Sunday, July 12, 2009

Some highlights of Third Year...

Peds (my first rotation): On the first day of this rotation, I was assigned to follow a pediatrician in the newborn unit and about 5 minutes after arriving, he was paged downstairs to the labor and delivery floor. A code had been called on a baby who just didn't want to breathe. It was this young couple's first child, a baby girl, and she had no complications whatsoever. Born naturally, the labor was a little rocky but nothing unusual. I struggled to keep up pace with the 70-year-old pediatrician (who is a mountaineer in his spare time) as he flew down the stairs and sprinted down the hall. We heard the shreaks, "my baby! my baby!" and the first person I saw was the husband, whose eyes met mine with the most expressionless, bewildered face I've ever seen. The pediatric nurse was thumping away on the baby's chest and another nurse was pumping the bag-valve mask as the baby lay prone, limp, and a dusky bluish purple, like the color of a fresh plum with some whitish goop (we call it "vernix") smeared all over. The pediatrician instantly whipped out his stethoscope, called a pause on CPR, and listened for a heartbeat. It was faint and slow, but steady. Ventilation was continued, but then the heartbeat was lost. Ten more people suddenly filled the room and I shrunk into the wall, wishing I could be invisible, but not wanting to leave. I was hiding behind the blue cart (the crash cart) and will never forget the trembling hands of a young OB nurse as she struggled to fill a syringe with epinephrine (adrenaline). It took her three or four tries to do one of the most common tasks - insert a needle into the tiny glass bottle and draw off the fluid. Meanwhile, the pediatric nurse deftly inserted an endotracheal breathing tube and hooked the baby up to ventilation. After the maximum dose of epinephrine, more CPR, and lots of shouting and frantic fumbling, the slow, steady heartbeat returned and everyone sighed in unison. But, it was too late. This baby's brain had already suffered irreversible brain damage and would later show absence of function on the EEG (no brain waves). The parents elected to withdraw care later that day.

For the rest of the day, a dark cloud hung over the newborn unit and no one dared crack a smile about anything. I learned quickly that OB is 98% joy, and 2% sheer panic. Of that 2%, some small portion of difficult births are bad outcomes. And of those bad outcomes, there is always a fraction that are in some part the result of poor decision-making. This burden must be borne by all, but the attending physician must take full responsibility for his treatment team. Nearly every physician, even the radiologist who overlooks a tumor on the chest X-ray, must be able to deal with his/her mistakes that mean the permanent harm or death of a patient, and realize that humans, by nature, are imperfect.

I only had three days of newborn peds. The rest of my 6-week pediatrics rotation was half inpatient, half outpatient, and lots of fun as I have always enjoyed being with and working with children. My first inpatient was a 6 year old boy who, while on a road trip across the US, caught E. coli from a roadside fast food joint. After a few days of diarrhea, he developed a fever and then bloody urine, and then stopped urinating altogether. It was our job, for his 3-week stay, to do our best to get his kidneys working again while doing dialysis in the meantime as they recovered. I read lots of papers on the latest treatments for HUS (Hemolytic uremic syndrome) from E. coli 0157:h7. From this, I will never forget the expressions of joy, the tears, and smiles from his mother's face the morning that he produced 70 ml (less than 1/4 cup) of smelly coke-colored urine. That was the beginning of his full recovery.

OB: I thoroughly enjoyed my two short weeks on labor and delivery. An emergency medicine resident was on with me and he had his fair share of deliveries and didn't mind letting me be first assistant. I delivered two babies all on my own - the first was with an attending who mistook me for the ER resident (I was all gowned up) and she just let me do the whole thing. During my two weeks, there were about 5 to 8 deliveries a day and a couple of C-sections a day. There were no bad outcomes this time. The most difficult aspect of childbirth for me as a medical student to take is actually watching, and hearing, a third-degree tear occur even as you're coaching the mother to push with all of her strength. I just can't imagine how painful that might be. It was a surprise for me to learn that most women endure some degree of tearing - after awhile you anticipate it as the baby always comes soon after, and it is a release of pressure that seems almost necessary in most women (hence the popularity of episiotomies).

