Tuesday, August 28, 2012

Sleep deprivation and doctor's notes

I'm no stranger to being awake for a 24-30 hour straight shift, but last night the sleepy delirium hit me in the middle of writing my admission note. During these wakeful-sleep moments, my brain tends to move from relevant thoughts to far off tangents. If my hands are on a computer keyboard when that happens...well, you'll see:

59 yo M with history of IPF admitted with dyspnea
1. Dyspnea - not likely IPF flare as able to wean very quickly. Would get an ICU overflow bed
- CT chest to evaluate nodule seen on CXR
- Sputum, blood cultures
- continue O2
- PRN albuterol-ipratropium
- continue prednisone/albuoterl as a guest speker
- would also like to add rifaximine. 
2. Lower extremity swelling - inadequate dose of lasix vs hypotension. dkl;
- will give IV vanc at 116%
3. Cor Pulmonale - Will get RHC, orthostatics, and WBC count together day? 
4. SIADH - stable, serial BMP 
5. Compression fracture - will continue home medications for pain. 
FEN/GI - Will give patient 3 g 5 CHO diet, low Na 
Dispo - Hpatient iwth risk of rincreased infection to due low of be louie s

What is really scary is that I knew I was sleepy and was actually making "corrections" to my mistypes. I can only imagine what kind of plan I would have had if I hadn't edited it.

Needless to say, a fellow resident caught my note in the morning, and I rewrote the whole thing.

Saturday, October 02, 2010

Life on a cancer ward

Last month I was on the hematology service at the University Hospital. It is a service primarily composed of patients with leukemias, lymphomas, or a disease called multiple myeloma (a rather unique cancer of the blood). Very busy service, routinely with 18-20 patients to see each day and manage outside of new admissions and coordination of discharges. It's easy to let yourself get automated in such an environment: are the labs normal? Ok. Any fevers? Yes? Draw blood cultures and start antibiotics, lets move to the next patient.

Medicine is perhaps easiest when you know the problem and know the solution, and you see that the solution works. A great example would be a patient with an ear infection; I simply prescribe antibiotics in the clinic and they go home, 5 days later their ear is better. Medicine is far more difficult when death comes into play, or you have a therapy that doesn't work. Such is life on a cancer ward.

I have seen a number of my or my colleages' patients die. Often though the patient is either too incoherent thanks to numerous narcotics and sedatives to know, or too young to comprehend. In those cases death is discussed with family.

On a cancer ward, you have the opportunity to diagnose someone with something that will take their life, but it may not be today that they die. It may not even be this month. The patient may not even look sick, but instead of telling the family that this loved one will die of their disease you will have to tell the patient. You have to tell them knowing that they will have to come to grips with their own mortality and it may sadden them or scare them, and you will know that you brought this news. This I have found is the most challenging thing I have faced in medicine.

Death tends to be a difficult thing for physicians, even though we are far closer to it than the general public ever is. Perhaps it is because of what death is, that somehow it represents a failure. We are called to bring health to the sick, and are known for bringing people back from the brink of death. We, as a group, have a hard time acknowledging that no matter what other disease statistics exist that 1 out of every 1 patient of ours will die eventually. Of course that's not entirely true (we do know that people die), we simply hope it doesn't have to happen on our watch.

On the hematology service, many people were sent home on hospice. The mood for these kinds of discharges is very somber. There is a lot of sadness. There is a lot of fear you can feel from the patient and family. There's the sliver of hope that somehow a miracle will occur and the patient won't die, and it's not always the patient or their family who entertain such hopeful thinking either. "See you later," somehow seems offensive, "Goodbye," almost a sentence. Somehow though people who were dying or went onto hospice were glad to know the true prognosis of their condition, and many when they know and could feel the reality of their fate desired more than all to go home, spend whatever time left with family and in comfortable surroundings.

I am moved on now to a new rotation and see far less terminal illness (at least, far less patients so near to death) and it feels easier. I am sorry though that I maybe am not as comfortable with death as I thought, at the very least not speaking of a patient's future death as a near and real thing. This hopefully will change in time. I hope I do not get numb to the mortality of patients, but I hope I do not fear their passing so much that I hide the reality of it from them lest they have no chance to prepare.

