Best. Decision. Ever.

Where I used to work:













Where I work now:

My competitive nature

I felt a certain pressure to match last year's pumpkin. I fear I did not manage it.

Last year:













This year:

Oops

I'm pretty sure I just heard Chase, on the show House, order Streptokinase and heparin. That would be a no-no. You can use tPa with heparin, but not streptokinase.

The environment of medicine is all wrong on the show, but usually the medicine (diagnostically) is accurate. Where was your physician-fact checker? Tsk tsk. I'm disappointed.

Pee

Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3

A week in the life

What school tells me my week looks like:























What my week actually becomes:

Breaking bad news

A recent assignment for school caused me to recollect a patient from my previous hospital. An excerpt (the original essay is several paragraphs longer) from my assignment summarizes the story...

The patient, an 8-year-old boy, was the elder of two sons of a recently immigrated family. He had been admitted for status epilepticus, which proved to be refractory. He was ultimately placed in a medically induced coma (which he continued to seize through for a month) and the parents were asked whom else they would like present for a discussion of his prognosis.

The family requested that a doctor from their home country be involved and so a teleconference was established. Various members of the care staff reported their opinions and summarized the boy’s course to date. There was almost as much silence as there was talking and each person was careful to solicit and answer questions. The questions themselves guided the discussion. The parents really needed to believe that every option had been exhausted. They believed that because we had been able to find an etiology, we should be able to find a cure.

From a physician’s perspective, after a month of seizing and coma there was likely to be little brain function left. A multitude of testing revealed a genetic defect in a sodium channel, which was blamed for the seizure activity. The boy was not a surgical candidate because the seizures were multi-focal and originated from both hemispheres. Everything had been tried and nothing would break the seizures, which were still occurring roughly every three minutes. There was nothing more that could be done.

Most of the conversation centered on the futility of our treatments. That we, as doctors, could not even promise he would wake up if we took away the sedatives. Eventually the parents chose to withdraw support. I think they knew their decision from the moment they sat down; they just couldn’t say it out loud. I didn’t get the sense we had persuaded them; more that we gave them a safe and justified way of letting go and not feeling as if they were bad parents, that they were simply giving up because it was hard.

It was then, when they stated their decision, that I was so thankful for the private room (not a patient room) the whole conversation took place in. The family had somewhere they could be where they wouldn’t be disturbed or overheard. Not by a nurse who needed to take vitals, not by a doctor checking on another patient. They couldn’t hear the business of medicine still working around them, healing some of the other children who would eventually be able to go home to their parents. But the room also allowed us, as the medical staff, to separate the conversation we just had from the rest of our work. When you walk out the door and back onto the ward, you leave the heaviness in that room and focus on health and healing on the floor. The spatial separation aids the mental and emotional one.

That separation is not learned with one conversation. Or maybe it’s always imperfect. But I do know that I was unusually quiet the rest of the day. When a friend needed sympathy later that night, I just couldn’t muster any. His problems seemed so petty. The boy was only eight and he was dead. Dead because of a sodium channel, which seems like such a insufficient and small reason. He had a little brother who clearly didn’t understand what had happened. He had a mom and dad that somehow had to keep going. And while I wasn’t consciously dwelling on it, something in me didn’t let it go immediately. Within the week though, the petty problems regained their gravity and the pressing concerns of work and medical school applications took over.

- * - * - * - * - * -

I have to admit that delivering bad news became easier. Maybe not in the moment, but my recovery got much faster.

With regard to the family in the story, the little brother had ongoing issues coping with his brother's death. I personally think some of this had to do with the fact that the parents never allowed the younger son to visit the older one (they didn't want him to see his brother sick or in pain). Then again, I am neither a parent nor a psychologist, so I am not at all qualified on the subject.

National Grand Rounds

Today at noon the National Physicians Alliance Foundation and the American Medical Students Association held a National Grand Rounds policy panel discussion on the current legislation on health care reform. There were three panelists: one from the House, one from the Senate and one from Health and Human Services. The questions were relatively predictable, centering on access to primary care, the public option, tort reform and quality of care. The answers were similarly predictable: sound bites encapsulating pretty much what we want to hear and how historic this whole endeavor is. Pleasantly vague and bland, with little actual substance.

