics. That latter privilege comes after I get an assigned DEA number. I need the state license first. It is interesting that there is no 'other' license issued to you at the end of residency. This is it. Of course, being licensed in one state means you can only practice in that state. Some states have reciprocity agreements and grant licenses easier if you are licensed in one of the states they have an agreement with. (I haven't investigated that much; having a license is plenty good enough for me for now).

It is interesting how I feel a little changed through this first year. I am a little (just a little) more sure of myself in the hospital and clinics. At least things are more familiar (I know where the cafetaria and rest rooms are) and I feel that I can usually do a few things rather than stand around biting my nails when things get scary. I am particularly proud of my ability to put in central lines (the subclavian is my favorite) and in my program, I have something of reputation for that.

To those of you who know me, I still draw biochemical graffiti on blank blackboards, greenboards or whiteboards whenever I see one. The program and residents tolerate me in that regard. You know, I think you really don't really how much has changed until you look into the eyes of the new interns and see their dazed look or they ask you questions and somehow (miraculously) you know the answers. Being a senior is kind of scary because while the intern does the H & P, you decide the management plan. Somehow though, I am not afraid of that responsibility and feel up to the challenge.

The USMLE exams are now a distant memory and are only relived whenever the intraining exams come around (which for peds is in a week).

Internship -- Critical Care

Hi guys!

I just came through spending a month in critical care medicine, and I think I've found my true love. At first, I was nervous in the CCU (Critical Care Unit). Everyone looked so fragile and on the edge of life (most of them just don't look like that, they are!). I was afraid to do anything -- a physical exam, ask questions or anything. By the end of the month though, I have lost that fear. I feel like I know a little more of what to do there. I got a chance to intubate a couple of people, participate in several code blues (cardiac and/or respiratory failure) and was part of several death-and-life dramas. There were many cool experiences.

And oh by the way, all you guys who gave me grief for spending so much time on the Henderson-Hasselbalch equation in biochemistry, just wait till you see how useful it is in critical care and how much you will use your knowledge of blood gases. More on that later...

Vijay

Marshfield Clinic magazine article

During my internship year, one unexpected surprise was a visit from a 'reporter'. This person worked for an inhouse publication called The Scope -- a publication put out by our institute's division of education. I was told that they wanted to interview the new residents to find out how things were going.

The only time I could find to do this was one afternoon, post-call. So, after a particularly busy night and morning, before I went home, I met the interviewer and answered some questions. The result is this article. I guess it is part of posterity now.

From the trenches of internship

11/13/2005

I am doing a Med-Peds residency at the Marshfield Clinic & St. Joseph's Hospital in WI. This was my first weekend off in 6 weeks. I actually got both Sat and Sun off -- didn't have to go to the hospital, didn't have to answer pages. Unbelievable!

I just wanted to say that residency is great but can tax you physically. I had to make a poster presentation at the American Society of Human Genetics last month. I was up all night preparing the poster. The next night, I was up all night on call. The following day, I was post-call and snoring loudly in the plane from Marshfield to Salt Lake City. I presented my paper the following day. The next morning, I was on the plane back and on call the following night.

Having said all this, I would not trade it for the world. I am living a dream. I am learning and doing a great deal and loving every minute of it. There are poignant experiences that burn into one's memory: like doing chest compressions on an 8 month old female infant who did not survive the code. I had been up all night and the child was flown in by copter in the morning, pulseless and not breathing. I don't think I shall forget that experience.

To all you medical students out there, doing USMLEs, attending classes and looking forward with trepidation to residency: hang in there; learn the best you can; make the knowledge yours -- not just short term memory for a test. You will need it! But it's worth it in the end. During residency, no one cares where you went to medical school, what grades you got in path or physio or whatever, or what scores you got in the USMLE. Everyone comes to know what you do and don't know by the way you function on the wards and in the clinic. It's the knowledge that's really yours that shows then.

Passing the last USMLE exam -- Step 3

I received good news over this 4th of July weekend and wanted to share it with you. In order to qualify for an H1-B visa, my residency program required me to take the USMLE Step3 before they could offer me a contract. It was scary thinking of doing step 3 before beginning residency. Did you know that while the pass rate for steps 1 & 2 for foreign medical graduates is in the 80s, the pass rate for FMGs for step 3 is only 56%? I wonder why. I have read horror stories on the web of folks who got 98 and 99 in steps 1 and 2 and then failed step 3. So I was nervous.

Anyway, I found out on Saturday that I have passed Step 3 with a significant margin. I want to encourage all of you out there from MUA and Saba that our schools do deliver the goods. I am proof of that. Keep working hard and you will match in the specialty you want and hopefully, where you want too.