Sunday, July 11, 2010

Learning Leadership

This past Thursday-Friday was the annual Internal Medicine Residency PGY-2 (means a second year resident) Leadership Retreat. At the retreat, we had several lectures, breakout discussion sessions, and role play practice in how to employ leadership skills that help foster a positive learning and working environment. The lecture and discussion series was led by facilitators who have been trained through the Stanford Faculty Development Center and utilizes their Clinical Teaching Program curriculum. The focus was for how we, as residents, can facilitate a positive learning environment for incoming interns and for medical students on the team. It also focused on how to set goals for an inpatient team, and how to best use your attending as a resource. Overall, it was a great retreat. Though many people think that some people are natural born leaders, I think many leadership qualities, if not most, can be learned and trained. Sometimes those who have had some kind of training or learning in how to be a leader are more effective.

Some of the titles of the sessions and lectures were: Learning climate, control of session, communication of goals, and feedback. I especially liked how as each session followed, the lessons from the prior sessions became utilized. An example was the role play I was involved in during the "Communication of goals" workshop. I had to correct an intern on the team and set goals to make the team more efficient and thorough. I found myself using many of the skills from "Control of session" to direct the conversation the way it needed to move.

Although we had mostly work-related lectures and discussion, there was time for some activities as well. A group of my fellow med-peds residents went canoeing and kayaking on the lake by the resort we were staying at. It was a lot of fun to get out and do some paddling. I rode a kayak and got quite an arm workout from the paddling across this huge lake. Later that night we had kareoke. Many of the faculty physicians, including my program director and the chairman of medicine, participated. One of the most hilarious moments came from seeing my program director sing Lady Gaga's "Poker Face" wearing a feather boa and pink wig. The med-peds girls submitted a song for us med-peds guys to sing that was secret until we went up to sing. We ended up singing "It's Raining Men". The kareoke ended with the whole room, faculty physicians and residents alike, singing Bohemian Rhapsody by Queen.

More lectures occured on Friday, but were more varied. We discussed our continuous quality improvement project requirement and how to apply to fellowships. There were a few smaller workshops, one of which was on thinking about how we think. The books "How Doctors Think" and "Blink" are now on my list to read. Soon though, after I finish one or two others I have already.

Saturday, June 26, 2010

Vacation and End of Intern Year

This week is a vacation week for me. A year ago I started my medical residency in internal medicine-pediatrics and since then it continues to be a whirlwind. In my program at Indiana University, we switch between working within the pediatrics department and internal medicine department every 4 months. This year I did 8 months of pediatrics, divided by a 4 month block of internal medicine. Since I am doing a program that actually combines two residencies, my "year" is 16 months long; I will complete 8 months on internal medicine and 8 months on pediatrics before I am officially an upper level resident.

This recent article in the L.A. Times blog highlights the current problem facing the U.S. healthcare system: spending. In most circles, the problem is usually blamed upon doctors and specialists, in a private setting, pushing expensive, sometimes unnecessary tests and procedures upon patients where they are not needed. It's portrayed as a pharmaceutical industry that spends way too much on drugs and then even more on physicians to prescribe those drugs. It is far less, if ever, portrayed as patients who abuse the system and the cost they afford the healthcare system. In the last month I have rotated through the ER of a very large private care hospital. I have seen some patients more than once in that same month. Sometimes I have seen patients who are supposed to have an upcoming appointment and can't wait any longer. Most of the time patients fail to have a primary doctor, and so come to the ER for any ill. This is despite the fact that my city, Indianapolis, has a multitude of safety net clinics that specialize to the care of uninsured (Wishard Advantage is by far an incredible, comprehensive health insurance program for the indigent in Marion County, where Indianapolis resides).