I would really like to see some of the legislators being honest about some of the real, and short-term unsolvable problems we're facing. How do we increase the number of primary care physicians to what we need when there aren't enough doctors going through school? How are we going to decide what medications and procedures are covered under the new insurance? How are we going to reduce the paperwork burden? How are we going to pay to insure/care for all these new people - most of whom cannot pay themselves? Because let's be honest, there will be a physician shortage in the short term and ERs will get even more crowded. We won't be able to cover everything for everyone. All these new committees and program will produce bureaucracy and without some planning, that will fall on docs and hospitals. And we don't have the money to cover all this new healthcare - either taxes will need to go up or spending will need to be cut. Public hospitals will need cash from the government to cover the services they have to provide to the population. Those are just realities.

The panelists all indicated in their introductions that their comments were off the record for any press attending, so it would have been nice if they had actually said something.

Transplant facts

Interesting fact: Identical twin transplant recipients do not need immunosuppression.

Another interesting fact: The first dialysis machine was made out of sausage casings and a bathtub. (picture)

Health disparities fact: While ethnicity is not a match criteria for organ transplant, blood type is. Caucasians (who form the majority of donors) tend to be O & A blood types. African Americans, who have the highest need (for kidneys) have a much higher incidence of type B blood. (source: http://www.bloodbook.com/world-abo.html)

Words medical school taught me to spell:

abscess
arrhythmia
component
dilated
epididymis
etiology
exercise
fourchette
gynecomastia
immunoflorescence
staphylococcus
wenckebach

Deet for men

I made an appearance at a local bar's grad night last night. None of my friends would go, but I met up with some classmates and made an appearance anyway. I was hoping at least one of the two cute guys I notice would be there. Neither was. A friend introduced me to his friend, an attractive German who was doing two months of research here. The German and I chatted for 30 minutes or so. Today I find out the German thinks my classmate is the most beautiful thing he's seen and that I was supposed to introduce them.

This comes after last weekend's fantastic ego boost of being told that I don't seem to know how to have fun. Not only did I let that slide, I was supposed to meet up with that guy later in the evening. He never showed.

FML.

Acute hepatic congestion or nutmeg?

Liver or pumpkin pie?

Finally watching tv

Old woman to doc: Dr, When I arrived at the hospital I had one leg and now I have two!
Doc: Well, there is a war on, is it possible you miscounted?

-Dr. Who [episode 10 season 1]

No means no

I was in the hemodialysis unit recently, chatting with a patient about how his life had been affected by HD and how he generally feels. As corny as it may sound, I find these touchy-feely encounters with patients to be incredibly rewarding and informative. I think those of us who are healthy underestimate the impact of chronic disease, but simaltaneouly underestimate people's adaptive resiliance. This summer I have been fortunate to have several one-on-one opportunities, but group interactions of this kind are a regular part of our medical school curriculum.

Anway, this one was especially awkward because the patient proposed to me several times and repeatedly offered to have my children. He was neither demeted nor joking. He wanted to take me out to dinner that night and put a ring on my finger. He thought it was a genetic imperitive that I breed because I (apparently) am "drop-dead gorgeous and a genius." Just about every question I asked was answered with some variation on this theme (along with some genuine insight into renal failure) for almost two hours.

An example interaction:
Me: Do you have other health problems too?
Him: I'm healthy enough, if you know what I mean; no disrespect.
Me: How about high blood pressure or high cholesterol?
Him: Yes, I got both of those, lady.
Me: Are you on medications for them?
Him: Yes, but I don't take em. I don't believe in pills. I seen to many people die from pills.
Me: I suspect those were different kinds of pills. It's important that you take your medicines.
Him: I feel fine. I'll take them if you hand them out though.
Me: Your health could get a lot worse if you don't control your blood pressure and cholesterol. You want to make it to transplant don't you?
Him: I would take them if I had you to come home to, lady.
Me: Do you live with anyone now?
Him: No, you can move right in. I'll take you out to dinner tonight and put a ring on your finger.