The C-sections were my first surgical experience. There's nothing like watching the experienced surgeon extract a baby in distress. He shuts out all of the emotional drama, focuses in on the task at hand, and swiftly slices his way through the various layers with big, broad strokes of the scalpel. Everything is nicely tensioned by the expansion of pregnancy and falls to the side to expose the uterus, in which he makes a small incision, just enough to allow the amniotic fluid to gush forth like a fountain. He then inserts two index fingers and proceeds to rip it open with perhaps a grunt or two (yes, studies show blunt dissection, not sharp dissection, seems to work better for the hemorrhage-prone uterus) and then pushes on the upper abdomen sometimes with the help of extra hands, and pops the baby out in just minutes. However, the baby is of no concern to the OB doctor. He hands it off like a football to his running back and doesn't glance back, turning full attention to the mother's needs while the pediatrician attends to the baby.

Neuro: The single most notable event during neurology was the death of my first patient. I was following an octogenarian female who had a traumatic intraparenchymal hemorrhage (bleeding in her brain from a fall) that would probably kill her without surgery. Her brain was beginning to swell from the trauma and bleeding, and she wasn't quite herself. She had lost vision entirely in one eye and had partial loss in the other eye. Her family talked with her at length and agreed to move forward with the surgery, knowing there would be significant risks involved. During the surgery, I will never forget the surgeons' conversations. It all sounded so cold, so blunt, as they joked about their recent low success rate with octogenarians. Even as they were evacuating the clotted blood from a hole in the back of her head, they doubted she would ever wake up and all of this would be for naught. They were right. Although I did meet a few neurosurgeons who were practically as noble as saints, the majority struck me as insensitive pompous jerks. Perhaps this is just something that occurs in our neurosurgery department?

Psych: I worked the Psychiatry Consult service and found this rotation to be especially challenging. Rather than focusing on the cold hard science of psychiatry, I found myself becoming emotionally involved with my patients and having a difficult time believing that what we were doing was meeting the true needs of my patients. I saw a lot of emptiness, loneliness, heartache, and despair, and I wanted to fill that emptiness with a message about Jesus Christ. Being a young medical student, though, with my career in jeopardy, I found it nearly impossible to initiate any sort of religious discussion. It seems that such topics are particularly taboo on the psychiatry service. I must say, there seemed to be almost a dichotomy of personalities among the residents. Some were consistently and genuinely compassionate, while others seemed to be quite the opposite. No doubt, I heard more swearing and saw more unprofessional behavior while on the psychiatry service than any other thus far - although this may just be an isolated occurrence.

Primary Care: Our medical school is famous for promoting Primary Care. We have one of the highest percentage of students choosing primary care specialties nationwide. Our country sorely needs more good primary care doctors - I did seriously consider pediatrics for awhile, but I found the field of radiology to be much more intriguing and fitting. Anyway, this rotation was a nice break. I had Fridays off and my days were typically 8am to 4-5pm or so. My wife at times wanted me to consider primary care, perhaps thinking our career life would reflect the med student life during this rotation.

I learned that the American culture and way of life creates many scenarios that lead to chronic diseases such as diabetes, heart disease, stroke, and cancers, and that the primary care physician is often powerless when it comes to changing a patient's lifestyle in order to get them back on track toward health and longevity. I learned that, despite our advances in understanding of disease processes and prevention, we still cannot get much of our population to follow even the most basic advice (e.g. colonoscopy starting at age 50). Primary care just wasn't for me. I felt like most of our time was consumed by the tasks commonly relegated to the social worker - getting a patient into a nursing home who can no longer be cared for adequately by the family; helping a patient get access to meals on wheels and other senior services; helping a parent understand why their teenage daughter needs to have some time alone with the doctor; dealing with drug seekers whose real needs are social support and home health visits.

The family practice doctor whom I shadowed was an older female - about my mother's age - whose patient population was skewed toward her own type. From day one, she assigned me the task of pelvic exams and pap smears on all women who would agree to subject themselves to my inferior exam skills. This is one thing I was never eager to learn or do especially on the younger women, and although I thought I became quite proficient after two months, there were always those women whose cervix just seemed to evade and shy away from my cold metal speculum and shaky hands, and I'd have to give up and turn to the attending for help. My favorite by far, as always, was working with the children. It seems that I have a natural ability to understand a child's fears, misconceptions, and pains.

Medicine: The internal medicine rotation reinforces most of our first two years of bookwork - pharmacology, pathophysiology, microbiology, epidemiology, genetics, biochemistry, physiology, and other subjects. While primary care touched fairly lightly on most of these subjects, internal medicine delves deep into all of them and requires an extraordinary effort to re-learn, re-memorize, and master the basic concepts of patient management. The shelf exam in this rotation is great preparation for the USMLE Step 2 (United States Medical Licensing Exam). I read several different textbooks and carried three or four different handbooks, and read or skimmed through hundreds of articles online in search of appropriate treatment plans for patients according to the latest research available.