Many of the visits in the ER are non-acute, that is not life-threatening. Many could be managed in a clinic setting or local urgent care center. ER costs far exceed the costs of a clinic or urgent care visit, however, and when that patient is uninsured the cost must be absorbed by the hospital. Hospitals then need to compensate with charges elsewhere, to patients who can pay, in order to continue to act as a safety net. If there were no surplus in profits, then uninsured would never be able to find an ER to care for them.

How could this be fixed? Many patients I have seen in the ER come to the ER because of an inability to see their doctor on the day they are sick due to the clinic schedule. I can vouch for that in that I seldom see a patient who feels acutely ill in the clinic. Urgent care centers are few, and those that exist in places like Walgreens or CVS are not always run by physicians but nurse practitioners. Most are lacking in the ability to run basic labs or do x-rays in their facility (such as my own clinic, who sends all blood work out for analysis). One thought I have had regarding acute illness care is that clinics adopt a rotating urgent care schedule. A practice could have a section of patient rooms that would operate as walk-in or same-day appointments only, and physicians could rotate through staffing the same-day clinic instead of seeing scheduled patients. With the presence of a basic lab and perhaps ultrasound and x-ray machines with appropriate technician, a large majority of acute illness visits could be handled.

If you go to an ER, you can expect to be there on average a few hours, depending on how busy the ER is and how many patients there are sicker than you (ER's work via triage, or the practice of treating the sickest patients ahead of less ill patients, and secondly in the order in which patients arrive). If primary care clinics operated with an urgent care service as well, higher volumes could be seen by the clinic and with costs less than that of a full capability ER.

Just some initial thoughts on the health-care system and potential areas of reform. This would in fact require there to be higher numbers of primary care physicians. The always avoided 21% cut in Medicare payments still looms, and so long as it does primary care will likely see difficulties as more new doctors pursue specialties that will ensure they can pay off their student loans.

Sunday, March 07, 2010

The Sterile Field

In 1847, maternal mortality from childbirth in a Hungarian clinic was approximately 18%. A second clinic that offered maternity services had numbers much nearer to 2%. Women begged for admission to the second clinic in order to avoid puerperal fever, the name of the illness associated with such significant death rates. At the First Clinic, medical students and physicians routinely performed autopsies as well as patient services, including maternity services. At the Second Clinic, midwives did delivery and did not participate in any autopsies. Following the death of a colleague who became sick with puerperal fever after being stuck with an autopsy scalpel, a physician named Ignaz Semmelweis inferred that cadaveric particles must cause puerperal fever, and that students and physicians were transferring them to mothers after doing autopsies. After instituting the practice of handwashing in the First Clinic, the mortality dropped from 18.3% in April of 1847 to 1.9% in August that same year.

The results of Semmelweis' observations lead to the realization that it was bacteria, not cadaver particles, that caused puerperal fever. The far-reaching consequences were the development of the germ theory of disease, and the eventual wide-spread practice of using sterile technique in any invasive procedure in order to prevent serious infection. From an operating room to simple bedside procedures, doctors and nurses everywhere observe sterile technique, which involves sterilizing the patient's skin with antiseptic solution, then donning a sterile gown and gloves, and finally draping the patient with a sterile cloth to cover all non-sterile areas and leave exposed only the area to be worked on.

This "sterile field" is a means of a barrier to prevent infection. It isn't the only "sterile" field, though. In some ways, most every patient encounter is "sterile" to some degree. A doctor must always remember to keep the doctor-patient relationship professional, cordial, and appropriately distanced. For many doctors this may be hard, as most of us want to care for our patients. Many situations that patients end up in though require much much more than we can give them; patients with terminal illness may require emotional provisions that we cannot give without breaching what would be considered "professional", and patients with difficult social situations may require much more than professional advice and assistance. The old saying "give them an inch and they'll take a mile" rings loud and true with some particularly needy patients. It is unfortunate, and hard, but necessary.

