Tuesday, October 6, 2015

To be a good doctor, be a Pathfinder

Reactive medicine is often the worst type of medicine.

If you're not familiar with pathfinders, they're a group of soldiers who are often dropped into the combat zone to provide reconnaissance, and set up drop zones, landing sites, and act as the first eyes and ears of the following soldiers.

Pathfinders map and assess.  They act and signal.  A good doctor is a pathfinder.  If you even spend one day watching someone's vital signs drop to just above shock range, then they go into shock without you doing anything, that's just bad.  For the patient and your career.

If you consult for a problem and the consultant points out that there's something you didn't treat for which originated the consult in the first place, that's just bad.  For the patient and your career.

You don't want to be the guy who didn't treat infection X for days or be the guy who thought "Hmm I'll just watch these blood pressures drop.  They don't have a fever anyway,"  and then your "stable" patient is gone from your care and in the intensive care unit.

I've already seen this a ton and I'm a little unnerved.  Just because someone goes from 140/80 (for example; this isn't a real patient) to 103/65 doesn't mean they're going to remain "stable."

If you see that, what you need to be doing is start running differential diagnoses, culturing if you think it's indicated, getting the right labs, an echo if it's indicated, and so on.  You need to start thinking about the patient's renal and cardiac status as you think about fluid resuscitation and pressors.  Get the bedside cardiac echo.

Medicine is a lot like chess.  You have to think ahead or the patient loses.

Medicine is a lot like war.  You need to know what you're dealing with and find out the best approach.  If you fail, the enemy reinforces (septic shock occurs, arrythmia occurs, preventable code blue is called).

Family docs aren't the only ones who do preventive care.  It should happen all the time, everyday on every service.

Wednesday, September 30, 2015

patients my age

It's a different experience taking care of patients similar to your age.  Sometimes I feel more connected to them, because we have similar interests or there's just the bond that comes with being similar.

Some of the patients I'll develop a good rapport with and I can say things like "Stay strong, man." or "Hey how's it goin?" and be a little more casual with them.  I can tell those patients really like being spoken to casually and don't prefer so much to be called Mr. Patient X every morning.  We grew up in a generation where it's acceptable to be casual and anything overly formal feels artificial and not genuine.

I'll call patients similar to my age by their first name if they tell me they'd like that.  It makes things a little therapeutic for both of us, because everyone calls friends by their first name.  Is it a little more humanizing?  I don't know.  Does it affect my medical management?  Not one bit.

Make an effort to seek ways to connect with your patients in appropriate ways every chance you get.  Being a patient is a taxing experience,  and every meaningful connection and conversation you can have with a patient makes a big difference to them.

what a good med student should do

I wasnt't a med student that long ago but I wanted to touch on what I think makes a good med student on a team.

This is just what I think, other people might be more lenient or more strict than I am.

A good med student will:

1. Show up early or be on time.  If you're late, I think you don't really care that much for the rotation

2. Ask questions on rounds.  I sure as hell don't know everything about medicine
so I ask a lot of questions on rounds.  If you just follow us around and aren't seeing any patients yourself, at least join the dialogue and ask good questions.

3. Ask good, thought-provoking questions.  Dumb questions do exist and they waste time.  Don't ask "what's the dose for this?" when you can look it up.  You should ask something like "If we maxed the patient on medicine X, where would we go from there?"

4. Realize that patients do not remain stable.  If a patient looks like they're getting sicker, let us know.  We can go reasses with you, or you can reassess when we're busy with other things and we'll follow up with you right away.

5.  Find the time to look up information and share it with the team.  It would be great if you could search for articles in your spare time, evaluate them, and share them with us.

6.  Spend more time talking to patients.  Not just H&P stuff, but asking them how they're feeling, if they are still nauseated, if their pain is controlled, if they're still oozing from a site.

7.  Not know everything.  This is ok.  We won't think you're a failure if you can't name 254 reasons for abnormal lab value X. I personally don't care.  You're here to learn

8. Will respect patients.  I don't tolerate people calling patients names when we're in the team room or in the hallway.  I haven't reprimanded anyone for that yet, but I tell students just to not dehumanize patients.

9. Make a short presentation on a topic.  You'll be surprised with how much you learn going through primary sources and see how well the foundation for certain treatments holds

Tuesday, September 29, 2015

things not to do intern year #2

I've been learning by the mistakes of others and haven't myself done these things.  There's no names in this post.

1. Do not give an arbitrary dose of naloxone to someone who is reasonably arousable and able to protect their airway.  This happened and someone vomited uncontrollably and aspirated and went to the ICU.

2. Don't give antibiotics before you draw blood cultures

3. Know your SIRS and sepsis criteria.  A fever alone isn't sepsis, so don't keep writing that in your notes.

4.  Don't copy paste your notes.  You'll be busy and "Event X yesterday" keeps popping up and it'll look like that patient coded everyday.  Don't embarass yourself.

5.  Don't give antibiotics without knowing guidelines.

6.  Don't give fluids if you don't know someone's cardiac or renal status.  I've seen people with EFs of 20% get slammed with fluids then people backpedal with diuresis.

7.  Don't DRE a neutropenic patient

8.  Don't rely on hand sanitizer to keep you or your patients safe.  Wash your terrible gross hands

9.  Don't go by the ER's H&P.  I guess its so busy down there that things often go missed.

10.  Don't make your patient feel rushed during pre-rounding, but don't spend so much time with them that the service starts falling apart.  Sorry.