I was assigned 2-4 patients at a time, many of which were liver failure (transplant candidate) patients due to our busy transplant service. I would occasionally get what we call a "rock" of a patient (because they don't move, ever, and they're nearly impossible to get out of the hospital). One such patient, "Mrs. Rogers" was my most challenging patient. A 65 year old grandmother, she went to her local ER in a small outlying town with acute abdominal pain. Morbidly obese but otherwise "healthy," the doctors couldn't figure out what was going on but decided to do exploratory surgery based on the fact that she had a cholecystectomy (gall bladder removed) several decades ago, and they thought she might have scar tissue (adhesions) from that, causing an intestinal obstruction. A few insignificant adhesions were found, her normal appendix was removed, and she was sewn back up. Unfortunately, this was the beginning of her problems. Several days later, her abdominal pain worsened and she spiked a high fever - she developed intra-abdominal abscesses as a result of her exploratory surgery and spiraled down into sepsis; surgery was done to clean out the abscesses and she had a hypotensive (low blood-pressure) crisis during surgery - her kidneys didn't get enough blood and they died of hypoxia.

She eventually stabilized in the ICU and, once stable enough, was life-flighted to our ICU. Our interventional radiology team placed four drains into her abdomen to help remove the abscesses that remained, and she battled a minor case of pneumonia among other things. About a month after arrival, she finally arrived on my general medicine floor and was assigned to me. She had several drains which continued to leak purulent yellow fluid, and despite a BMI of 45, she was starving and weak, and had lost much of her muscle mass to her sickness. Mrs. Rogers didn't want anything to do with me, hated being woken up so early for morning rounds, and refused to take part in our treatment plan. Worst of all, she refused to eat ANYTHING. I recommended a psych consult - they recommended antidepressants. We had physical therapy, occupational therapy, even speech therapy, a social worker, and a chaplain. Nothing could get this lady to exercise, eat, or open up to us. I would come back in the afternoon when I had more time and she would often ask if I had brought a gun so she could shoot herself and get it over with. The best thing I did was discover that she had two horses, whose names I wrote down and asked about frequently. This seemed to help, a little. She wanted nothing to do with religion or prayer. Eventually, I made a recommendation that we often used during my psych rotation - we began giving her small doses of Ritalin (a stimulant used for ADHD and controversially for weight loss), hoping it would provide her enough energy to engage with the physical therapists and perhaps work up an appetite. I never did see her get out of bed, and the only time she sat up was when three of us strained to lift her to a sitting position for the sake of a proper lung exam (which, honestly, was nearly impossible through the thick folds of adipose tissue). After a few weeks on our service, we determined that her abscesses were sufficiently resolved, pulled her drains, and sent her to a long-term care facility for rehabilitation.

One of my favorite patients was a young 45-year-old Native American man who drove himself and his girlfriend from a small town several hours away to get better treatment at our VA. Despite his circumstances, he was the nicest and most appreciative patient I have ever encountered. He was thrilled to have the privilege of being visited by a student doctor, and even more thrilled when I announced that I would present his case at our weekly conference. He arrived with the longest list of symptoms I had ever recorded - we have a form for "review of systems" and he had some sort of complaint involving 90% of his bodily systems: leg swelling, itchy skin, bruising, dizziness, shortness of breath, chest pains, abdominal pain, bloating, constipation, change in stool caliber, burning with urination, general weakness, insomnia, restlessness, muscle twitching, generalized muscle pain, and a recent onset cough. I was convinced he had something bad - perhaps an advanced case of leukemia due to the 7 months of weakness and bruising. We have this very rudimentary way of distinguishing patients - sick or not sick - and this guy looked sick. He wore sweats and a t-shirt and his hair was pulled back into a long, thick, shiny black braid. He reeked of cigarette smoke and who knows what else, and his clothes were blood-stained and tattered. He had what appeared to be ascites, or free fluid, in his abdomen making him look pregnant, and skinny, wasted extremities more typical of a 90-year-old. He had sunken eyes, bruises on his face, and multiple deep, dark bruises on all extremities. He had fresh excoriations (scratches) oozing dark red blood - and yet he continued to scratch at them, collecting dried blood under his smoke-stained fingernails. His physical exam was not too helpful otherwise, except that I was most intrigued that there were no lung sounds at all from the left half of his chest. He also had hypertension - which he said was new. Interesting!