Helping someone often involves avoiding getting into the same dirt that they are. Pulling someone out of a hole tends to involve keeping yourself out of the same pit. There is a fine line though, between being far too distanced from the care of the patient and far too involved in a patient's situation, to the detriment of your own personal life. To protect themselves, doctors tend to need to use their "sterile field" of a clinic office, an organized patient encounter with clear goals of therapy and their role in a patient's health, and avoiding trying to go farther than what their role dictates. It doesn't mean that a doctor should not go to great lengths for a patient, just to remember to keep the appropriate professional as well as mental and emotional relationships with patients.

Wednesday, January 27, 2010

Critical Thoughts

It has been much too long since posting an update. Now I am graduated from med school (officially Dr. Peppers!) and I am 7 months into my intern year in med-peds at Indiana University. I spent my first four months on pediatrics, and now am finishing my 3rd month of a four month stint in internal medicine. Currently, I am finishing my ICU rotation.

What I have learned about medicine in the ICU is that if you take care of a patient's basic physiology, that is their basic biological processes, they will either heal themselves or not. Those who get better tend to do so of their body's own accord. Medicine is simply a means of preventing the processes that are 'damaging' the body from continuing to spiral out of control to the point of causing death or further injury. It is incredible what the body can bounce back from after serious illness. It's also heartbreaking how impossible it is to reverse some irreversible damage, such as a massive stroke leading to a coma, or the prognosis after a major cardiac arrest leaves the brain permanently damaged after being starved of oxygen.

Also, I have learned that the skills in talking to patient families that have come in handy so much on peds come in handy daily in the ICU. In the frequent cases that patients are critically sick, on a ventilator, and not able to interact with us, we tend to interact primarily with the family members and treat them as the patient's proxy.

The work is interesting, and exciting, however the on-call shifts lasting 30 hours tend to go without a chance of rest even for a minute. I don't think I ever knew exhaustion could reach such depths.

Saturday, December 01, 2007

Surgical notes: Bleeding always stops eventually

It was Wednesday night last week that I had my first night of trauma call. Instead of my normal quota of one pager going off no less than once per day (usually with breaking news on our lecture schedule, but often to find my team or receive tasks), I was carrying a second: the trauma pager. It's not so much a pager to answer as it is an alert to begin making your way to the ER to admit an incoming trauma patient.

I paged the resident on call for trauma service, and gave him my own personal pager number as well in case he needed to reach me for anything else. That was at 5 pm. It was almost 6 pm when I was paged and informed there was an in-house patient headed to the OR with an upper GI bleed. The surgical team was informed I would be on my way to help out, and I was to head to suite 15. I hung up and left the lounge to head towards the OR.

I scrubbed before I walked into the OR suite, hat and mask in place as well, and was greeted by the scrub nurse who asked for my glove size as she gowned me, and once all was in place I stepped up beside the patient with the attending just as the incision was being made vertically down the abdominal wall. The abdomen was already beginning to look distended, and after cutting through the muscle fascia the small bowel swelled into view.

I realize most people have never seen the site of a human's intestines laid open, much less know the site of intestines that are swollen like a water balloon with blood, but that was the situation presenting to us. On top of the large amount of distended bowel to deal with, the abdominal cavity was a basin full of blood. Multiple suction tubes were prepped and inserted to drain the abdomen so that the anatomy could be visualized. As the resident and attending discussed the patient I learned he was having an upper GI bleed, somewhere around the duodenum (the first part of the small intestine just as you exit the stomach). After much of the blood in the abdomen was drained away, the surgeons cut through the stomach and duodenum in an attempt to find the bleed. Blood continued to pour from the bowel, and no definite site of bleeding (at least not in proportion to the amount of bleeding occuring) was found. Blood continued to pool in the abdomen faster than I was able to clear it with the suction tubes, and many times I had to resort to using my hands to scoop large preformed clot from the cavity.

Eventially the bleeding was enough of a problem with working that a vascular clamp was placed across the aorta, above the celiac trunk. For those who aren't familiar with anatomy, the celiac trunk is the first artery to come off the aorta after it enters the abdomen from the heart. The celiac trunk and every subsequent artery provides every organ and limb below the lungs with blood. Essentially, we cut off the blood to half his body.