Vijay

Good NEJM articles on becoming a doctor

In the last two issues of the New England Journal of Medicine, there have been some excellent articles regarding becoming a doctor...1. Abraham Verghese's The Calling talks about how he came to choose medicine as a career and the importance of literature in developing as a physician (if you were my student, you can guess why I liked this one).2. Dr. Treadway's The First Day describes the experience of learning to take a good history and conduct a good physical examination and how learning these skills go hand in hand with developing compassion for patients.3. Sobel (a fourth year medical student) writes about the language of medicine one learns while a clinical clerk -- its great reading for learning to give the short presentation of your patient on rounds, to an attending or a consulting physician.4. Dr. Goldfinger (no, I do not think he is a proctologist) writes a humerous but pointed piece about the use of medical jargon and acronyms in medicine -- especially in students' presentations.

Match Results 3/18/2005

This is a quickie...

I remember the moment I found out where I was to spend the next four years of my life doing residency. I was working in a lab at the NIH. It was 3/15/2005 -- Match Day. I had been logging on to the Match website every few moments waiting for my news. It finally came! I had matched in Med/Peds in the Marshfield Clinic in WI. I remember going down and stepping outside the building. It was a cold morning. I called my mother in Panama and gave her the news. I posted a message on our school's clinical experiences web site that read:

Congrats to all of you out there that matched this year! I've heard from a few folk with their good news. As for me, I matched in the Internal Medicine/Pediatrics program at the Marshfield Clinic in Marshfield, WI. I am thrilled that I got the specialty of my choice. I am also thrilled that I got into the Marshfield Clinic -- a national center for genomic medicine as well as a major place with lots of fellowships and residencies.

I am sure we all share the same feelings of gratefulness to our schools' faculty and administration for all their support and help through the years that led to this day.

First Call Night in Ob/Gyn

March 14, 2004 8:35 pm

It’s the first call night. It’s been an interesting day. I came in at 5:00 am and found the night resident. He told me to hop to it! I had to have notes written on all the post-partum patients before the morning resident was to come in. Of course, I had already begun and he was pleased to know that I had the notes all done. We had a lady come in. She was not quite in labor but the fetal monitor showed that the baby’s heart rate was decelerating. In a flash, we were all in the OR and the morning resident, to whom we had not even had a chance to say ‘Good Morning’ was doing the C section.

Things slowed down a bit after that. Outpatient got interesting. A Vietnamese couple came in. The woman was having some back and abdominal pain. This was her second pregnancy. She was only 20. I did an H & P on her. As we monitored her, it appeared she was in the beginnings of labor. The attending physician was contacted over the phone. He instructed us to admit her. We did. I began writing labor notes on her, monitoring her progress over the next couple of hours. I was called to outpatient to look at another patient. About 25 minutes later, as I walked back to the nurses’ station opposite the L & D rooms, I noticed activity in my patient’s room – the Vietnamese lady. I rushed in to find that the baby had been delivered, by the nurse. Things changed so fast that not even the resident could get there from the call room a few doors down the hall. I watched as he sutured a tear in her vagina. Babies can come so fast!

It’s a couple of hours later. I just checked in on the patient again. She is sitting up in bed, her husband beside her. Their little baby girl is in a warmed crib. They are eating sandwiches and watching ‘Men in Black’ on television – just another evening. Imagine that! It was a pretty picture.

Last Friday was not so pretty. We were in outpatient and saw a 33 year-old G3P0. She had got pregnant after 10 years, after having lost her previous two pregnancies at 9 weeks – one a placenta previa and the other a miscarriage. She came in, this time at 9 weeks complaining of bright red bloody discharge. We checked her and she was rushed for a stat ultrasound, where it was determined that her fetus was no longer viable. Of course, she was very tearful. We admitted her to the unit and in a couple of hours took her into the OR for a D & C. It was kind of ironic. The D & C was being done by a 3rd year Ob/Gyn resident who was pregnant herself. A female medical student who was in call and myself, who stayed behind to watch this procedure were in the OR with her. When the anesthetic began to wear off in the OR after the operation and as we wheeled her into recovery, she sobbed uncontrollably “You took my baby. My baby’s dead. I want my baby. Why did this happen to me?” I had spoken to her for some time, comforting her before the D & C. She cried, believing that she might never get pregnant again.

As I stood in the OR recovery room trying to pacify her as she sobbed inconsolably, I thought of that verse from the Bible “Rachel weeping for her children and refusing to be comforted, because they are no more.” Who says OB is always a happy specialty?

First day in Ob/Gyn core rotation

3/9/2004 9:41 pm

Well, Psych is over and I was excited about getting started in ob/gyn. I was apprehensive about this rotation because: (1) I am a male and have limited exposure to female problems (no jokes, please!), (2) I do not have any children and have never witnessed a live birth and (3) I have not been around infants and small children a lot.

