Sunday, January 31, 2016

WILTIMS #422-6: End of January catch-up post

Tuesday was a good day. As I assume is the case with most jobs (not that this is quite my job, yet), most days are OK, some suck, and a precious few validate all the work I do the rest of the time. On this medicine rotation I've had a surprising amount of moments that remind me why I love medicine (the royal medicine, not just internal medicine). Tuesday just had a few more than normal and it felt nice.

I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!

Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).

Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.

MondayIL: BIBEMS is an acronym for brought in by emergency medical services.

TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.

WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.

ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.

FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:

If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.

*Patient details changed for anonymity*

Saturday, January 23, 2016

WILTIMS #419-421: Living on the cliff

WednesdayIL: A CADD pump is like a PCA at home. So, PCA (or patient controlled analgesia) is a way of giving pain meds to patients in a hospital where, instead of having to request a dose of medication from a nurse, the patient has a button they can press every so often to give themselves a dose of IV pain medication. There are safety measures so that a patient can't overdose, but studies have shown that patients actually use less pain medication when they have control than when nursing does. Anyways, CADD (or computerized ambulatory drug delivery) is an easier to use system that can be used outside the hospital, when appropriate.

ThursdayIL: Palliative care shouldn't exist. Let me explain. A good definition by the Center to Advance Palliative Care is "[palliative care] focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family." Wait...? Isn't that what all of the medical field should be doing anyways?

On Thursday my classmates and I took a field trip to Calvary Hospice Hospital in the Bronx, the only exclusively palliative care hospital in the country. It's a strange place (but again, it shouldn't be). The average length of stay is just over 20 days and 43% of the patients pass away in the first 9 days of after being admitted. But once you see how they take care of the patients, you realize it's not depressing. These are good deaths or, at least, far better deaths than these patients would have gotten in an ICU or even at home.

Most hospice care happens at home which is usually better for everyone, but for some patients appropriate comfort measures really require acute nursing care. One woman we met was doing fairly well with her terminal breast cancer, but only because nurses and wound care teams were taking care of draining the excess fluid building up around her lungs and in her abdomen. This type of patient would be in agony (or already dead) at home.

The patients at Calvary are treated well. Pain management is addressed immediately. The doctors do not shy away from giving high doses of heavy-hitting narcotics - whatever it takes to keep the patient comfortable. Of course, this is adjusted for each patient; some people are really bothered by the loopiness that comes with some pain meds and may prefer to feel some pain to losing some cognition. But in this day and age, no one deserves to die in uncontrolled pain.

Another big selling point for this hospital is how clean it is. First and foremost, the patients are clean - not something to take for granted when you have 200 elderly bedridden patients who may be incontinent or have non-healing wounds. On the day of admission every patient gets a 2-person assisted head to toe spongebath that can take hours. And everyone and everything is kept clean from there on. I've been in many hospitals and I have never seen such well maintained and meticulously scrubbed hallways. There is also no clutter from disused medical equipment and no chaotic noise. Nurses, doctors and other staff talk quietly rather than screaming over the beeps and pings of equipment alarms. And those alarms are responded to quickly. Especially compared to the crazy hospital I'm working at normally, this place was serenely peaceful.

But my biggest takeaway from the day was that this shouldn't need to exist. It makes sense that NYC could support a full hospital for acute hospice care, but every medium-sized hospital should have unit like this. Or, better yet, patients should be able to be treated like this on any normal unit in a hospital. There is no special technology that these patients require. There is nothing that actually qualifies these doctors and staff to be compassionate, clinically competent providers any more than any other medical staff.

The whole subspecialty of palliative care arose, not because we needed people with special training to do those jobs, but because regular doctors have a longstanding inability to do theirs. I wish every medical and nursing student could visit a place like Calvary, so that someday places like Calvary won't be noteworthy at all.

FridayIL: Blood can keep showing up in stool (as detected by fecal occult blood tests) for up to a week after the source of bleeding has stopped.

[I'm sorry that after such a nuanced middle post, the last one was a one-liner about poop, but such is medicine.]