Liver #2

I went to bed excited because we had consented another patient for our liver transplant study. The OR schedule said they would induce the anesthesia at 10:30am, so I hit the sack just before 2 with my alarm set for 9. At 4:46 my pager goes off. They are inducing now. I head straight to the OR where I find out that this is expected to be a tricky case. I have had 3 hours of sleep and haven't eaten since 8:30pm the previous night. I emerge from the OR at 10:30am, put the samples on ice and head straight to Einsteins for a large coffee and a honey wheat bagel with honey almond smear. Never tasted so amazing.
The surgery itself was longer than the last one I observed, but they didn't have to use any blood products and were able to extubate before sending the patient to the SICU. It speaks to the skills of the surgeons and anesthesiologists in managing the anatomy (surgeons, no blood) and physiology (anesthesiologists, not acidotic).
The patient was awake when I went up to the SICU for the 2 hour post-op samples; the family was there too. It's really kind of fun when you can say you were in there with the patient the whole surgery.
I left the hospital around 2:45pm and was kind of dragging this afternoon, but I just had some coffee and a chocolate chip cookie. Nothing like caffiene and glucose to keep yourself on point.
There's another harvest this afternoon. If they keep the liver in house there's a chance I'll have another surgery this evening, although it looks like the graft is of poor quality, so I may get some sleep instead.

Crystal ball

Before medical school I took a quiz to see which medical specialty I should be. Those answers are here. I retook it now (beginning of M2 year) to see if it's changed at all. Apparently, the new list is:

1. Thoracic surgery
2. Urology
3. Plastic surgery
4. Orthopaedic surgery
5. Ob/Gyn
6. Nephrology
7. Neurosurgery
8. Infectious disease
9. Cardiology
10. Nuclear Medicine

Apparently I am straying farther into surgery and surgical subspecialties. It is worth noting that the quiz does not separate pediatric specialties from adult. If I remember, we'll try again after third year and see if I'm any different then.

Don't tease me!

(18:21) I get the email that there is to be a liver transplant at 20:30.
(20:07) I get the page that says the transplant will begin 21:00.
(20:14) I get the page that says the transplant has been canceled.
(22:00) I go out dancing instead.

Turns out carrying a pager in a club makes you attractive. A law student asked for my phone number.

Cirrhotic liver. The kind you take out, not put in.

Big trauma

A class one rolled in with the survival flight paramedics; he had been broad-sided in a MVC. He looked to be in surprising good shape: unstable pelvis and dehydrated, but good vitals, responsive pupils and moving all four extremities. The CT scan, however, told a different story and he went up to the OR emergently: 3 perforations in his bowels, multiple pelvic fractures (with bleeding) and an aortic dissection. He went straight from OR to IR to BICU... we'll see how he does.

Yet more trauma

It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.

"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"

It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.

On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).

"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."

It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.

While eating a delayed dinner, the pager again beeps.

"Class 2, M, dirt bike accident, GCS 15, not int, in ER"

Five minutes later...

"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"

More trauma pages

The trauma pager has beeped a few more times and I've seen multiple bike vs. car and a falling off a 30 foot ladder. Think chest tubes, intubation, consults with a neurosurgeon and lot of leg fractures. Any thoughts I had of becoming a bicyclist are definitely out. Mostly I just watch the trauma team in action, but occasionally I get to do things like put a gown on the person, stabilize the neck while rolling him.. small things of that nature.

I've also had two more gen med clinics. Yesterday's was particularly cool because Dr. K went in and did the appointment (without me), then sent me in to try my hand (observed by Dr. P). I asked my questions, did a limited physical exam and then explained what I thought it was and attempted to address the patients concerns and questions. Upon debrief with Dr. K and Dr. P... I got it RIGHT! I successfully diagnosed a real patient based only on information I gathered myself in real time. I have to admit, that felt really really good.

There was a second ego boost later in the day when the M4 on trauma rotation was quizzing the M3s on surgery about thoracotomy and pneumothorax. M3s didn't have a clue (and I knew all the answers, but kept my mouth shut because no one likes a show off). The current M3 class has been running around patting themselves on the back for their record-breaking board scores (their average was the highest at UofM ever), but they are being outdone by lowly little M2s in the trauma bay.