I arrived my first day at 5:30 am. Our scheduled time of reporting in was 6:00 am. However, I always find it useful to arrive in time to meet the night shift of nurses and get a heads up on what's cooking. We had one first-time mother (grava 1: Para: 1) ready to give birth. Since she had been there since midnight, it was decided to induce contractions with oxytocin (Pitocin). By about 6:30 am, the resident decided to induce artifical rupture of membranes (AROM). pardon the comparison but seeing the meconium-stained amniotic fluid flow out of the vagina was like watching Linda Blair vomit the green stuff in the movie 'The Exorcist'. By about 8:00 am, the baby's heart rate began to fall into the 80s. Interesting that for fetuses, normal HR is 120 to 160. Anything below 120 is considered bradycardia. Interesting contrast with adults where normal HR is 60 - 120 and anything above 120 is considered tachycardia. Anyway, after trying various things -- adjusting the position of the mother, discontinuing the oxytocin drip, a decision was made to do a C-section. Since this was my first day in the unit and I had never scrubbed in for surgery before, I was assigned the role of watching another medical student scrub in and told to observe everything she would do during the procedure.

The C-section was great. It was everything I had read and seeing the baby be drawn out of the opened uterus was the coolest thing I have seen yet. The resident did all the work, while the attending just helped. I had a great view and could see everything clearly.

We went to lunch afterwards and I had a pizza with lots of tomato sauce (I know, pretty sick of me, no?). The rest of the day was kind of slow. I developed either the beginnings of a cold or an allergic rhinitis and was sneezing all day. That was not so good. My first call is Sunday. It seems that in this unit, medical students are really encouraged to participate in delivering babies, procedures and the like. I am excited and looking forward to every day here.

Shock Therapy

It was my last day in psych and I got to see some interesting stuff. A patient in the unit who suffers from severe depression was found to be a suitable candidate for ECT. A nursing student (an ex-Vetinarian) and myself (an ex-Biochemistry) accompanied her from the unit to the Main Hospital where ECTs are done on the 5th floor. We chatted with the patient. She was nervous, even though this was the second ECT treatment she had received. Once in the room, an anaesthetist proceeded to administer Pentothal and succinylcholine and robinol. In addition, since she was being treated with benzodiazapines for her depression, Romazicon was also administered to lower her seizure threshold. She was administered 50 sec of 80 mA at 220 ohms resistance, which translates to about 176 volts. The entire procedure was followed on a monitor (to watch heart rate and blood pressure) and an EEG to follow the seizure activity. Because of the muscle relaxant, the patient did not 'jump off the bed' when the shock was administered. Furthermore, the major region of the shock was the temporal lobes bilaterally.

The patient regained consciousness soon afterwards in the OR holding room. She did not remember who the nursing student and myself were due to loss of short term memory. Overall, the procedure was nothing spectacular to watch. ECT is administered in a much more humane way these days with appropriate anaesthesia and limiting the major electric disturbance to the region intended. It is still a treatment modality of choice in certain refractory depression and even mania cases.

I talked to God today

Mentally Retarded and Emotionally Disturbed Children.

Today I got to spend several hours sitting in a class for ‘low-functioning’ mentally retarded and emotionally disturbed children. There were about 6 children in the class. One was a 12-year-old with Fragile X syndrome, another a 14-year-old with an IQ of about 60, a couple of girls – 9 and 11 with autism and mild MR with emotional disturbance respectively and a conduct disorder MR child (age 12). The level of the class was about that of a kindergarten class. Basically, the kids worked on tracing the lines in coloring pictures. They went over some flash cards of common signs (such as danger, poison, pedestrian crossings, etc.).

It was discouraging to hear that the two girls were raped as toddlers, one by her father (now in prison) and the other by several men at different times. Apparently, sexual abuse of the mentally retarded tends to be more common than of normal children.

It was interesting to interact with children suffering from disorders that I had only studied about in medical genetics and other courses. I had interesting discussions with their therapists and teachers regarding the goals for the children and the methods of communication. Most of these children have difficulties describing their feelings. Picture books and clever techniques are used. I felt a sense of admiration for the teachers and therapists that work with these lowest level of functioning children. Often the goal is simply to get the child to follow staff directions, to raise self-esteem and to help the child achieve the level of independence of function he or she is capable of, e.g. dressing themselves, toilet hygiene, anger management, etc.

In the afternoon, I got to talk to ‘God’. This was a 50-odd year old male who for the past 11 years has had the delusion that he is God. He does, however, also know that ‘here’, he is identified by the name that is on his official records. When he was brought in, he was paranoid, believing his neighbors and his wife and his doctors wanted to kill him. During the mental status exam, when I asked him to interpret the proverb, "People in glass houses should not throw stones" he laughed and told me "yeah, that's stupid, because the glass would fall on me!" He has since overcome this belief somewhat. He still maintains that his neighbors are trying to get him but he is content to ‘what goes around come around’. He no longer seems to manifest any homicidal tendencies. What is this person’s baseline function? What would be our goal for the inpatient treatment he is receiving? Today, he was due to appear in court. He told me he was going to tell the judge that he was ready to go home. Do we have any hope of convincing him that he is not God? Or should be just release him back into his situation when he is no longer a threat to self and others? I had some interesting discussions with his therapists and psychiatrist on these matters.