[[Also, incase you were wondering about the title of this post, I totally forgot to explain it. So here you go: People dying of chronic conditions such as cancer often have a long slow decline for a while and then suddenly, over the course of hours or days, the trajectory of their health falls off a cliff. While doing rounds with one of the doctors at Calvary, I kept thinking of how hard it must be adapting to caring for patients just before and during that unpredictable decline. The patient you admit is chugging along. Obviously not doing well, but usually not doing dramatically worse than a day or week prior. You never know which day you will come into work to find out that a particular patient has been put on critical status (~24-48hrs until likely death) - to find they've gone over the cliff. It must be emotionally taxing living on that border in so many people's journey to death.]]

Tuesday, January 19, 2016

WILTIMS #416-8: Random fact grabbag

ThursdayIL: Jaundice is first seen at the top of the eye due to that part of the sclera being most hidden from bilirubin-destroying sunlight.

Charcot's triad consists of fever, jaundice, and RUQ (right upper quadrant) pain. Reynolds' pentad consists of the triad plus, hypotension and altered mental status. The triad and the pentad are used to diagnose ascending cholangitis, with the latter being for diagnosing a worsening is the condition.

FridayIL: Clindamycin is the best antibiotic for necrotizing fasciitis because it is both bactericidal (it kills bacteria rather than just preventing their growth) and binds to the toxin that damages the tissue.

In the early stages of diagnosing a patient who might have cancer, try to delicately find out the patient's experience with cancer up to this point. If they do turn out to have cancer, you can better tailor the conversation by knowing if, for example, they have a friend who managed treatment well, or lost a family member who died in pain, or know nothing other than cancer is scary.

TIL: Systemic inflammatory response syndrome (SIRS) is the broader term for the syndrome of sepsis, with or without an infectious source (sepsis is specifically infectious SIRS (confusingly, non-infectious SIRS is just SIRS)).

Wednesday, January 13, 2016

WILTIMS #415: It's-a me, Dr. Mario! Hello!

I was the hero of the 6th floor yesterday. No, I didn't save a life or medically help anyone in any appreciable way. But I did turn off a toilet.

My resident and I were sitting in the nurses station when we hear a cacophony of voices and swooshing noises come down the hall. Apparently the toilet in one of the 4-patient ward-style rooms had become jammed in flush mode. The mighty little toilet was swirling like the whirlpool at the end of The Little Mermaid. Water sloshing all over the floor, threatening to flood the small bathroom and spill toilet water into the patients' room.

The maintenance people had been called but weren't coming fast enough. Nurses and techs had strewn various linen across the floor to hold back the tide. And a half dozen members of the nursing staff were yelling at no one in particular that this was unacceptable, dangerous, and meant they would have to move the patients to other beds that we simple didn't have to spare.

I was sitting there with the doctors who all had expressions of, "That sounds like a problem, but not my problem." Being on call for the evening, I had already finished my daily work and was waiting for a new patient to arrive. Loving chaos, as I do, I decided to investigate this toilet-pool of death. Turns out the nurses were exaggerating a bit. The water was indeed swirling Ursula-with-a-trident style, but very little water was accumulating on the floor. The noise was impressive though.

Giving the toilet a good look, I quickly recognized it as the same model that we had at the movie theater I worked at for 5ish years. All I needed was a screwdriver... like the one on my key-chain-sized multi-tool. It took just a few turns of a hidden screw for the water and noise to stop. Walking out of the suddenly silent bathroom, I was looked at like a wizard as I calmly said that I had stopped the toilet.

Me: "I stopped the toilet. It needs to be turned on again, but at least it's not flushing anymore."
Nurse: "You what? How?"
Me: "I just used a screw driver to turn it off?"
Nurse: "Where'd you get a screw driver?"
Me: "My pocket."
Nurse: "Wha...Who are you?" [looks at my name on my white coat]
Me: "A medical student?" I say apprehensively.
Nurse: "Christopher? Well get in here for a selfie; I need to send this to some people."
Me: "Uh, ok?" [smiles in celebratory selfie with two nurses and a PCA... for some reason?]

TIL: The functional reach test is a way to assess balance in elderly patients. You have the person stand straight up with their arm outstretched and then reach as far forward as possible before they feel unsteady. A normal result is six or more inches.