Our first challenge was to correct the Native American man's potassium. It hovered just above 2 despite our best efforts - oral supplements, bag after bag, and yet it would come above 3, then drop right back down. Then we focused on managing his pain appropriately with morphine injections, and providing benadryl to hopefully help with the persistent itching. The chest x-ray finally came back and revealed a 7cm x 7cm mass in the left lung (no wonder I couldn't hear anything!) which appeared consistent with cancer. Here's where this case gets interesting - I had it all to myself since the intern and others were busy with new patients, so I read about the lung cancers that appear centrally. I read about small cell lung cancer and decided that, based on the rapidity of his symptom development, it had a good chance of being small cell - the most aggressive type. Trying to tie it all together, I considered the possibility of an ectopic hormone causing his other symptoms and, the more I read, the more I realized that the picture fit with ectopic ACTH syndrome, which is exceedingly rare. In other words, his lung cancer was producing a hormone normally produced by the hypothalamus that plays the role of stimulating the adrenal glands to produce cortisol, a stress hormone, our natural steroid. His body was being overloaded with steroids, causing all sorts of metabolic and hematologic derangements. This accounted for the low potassium, the new high blood pressure, the itching, muscle aches, and bruising.

Upon discovering these correlations, I excitedly called the attending physician and he gave me the awful task of bearing the bad news - the diagnosis of terminal lung cancer at an advanced stage - to the family. All this business of ectopic ACTH syndrome sounded very exciting to him as well, although he remained skeptical. He did allow me to order the test for it, which came back positive. Bearing the bad news was an excellent experience for my learning. I used all of the techniques we were taught and, although they had questions I couldn't answer, it went well. Since the cancer was so advanced and the chances of living longer than 3-6 months were very very slim even with the best treatments, he decided to choose palliative care (relieve the pain but allow the cancer to take its course) which is exactly what I would have done if it were me.

Surgery: I thoroughly enjoyed my time with the trauma surgery team to which I was assigned. Treating victims of high-speed car accidents, falls, horse-riding injuries, and work accidents required a little bit of quick thinking followed by a lot of watchful waiting. Most patients very predictably improved and left the hospital a few days after arrival. We'd get hammered with high numbers of new patients through the weekend, then they'd slowly taper off until Friday evening around 10pm, and then it would all start up again. It was nice to treat patients whose bodies were young and responsive to injury. Most were grateful for their care, felt lucky to be alive, and cooperative with treatment.

One of my most memorable patients was a man who shot himself through the head "on accident" and survived with nearly full cerebral function. Due to damage to his frontal cortex, however, he seemed to be somewhat disinhibited and seemed quite frank and open about everything. He would simply speak his mind no matter who it might offend. He reminded me of the case of Phineas Gage who survived a freakish accident in which a 3-foot-long 13-pound iron tamping rod speared his head, entering the right cheek and exiting the top of his head. This man shot the bullet through one temple and it exited the other temple, blowing out one of his eyeballs but otherwise causing little neurological dysfunction. He was expected to make a good recovery and possibly return to work. We treated him in the ER trauma bay but then turned him over to the neurosurgeons.

As part of trauma surgery, I also spent a week in the burn unit. The art and science of skin grafting became my subject of study each evening. Burn surgery is a very messy process. We always wore long booties to protect our shoes from the cascade of blood and skin that was sure to follow. The first order of business in a burn surgery is to remove all dead tissue. Using something similar to a cheese grater, one shaves away whatever looks dead - hopefully just the outer layers of skin, but sometimes all the way through the skin and down into the subcutaneous fat and muscle below. The result is what looks like a skinned arm, or leg, or back, or face. Then, we would shave off a paper-thin slice of healthy skin often from the thigh, send it through a meshing device, then stretch it out and place it over the denuded flesh to seed new skin growth. The graft is stapled in place on the edges and sometimes glued in place using an incredibly expensive fibroblast-stimulating collagen-based spray-on glue. It is an art to get the pieces of skin graft to fit on just right, trimming them to size and using the extra trimmings if possible. The big challenges in patient management are pain control, fluid replacement (it all leaks out of the burns onto their bandages, bedsheets, and gowns), infection control, and physical therapy (to prevent scar tissue from freezing joints in place). It's a constant battle, and if the patient is "on board" and in good spirits, things go so much better. It's amazing what a difference it makes when a burn patient has the will and determination to get better and get back into life!


Edith said...

Very interesting. I was glued to this post, I love reading about your experiences. The first baby story made me teary.

Edith said...

2nd half just as interesting as the first. Thanks for sharing.