Child Psychiatry

Well, this past week, I have working in the childrens' psychiatric unit. At first, I was apprehensive since I have not been around kids a lot. I wondered if I would be able to relate to them and help them. The apprehension was soon replaced with a kind of sadness as kids matter-of-factly told me their stories. We had one kid who was admitted to the unit because he had thrown a chair at a teacher (in the US, you can forcibly admitted to a psych unit -- EOD -- emergency ordered detention -- if you are considered a harm to yourself or others; this kid fit the latter requirement). It turns out that he has a lot of problems, losing his temper and getting into fights with other kids and adults. The only person he does not fight with is his mother. When I asked him about his dad, he told me his dad was in prison. He last saw him 3 years ago and last spoke to him a year ago. I asked him if he missed his dad. He shrugged his shoulders and said that "a little", then added that he hadn't got to know him really well, since he had been in prison before and was only out for a short while before he was back in again. His problem: depression. Well, I think I would be depressed too! We are giving him anti-depressants and teaching him 'anger management' skills. Another kid has been hallucinating since the age of two! He hears whispers around him at all times, sees snakes and imagines his entire past. The prognosis for him is not good. He is a loveable, if somewhat hard to manage kid, but one who has developed the symptoms of schizophrenia very, very early. Of course, there are several mental illnesses in his family: schizophrenia, bipolar disorder and depression. That can't help. There are lots of stories to tell. Every child is a story, most of them not happy ones. I mean, how do handle hearing a 9 year-old girl tell you that she wants to kill herself because she bear to go on living? She even had a plan -- to slit her wrists. Interestingly, in this particular case, we could not find a precipitating stressor for the depression. Of course, there is a family history of depression, though none of suicide. There were many interesting cases.
I really came to love the staff who work there. They love the kids and discipline them too. The kids know that they discipline in love, so they love them back (that is, those kids that are capable of loving; we have some kids with attachment disorder, who do not know how to do that).
This coming week is my last week in psych. After that, I begin ob/gyn. That should be 'fun'. I have never seen a live birth before, so working in the L & D (Labor & Delivery) unit should be lots of fun. I also look forward to gynecology -- everything from routine pap smears and pelvic exams to surgery).

The Charles Manson Fan Club of 1

I just had to talk about this session this afternoon. The patient is a 20-something caucasian female, slightly obese, dressed in a T-shirt and jeans. She sat with a grimace on her face and pulled at her shirt sleeves, looking somewhat uncomfortable, somewhat anxious, somewhat depressed. The session blew my mind away. She talked about being a fan of Charles Manson. She sent death threats to another psychiatrist who hospitalized her over Christmas for suicidal ideation. She said to relieve stress she was thinking of doing something different... like smashing someone's head with a sledgehammer. Her therapist recommended she try smashing a watermelon first -- you know, just for practise and to see what she would have to deal with afterwords. She did. She set up the watermelon in her kitchen and smashed it with a sledgehammer. Somehow, this convinced her to abandon her plan because she says she's been cleaning out watermelon seeds and pieces from all over her kitchen for weeks now. Instead, she thought she might try jumping from a high point. I thought she meant bungee jumping, but further elaboration revealed she meant without a cord or a parachute. I surmised this when she said "the jump would be fun, but hitting the ground would hurt." Incidently, she brought in something she had sketched. It was a pencil sketch potrait of herself, drawn as Mona Lisa sitting in a bathrobe on a torn sofa. The Mona Lisa looked liked a photograph. I thought she must have been drawing it from a picture. She casually mentioned she had drawn this from memory. Of course, how much of this was shock value and how much of this was psychosis? Apparently, her body is like railroad tracks from the self-mutilation. Laugh if you will, but look behind you when you're walking home alone at night...

In the morning, I got a wish I had for some time. I was really interested in seeing dementia -- vascular, Alzheimer's infectious disease-induced... Well, I spent the morning in the geriatric psych ward. Fortunately (or unfortunately), I had been on call with my attending covering all the patients there both Saturday and Sunday, so this morning when I went to see them again, but this time with an internal medicine doc, I felt like I was meeting old friends. One of them -- a troubled 60-something year old female of mixed caucasian-indian descent came up to me and hugged me and woulnd't let me go. This, in the middle of the lunch room at lunch time. Whether from the meds she was on or from previous activities, her voice was heavily slurred and words came out agonizingly slowly. As she held me close, she announced to me and to all present, "Doctor, will you kill me please?" Then in a little louder voice, "Please doctor, kill me!" Finally, screaming while hugging me tighter, "Kill me, Doctor!" Okay. So I think I've seen enough dementia. There was one really cool thing though. Over the weekend we had seen this sweet little old lady with crippling parkinson's. Today when I saw her, she kept sticking her tongue out at me in a tic-like fashion. It took me a few seconds when I realized what I was looking at...tardive dyskinesia. And finally, there was the retired psychiatric Charge Nurse who over the course of her 40 years of service has probably trained half the psychiatrists in the state we're in. My attending spoke respectfully to her and told me later that she taught him and helped him a lot when he was an intern 20-odd years ago. Her memory has gone to pieces, but as is often the case in such dementia, when he quizzed her on some old psychiatric drug pharmacology, she spit out the answer even before I could hazard a guess. I'm enjoying the psych rotation... in a strange kind of way. Now when I walk in the mall, I see people differently...