A quick way to tell if a dialysis fistula is still patent is by placing your hand over the radial artery near the fistula. If you feel vibrations, it's good. If you just feel a normal pulse, it's probably no longer connecting.

Tuesday, January 12, 2016

WILTIMS #413-14: A systemic problem

One of the more nebulous concepts I've learned this year is the interplay between correctional facilities, law enforcement, psychiatry, and medicine. The patients that have experience with the first two likely have a prickly relationship with the latter. The rule with the last three is that they will give you the benefit of the doubt if you're nice and don't heavily abuse any one part of the system. Of course biases exist, as studies (and experience) have shown over and over again. If your community's criminal or indigent population are socioeconomically distinct from the people taking care if them, they fare worse in the system.

Yesterday my medical team got a patient that had been spurned by the other three parts of the network. He was put in jail for drug charges, treated for opioid dependency with methadone while in jail and then released without any attempt to taper the medication or set him up with a rehab facility. In an attempt to get a fix, he immediately did IV heroin for several days while living on the street. Realizing he needed help, he came to our psychiatric ER looking for help detoxing. He was released a few hours later because there weren't enough beds to admit him for detox. He was given a MetroCard and directions to rehab shelters with instructions to go to an ER if he started showing any of the dangerous symptoms of detox.

Six minutes later he checked into our medical ER. At this point he complains of some vague detox symptoms and, oddly enough, pain in his finger. Over a month ago in prison, he had cut his hand. The wound had never healed and now was deep into the joint. Sadly, he probably should have been just bandaged up and sent on his way if one ER doctor hadn't heard a heart murmur when listening to the guy's chest. We never heard the murmur again, but it was enough to get him a bed for the night as we worked-up an unlikely, but potentially serious diagnosis of ok infective endocarditis.

I find it interesting and terrifying that these entities that are meant to help people can be so temperamental. One moment, a patient is our charge to be defended by the system when the next they are a burden to be pushed to the next sap that has to take them. People who need psychiatric treatment are arrested, in jail they are kept from the psychiatric and medical treatment they need, then they are released without any hope of recovering or surviving on their own and end up either in an ER or on the way back to jail. Don't get me wrong; sometimes the system does work. But in my very short experience in medicine, I've already seen it fail more times than should be allowed.

The benevolent connection between all four of the previously mentioned groups (corrections, police, psych and med) is social work. These are the only people that seem to bridge the gaps in this societal support system. They are also frequently the only people who help the patients navigate the time between the four services.

YesterdayIL: The frog-leg test is a way to test for asterixis (flapping movements indicative of a brain infection) when the patient is unconscious. 

TIL: For a P wave to be a P wave it must come from the SA node.

Cardiac pain is midline and lasts 2-20 minutes NOT seconds or hours.

Heart pain can cause a patient to tense their chest muscles to the point where they are sore. This is good to remember because a reproducible pain usually rules out heart problems, but the muscle sprain can be reproducible even after the heart pain has subsided.

Friday, January 8, 2016

WILTIMS #411-12: Where is everybody?

My team at the hospital is weird because our unit doesn't exist. The 7A team is on the seventh floor in the A wing, the 9B team is on the ninth floor in the B wing. My 8D team... has no physical location. There is no D wing. This means that our patients are scattered to the wind in a half-dozen other units, and frequently so is each member of my team. Group text messaging has never been more useful, as we run between the various floors in search of each other.*

YesterdayIL: 85% of patients who achieve full remission from acute myeloblastic leukemia (AML) will have a recurrence. The problem with this disease is that chemo targets rapidly dividing cells and some AML cancer cells revert to a state of quiescence where they essentially go to sleep. The chemo kills all the active cancer cells but some of these sleeping cells wake up eventually, growing into full blown cancer again.

Also, somewhat counterintuitively, large volume diarrhea is likely coming from a defect in the small intestine. The small intestine normally absorbs about seven of the nine liters of fluid that flow through the GI tract every day. The large intestine only absorbs most of the remaining two. So if five liters of watery diarrhea are coming out, then it must be a small intestine problem, because the large intestine never even sees that much fluid (and can only handle about 2 liters maximum).