More later...

The woman with no hair anywhere

I met an interesting pt during one of my weeks of rotation in psych. She appeared to be a pleasant Caucasian female. Moderately obese in either her late 30s or early 40s Some years ago, she was disgnosed with panic disorder with agoraphobia she was admitted to our inpt. facility here and received treatment. She is much better now. She recently gave birth. She has children from a previous marrage. Her ex-husband -a cocaine addict is having Paranoia and hallucinations.

When this woman had panic attacks, she was put on Paxel. Apparently. A rare side effect of this group of drugs ( the ssris) can be aloepecia totalis the complete loss of all hair. Sae has no hair anywhere! she has approached the makers of the drug for compensation but so far has got none. she was telling us how expensive wigs are to maintain if one wears them all the time as she is forced to do. She was an interesting person, telling us of her ongoing interests in sports. She takes care of a house of children and occassionaIly a psychotic ex -husband.

She was also reporting on another interesting side-effect of ssris. Vivid dreams and nightmares. Apparently. These are due to serotonergic activity.
I thought the unfortunate side-effect of aloepecia totalis was interesting and unfortunate, especially for a young female.

The Psychotic who predicted her death

This is the story of a dear patient. Sne was a cauc. Female in her early forties who was found orthe floor of her home in feces and filth. She was malnourished.when we interviewed her,she was actively hallucinating. She saw bugs, heard voices. In got to do the complete psychiatric interview on her. She was very interesting. A few days ago, in the early morning, she was found pulseless and not breathing. A code blue was called. PEA was identified and the appropriate procedure initiated. Forty minutes later, a pulse and respiration was re- established. We do not know how long she was down for. since the last person to see her active was a phleblotomist who came to draw blood @ 4:10am in the morning.

She was intubated and transferred to the icu as I write this. Will she make it? She told a nurse yesterday that today she would die. Depending on how long she was down, her brain has been deprived of O2 for a good while. Did she attempt suicide? If so, how? She told another med student yesterday that there were 2 people in the roomM with her (hallucinations). Did 'they' kill her?

Iain writing this update a few days later. The pt. is dead. She died in the evening after we all left the hospital. From the time she wss transferred to the lCU she never regained consciousness. We determined that she was breathing a little on her own, but otherwise there wss minimal brain function. We had her on 8 ug of dopamine to keep he BP up. Towards the end of last week, it was agreed upon by family and her attending doctors that she was never going to regain consc. Her pupils were fixed and dilated and she showed only primitive reflexes. Her relatives asked that we disconnect all machines. Her attending physician felt that this would be too aggressive and active a move. Instead, heopted to keepthe ventilator on. Towards yesterday evening the pt. began to develop a climbing fever. Nothing was given for it. This was the acute Cause of her demise.

This case was interesting because of the rapid turn of events, the psychosis and in the end, our inability to elicit a favorable outcome for her. It was a tragic story. I believe that everyone acted appropriately. However, none of us who participated in the case came away happy. We lose some battles in spite of everything.

Juvenile sex offenders

Thursday, February 05, 2004 Juvenile Sex Offenders – a first experience

It was an interesting day. I was scheduled to spend the day with Dr. B – a psychiatrist in the Adolescent Unit. I met him at 8:15 am in the unit on the 3rd floor and sat in on the treatment plan meeting. During this meeting, the psychiatrist, therapists and case manager (along with medical students, nursing students and a few other odds and ends) sit in and discuss the progress and plan of each resident. Before the session, I accompanied Dr. Bell to do an H & P on a patient admitted the night before. She was a 14 year old girl. She was admitted for feeling suicidal. I learned that she had been raped by her step-grandfather. She had marks on her wrists from where she has cut and mutilated herself in the past. During the treatment meeting, there were may interesting cases. There is a lot of history of abandonment, neglect, drug abuse and poor parenting. There are also a lot of examples of physical and sexual abuse. The unit we were in was the acute unit: where patients are admitted for short periods of time – upto a couple of weeks. This is in contrast to the unit on the 4th floor, where patients spend 6 months to a year. These are patients with no where else to go – they have been thrown out of practically everywhere else.

After the meeting, I went to the hospital to go psychiatric interviews on two consults for Dr. C (my attending). The first one was a 50 year old Black woman admitted for CHF, hypothyroidism, DM2 and gouty arthritis. She was cooperative and described being institutionalized when she was 11 years old because of physical abuse by an alcoholic mother. She was kept in various institutions until she was 17. The second patient was a contrast. He was a 46 year old white male with a relatively high level of functioning. He felt the human race was nothing but “technologically advanced cockroaches.” He was suspicious and declined to participate in the interview. I managed to get some information about him. He reports being allergic to Thorazine – “causes muscles all over my body to lock up”. He has been institutionalized and used drugs in high school. I wrote up the reports and took them over to Dr. C who by that time had returned from his talk in another city. He felt that the male patient must have been a late onset schizophrenia in view of his high level of functioning and intelligence. He explained that perhaps his animosity to the questions and his decline to participate in the interview was because of a sense of shame and feeling that people treat him differently because of his illness. When I asked him about suicide ideation, the patient had said “I’ve been asked that question so many times and I think it is a personal matter.” He denied homicidal ideation. And admitted to having been given Thorazine for the first time in a state psychiatric facility, I found out later. We also chatted about astronomy and Mars, since the patient expressed interests in those areas. I promised him a magazine on Mars.

In the afternoon, I drove in the snow and rain over to the other campus of our Bahavior Medicine facility on 59th street. This is the facility where the geriatric and juvenile sex offenders units are located. I spend the afternoon reviewing charts and reading about juvenile sex offenders. The first chart I read was the case of a 14 year old boy who had raped his 8 year old half-brother in a foster home. He had had anal intercourse with him. Later, to prevent the child from telling on him, he had suggested to him that he poison the entire household. When that didn’t take, he stole his foster father’s gun and gave it to the boy and suggested that he shoot himself and end his life. The boy eventually told someone and the patient was taken into custody and brought to this facility. His own history is interesting. He is the product of an incestrous relationship between his mother and his maternal grandfather. He was eventually taken away from his mother because of her abuse. He was physically and sexually abused by her boyfriends and male relatives. The stories of most of the boys in the facility – ages 13 to 17 were similar with elements of abuse and neglect. Interestingly, many of them sexually abuse boys 5 years younger than themselves in the same age and in the same way as they themselves were abused. I then sat in on treatment plan meetings, in which the boys were brought in one by one to a meeting with the therapist, the psychiatrist and the Charge Nurse. Besides myself, a social work student who works at the facility doing her practicum were also present.

Rather than be disgusted and feel hatred towards these boys, I felt a morbid curiosity. It is creditable that the state does not just lock them up and throw away the key. After all, they have committed heinous crimes and are in such small numbers that one might not want to invest resources in ‘fixing’ them. As a Christian, I struggle with the finality with which specialists and experts pronounce judgment on the future of these and other pediatric patients saying they are marred for life. The Bible teaches that one can be completely made anew.

I love what I do...

Competency

February 5, 2004 Competency

Today’s learning experience in psychiatry can be summed up in one word: competency. We were consulted on two patients. We were asked to determine whether they were competent enough to make medical decisions.

This pt. is an 88 year-old black female who has suffered 2 strokes in 2003. In Jan .2004, Home Health called EMSA and asked them to take the patient to the Emergency Room because herb lood pressure was elevated. More importantly. Her speech was slurred. This pt. had been living on her own all this time, by herself, with someone coming in to help her with groceries

The pt was admitted to our hospital a week earlier. Psychiatry was called to assess the competency of the pstient. I found her in her bed talking to an empty room. When I asked her any questions, she would answer but then she would keep talking.

Finally, I asked her if she knew why she was in the hospital. She said she knew she had a stroke. She emphatically communicated to me she did not want to go to a Nursing home. She wanted to go home, she said. When I asked her why she had refused to take injections. She got a bit agitated. She said that her doctor thought she was crazy. He was trying to give her medicine like Haldol for being crazy, but she was not crazy. She said she wanted to gone home.

Question: Is this woman competent? If we decide she is incompetent to make decisions, then we must release her to home. If on the other hand we decide she is incompetent She will be forcibly administered Haldol. What are we to do?

This case raises the question of whether an elderly person who is not choosing well is necessarily incompetent. She may not necessarily be choosing wisely. She also may not be the smartest kid on the block. However, all of us perhaps know some cantankerous old folks, fiercely independent who live life on their own terms. When do we infringe upon their autonomy?

I learned from my attending that one asks several questions, such as

Do you understand your illness, that you are sick and in need of treatment?

Can you understand the treatment options, their associated risks and benefits and what they mean?

Can the patient hold the information needed to make a medical decision in their minds in an orderly and rational fashion?