If a patient reports coughing up "a cup" of mucus in the morning, think either bronchiectasis or a lung abscess. Bronchiectasis is when the respiratory tree gets all stretched out and mucous can build-up in the enlarged passageways. A typical patient that may have an abscess is an alcoholic who vomits up some food, breaths it into their lungs (aspiration), and then the gut bacteria start multipying and eating away at the lung walls.

TIL: Spondylosis vs. spondylolysis vs spondylolisthesis. -sis: degeneration of the discs of the spinal column; -lysis: degeneration of the spinal bones themselves; -listhesis: slippage of one spinal bone forward onto the one below it.

*Floor numbers have been changed to make it harder to deduce anything about my patients incase any of my readers are creepy patient sleuths.

Wednesday, January 6, 2016

WILTIMS #409-10: Medicine orientations

Preemptive clarification: This is the start of my internal medicine clerkship. In the medical field it is common to abbreviate internal medicine to IM or just medicine. The latter can be quite confusing. "What are you studying right now?" "Medicine." "Well, obviously, but what field?" "Medicine!" "And who's on second?"

You have been warned.

The past two days have been orientations to the medicine clerkship and the procedures at my hospital, respectively. Yesterday, we also had a couple lectures that were surprisingly interesting (to me, at least). One was a pretty straight forward affair about acid-base dysfunctions as taught by a well-spoken nephrologist (kidney doctor). The other was a two-hour whirlwind tour of the history of translational research. That is the step in medical research where an idea that showed promise in the basic science lab is tested on tissues or animals to see if it does enough to warrant clinical trials.

Today we had a quick orientation before being introduced to our inpatient team. We were all rather anxious at this point because your team can make or break your rotation. Turns out, I didn't get much time at this point to discover the coolness of my team (and the are cool), because we needed to see a patient immediately. She was transferring from another unit and we wanted to interview her to get an idea of what she understood about her situation. As it happened, she didn't know she has a large mass that very well might kill her... soon. It was a rough reminder that medicine doesn't start slow because we need a warm up.

YesterdayIL: Alzheimer's sucks to do research on. Of the two findings from autopsies that have been noticeable for the 100 years since Dr. Alzheimer differentiated this dementia, we have probably been putting all of our efforts into the wrong one. And even if the drugs we make work, we can't find good animal models for Alzheimer's. Then, if you make it to clinical trials, you can't tell if it's working or hurting because the super-sick patients that qualify for early trials are too demented to give you feedback.

TIL: Prescribing iron for a patient with iron deficiency anemia when the patient is on a PPI (proton pump inhibitor (drug that stops stomach acid production (e.g. Prilosec))) doesn't really help because the iron needs acid to be reduced to Fe3+ instead of Fe2+ to be transported into intestinal cells from the GI lumen.

Tuesday, January 5, 2016

WILTIMS #408: Intersession

Today was a weird day for a couple reasons. First, the entire third-year class was back together. Normally we are scattered to the winds, at hospitals in five boroughs, a half-dozen counties, and three states, and learning nearly every field of medicine. We are all between clerkships and all halfway through the year - hence the impressive sounding title for the day: "Intersession 2016".

Today was also weird because the subject matter was surprisingly philosophical. We started the day learning about the cost of medical care and how we tend to order far more tests than are actually useful (even if they weren't stupidly expensive). Often tests are ordered, just because that's what is expected, as was poiniently displayed in this clip from the show Scrubs:

Next we were lectured on health care policy by our dean of medicine, who expanded on his talk from our third-year orientation. Lastly, the driest speakers of the day taught us about the hospital policies in place to deal with and prevent medical errors. It was sad that the latter presentation was so lackluster given its importance, but I guess they all can't be winners.

Word of the Day: Anti-mentor - (n.) a person who through example shows you how NOT to act.

TIL: The cost of medical procedures is really stupid and seemingly arbitrary. CT $1000: Really? MRI $2000: Sure, I guess? Echo (cardiac ultrasound) $1500: Wait, what? Why?!

Please don't judge doctors too harshly for the cost of the things they order - we rarely have any say in it. In a world of finite resources, cost should be part of what we weigh into our decisions, but often physicians simply don't take money into consideration - not that their actual justification is necessarily good either.