If the answer to any of these questions are ‘no’, then the patient is deemed non-competent to make their own medical decisions. It is, of course, highly subjective

Our second competency case was a 46 year old Caucasian male. He appeared highly intelligent but somewhat bizarre in behavior. He spoke with stilted speech and during the course of the interview would go from being friendly to clamming up and withdrawing from giving more information. When asked about medical issues, he answered, “I think it is personal” and would volunteer no more information. He used the same words and answer to several subsequent questions (preservation). If we changed the topic and asked about something else, he would answer in short sentences. If we talked about sports or astronomy (his interest), he would thaw out, but only a little. Lately, he had been refusing medications. When asked about it, he denied he had done so. My attending found him non-competent to make medical decisions.<

Both the above patients lost their autonomy in the hospital setting and would now have little or no choice in their medications, perhaps need to be restrained if they became uncooperative. I shall keep following the case to see if their consciousness resolves and they regain their competence

A case worker for the first case told me that if a person is found non-competent, then a state body called Adult Protection Services comes in to protect them from themselves. They may be placed in a group or nursing home. The philosophical ramifications of today’s experience were immense and gave me a lot to think about.

Drug reps and Pharmaceutical dinners

Wednesday, February 04, 2004 The world of drug reps and drug company sponsored dinners

I am learning that drug reps can be a great source of information. However, one has to learn how to ‘exploit’ this resource just right. I am not talking about exploiting them literally. I am referring to learning and getting as much knowledge as I can for the benefit of my patients. I had an interesting experience this afternoon. The rep from Zoloft came over. Since my attending was busy, I talked to her for a bit. She gave me a brochure that showed a study comparing weight gains with Zoloft compared to Paxil. The graphs showed that patients on Zoloft had a much lower weight gain than patients on Paxil. Okay; A hour or so later, the Paxil rep showed up. She spied the Zoloft literature on the table and asked me about it. I shared the results of the study with her and asked her about the weight gain issue. Well, she produced another full-color brochure with a different study comparing the effect of patients taking Paxil to placebo. Her study showed that patients on Paxil actually had less weight gain than patients on placebo. It was an interesting contradiction – the two studies showing opposite findings. The next day, the rep from Wellbutrin came over. She had some things to say about Zoloft and Paxil and compared them to Wellbutrin. I think that if one listens critically, one can learn quite a bit from the comparative assessment. Finally, I asked my attending what he thought about these drugs and what his experience was using them. All this coupled with reading the relevant chapters in Blueprints in Psychiatry made for a good pharmacology learning experience. Moral of the story: learning to critically evaluate facts, studies and such and drawing the best conclusions.

Today I also got to go to my first drug-company sponsored dinner talk. It was held at a fine restaurant in Bricktown. I arrived at the restaurant to find about 20 people. I sat with an elder Indian couple – husband a general surgeon and wife a psychiatrist at the VA. The speaker was an asst. professor from USC, LA. He spoke about the use of Risperdone in bipolar disorder. The talk was in PowerPoint and interesting. He made disclosure that he was a consultant and speaker for several drug companies. The food was great – lobster brisque, cold water lobster tail, cheesecake, pasta. I loved it. After the talk, we all went our separate ways. I kind of enjoyed being a medical student/future doctor this evening. One wonders about the ethics of such things. Surely, the good treatment and food softens one up a bit to the drug reps and the companies and products they represent. It probably doesn't hurt either that most of the reps are pretty, well-groomed (well nourished and in no apparent distress, but I digress) and seem to flirt and flatter a little as they deal with us. Maybe that's just marketing...

First week in Psychiatry

1/31/2004 2:38 pm

I finished my Internal Medicine on a Friday and began my psych rotation on Monday, Jan 26, 2004. The first day, I was asked to report to my preceptor, Dr. C at 8:00 am in the morning. This itself was a big difference from IM where we used to report at 6:30 am. Dr. C is the head of a department of Behavioral Medicine. The first day was kind of unstructured. He took me around to the Children's Inpatient unit, the Adolescent Inpatient unit and the Adult Inpatient units. We also got a glance at a special unit for mentally retarded children. I basically got to spend the day in the lounge outside his office. He could not let me in while he interviewed some patients as my presence would affect the dynamics of the interview.

The Department of Behavioral Medicine has several programs/units:
Child Psychiatry
Adolescent Psychiatry
Adult Inpatient Units
A special unit for children and adolescents with mild to severe mental retardation
A Chemical Dependancy Unit and
An outpatient facility that runs intensive throughout-the-day psychotherapy, psych-education programs.

In the afternoon I got to sit in on the outpatient day therapy sessions. They were in groups and the topic being discussed was dealing with grief.

During the rest of the week, I spent a couple of days at the Chemical Dependancy program attending the day sessions -- almost all of the therapy is done in groups in this unit, and studying the drug protocols in the charts. For alcohol dependency/abuse, the detox protocols consisted mainly of Librium and Clonidine. I was surprised to learn that Clonidine is used. I was told by a psychiatrist in that unit that alcoholics will often exhibit sympathetic respnses during their detox -- higher blood pressures, perspiration, tremors, and that Clonidine helps with this.

Since my days were so slow and I was not spent yet, I volunteered to join the staff that man the ER in the 3:00 pm to 11:00 pm shift. Apparently, that is when they get most of their admissions to the psych unit. I was amazed and appalled at how many people come in with suicidal ideation and even a plan. Amazingly, almost all of the people I saw in the first week there were females in the ages ranging from 13 to 25. One evening, after 4 such "I want to kill myself" cases in a row, I was somewhat encouraged when the fifth person I interviewed, a 31 year old Caucasian male said "I hear voices". I asked "What are the voices saying to you?" The answer: "The voices are telling me to kill myself. Here we go again...

I like working the ER because I am getting to see some florid pathology and I get to practise my ability to do the mental status exam and come up with the appropriate DSM-IV diagnosis.

More First week in Psychiatry

1/31/2004 2:29 pm

I spent a couple of afternoons during my first week sitting in on Treatment Team meetings. This is when the Treatment team consisting of the psychiatrist, case managers, psychotherapist and charge nurses present updates on each case to the psychiatrist. A plan is formulated in terms of time to be spent on the unit, med changes, therapy changes, etc.

I was absolutely thrown offbalance by the horrible stories I heard in the Treatment Team meeting of the Children's Unit. I was told stories of drug-addict parents, abandoned children, physically and sexually abused children (one child was sexually abused by her grandfather from the age of 6 months to 4 years of age) and drug babies -- children affected by their mothers having taken drugs or alcohol or both during the pregnancy, or of mothers using damaging medication while breast-feeding their kids.

One 2 year old was found on the streets by police, wandering by himself. When asked what his name was, he said "Motherfucker." He'd probably been called that so many times, he actually thought it was his name!
I have been learning about attachment disorders. I was so moved that I went out and bought a couple of books about it to learn more.
On a more practical note, stuff in the basic sciences that relate to this rotation are:
DSM-IV criteria for diagnosis, Mental Status Exam, The psychiatric interview, and mechanism of action of all the drugs -- antipyschotics, anti-depressents particularly.
More later...

Advice to the third year med student doing psychiatry

I finished 6 weeks of my psychiatry core rotation last week. It is Sunday as I write this and tomorrow I shall begin a rotation in ob/gyn. I wanted to sum up the rotation.

It was interesting that in this hospital, I was told not to wear my white coat and that I would probably not need my stethoscope, although I was to keep both items close by (in the car) in case I needed to a physical exam. Throughout the rotation, the procedures I learned were: the complete psychiatric interview, writing a progress note on inpatients, writing a consult note for hospital patients on whom we were called in for a psych consult, the Mental Status Exam, the Mini-Mental Status exam, contributing an evaluation to furnish materiel for a psychiatric evalulation of competency.

I got to spend time in: outpatient group and individual sessions with both the psychiatrist and therapists, medicine management meetings, inpatient adult, adolescent, childrens' and mentally retarded children with emotional problems facilities. I also got to visit geriatric psychiatric facilities and a special facility for juvenile sex offenders. I got to see take-downs, face-to-face evalulations, ECTs and pts. in various stages of mania, psychosis, depression.

I thoroughly enjoyed the rotation. My only peeve was that things were pretty slow and some days, there was precious little to do. I like to be busy and some days I wasn't very.

Recommendations for books and things: I highly recommend the Blueprints for Psychiatry 3rd edition. It has additional materiel and questions not found in the previous editions. For the PDA, I highly recommend the Washington Manual Psychiatry Survival Guide. This is a new program from Skyscape. It is EXCELLENT. It has discussion articles on each of the major disorders, an abbreviated DSM-IV, a drug formulary and full examples of every kind of note I needed. Buy it. It will not be a waste and you will not have to carry any other book or PDA program in your pocket.

I am looking forward to the next rotation...

New attending, different style

Hi!

I am in the last week of my internal medicine rotation. I have been fortunate to be able to spend this week with a new attending. He is double board certified in internal medicine and pediatrics. So far, my attendings have been pretty laid back. He is not. He is quite demanding and formal. However, it is great to work with him, as he really teaches. For example, over the weekend (yes, I had to come in on Saturday and Sunday this weekend), he sent me to see patients and asked me to write a SOAP note on them. Then he came down to see the same patients. Before seeing them, he asked me to 'present' the patient -- basically use my SOAP note to update him. The last part of the note is of course, the plan. He asked me what I wanted to for the patient today. This, by the way, was an unconscious patient in the ICU on a ventilator! Well, I gave him my plan. He told me to write them out on the yellow 'Physician Orders' sheet and then he signed them! It was pretty cool. I felt like I was managing the patient. Of course, not all my presentation went as well. Sometimes, I was completely lost. Well, rather than tell me what to do, he would ask questions. The answers led to the plan. For example, I wanted to get a CBC on a patient we suspected of having an infection. He asked me "What is the life span of a WBC?" To my shame, I did not know. He said, "Guess". I guessed 20 days. A 4th year medical student guessed 2 months. The answer: 4-6 hours. Oops!

Oh well... one can't get them all...