11. Don't take things personally.  

12.  Don't do something you feel is unsafe for a patient.  Ask for help.  It might seem cool for a while that you're independently doing things, but you should rather ask than be dangerous.  I saw a patient with a slightly elevated potassium get insulin and their BG tanked and they had to get called back into give them D50 amps.  Bad doctoring.

13. Don't think that you can diurese forever without AKI.  An increase in serum creatinine 0.3 or higher means you probably caused AKI.  If creatinine keeps going up you can hold diuretics if the patient is stable and asymptomatic.  No need for a nephrology consult unless there are things complicating the picture.

14.  Don't start feeds at a high rate if someone's on pressors.  The gut will go ischemic and that'll be your fault.  Be sure to know when to start feeds.  Discuss with our team.

15. Don't forget to provide sedation breaks for patients in the ICU when indicated.  It cuts down on sedation days.

16.  Don't forget to talk to family members.  If you have time, stop by again and answer questions/provide updates.

17.  Don't forget to to involve nurses.  They feel like order robots so give them updates, be nice to them, order multiple blood draws for testing at the same time instead of one lab test at this hour and anothe rone an hour later. 

Wednesday, September 23, 2015

intern year doesn't suck that much

being an intern isn't fun but it can be great if you're at a very collegiate program like me.  at other programs everyone dumps stuff on the intern, but at my program, so many people are so helpful and share the burden of tasks.

I try to teach the med student on my service as much as I can because they're paying to come in early and work while we get paid even for time we're not seeing patients.  You get to put in orders too!  It's pretty awesome being directly involved in patient care after being a med student so long.

If you're at a program where the intern gets dumped on, just try to get through it and then when you become an upper level help the intern out and make a positive change in your program and hope it catches on.

anyway, more reading to be done

Thursday, September 17, 2015

real talk from the ICU

A lot of people say the ICU is "fun."  Maybe because they get to do a lot of procedures, or because they "like unstable patients" and feel more "doctorly" managing them.  I think it's a grim place where many people only get worse.

There are a lot of people who get discharged from the ICU to a lower level of care, but those are mainly the "why does this person even have to be in the ICU?" types.  Those types though are usually stable and just need closer monitoring that they won't get on the floor.

The ICU is a hard place because patients can "crash" at any moment.  On a typical day, I've had patients go into respiratory failure in the middle of rounds so I'd run off to assess, treat, and get the stat intubation.  Other times I'll be sitting at a computer working and I get called because the patient's sheets are soaked with blood and they end up needing going to the OR immediately after fluid resuscitation and stabilization.

Other times I'm taking care of patients with multiple organ failure who got tipped in the wrong direction because of an infection they couldn't fight off given their age and failing organs.

I've never had to try to "save" people from death who already have established end-stage irreversible organ damage prior to the ICU and who are full code.  It's hard on me emotionally.  It's harder on the families and the patient.

We have so many people who have end-stage illnesses and despite our best efforts, despite myself doing nursing duties like recording vitals and managing pumps, they get worse.  The patients develop clots in bad places despite being on prophylaxis, they get a pneumonia despite me urging nurses to suction secretions and watching them like a hawk.  They get a new fever, or this infection doesn't get better and it turns out it's resistant to this antibiotic, or the infection gets disseminated, or they got hypovolemic and we resuscitated them but bacteria translocated and how they have an infection running around their entire body.

Or the patients "Code," sometimes 2+ times and we have to do CPR and run the code and give them epinephrine, amiodarone, etc, and people line up to relieve the previous person doing chest compressions.  Sometimes they die, sometimes we get spontaneous circulation back and they turn out okay but not the same as before..or they suffer massive brain damage because we couldn't get their pulse back for a long time and only their brainstem survived.

I don't know why the ICU is fun to people.  Most of what I see are very sick patients who are suffering, lackluster nursing, crying families, and stressed out doctors.

That's not to say I didn't have a majority of patients get discharged from the ICU, but the bad stuff seems to overshadow the good.  It's hard when you talk to patients and family and the patient is very sick with little chance of survival and they're still full code.  There's nothing wrong with choosing full code, it's just hard on us and families.

Many people think comfort care is "giving up" or "pulling the plug."  I don't think it's bad to pass away with your pain and dyspnea taken care of when medical intervention can't rescue you anymore. I want to pass away at home, comfortably, in my sleep, with my loved ones around, not in a hospital.

I encourage more families to have dialogues with their very ill loved ones about what their loved one really wants.  CPR doesn't always bring everyone back every time.  Coming in with multiple organ failure and ending up sicker in the ICU happens often.

I wish with my entire heart I could save everyone who came into my ICU.  I wish I could see them transform from skin and bones, I wish I could see them smile and see them strong enough to stand up and shake my hand and walk out of the unit.

I just can't always save people who already have failing organs and come in with shock or respiratory failure.  But I accept the challenge and put my entire heart and soul into it.  I talk to those patients like they're family or friends when I have time during the day.

I hold their hand before I leave the room.  I tell them I'm always around in the unit whenever they need me.  I tell them I'm watching their vitals constantly on the monitor at the nurse's station.  I explain procedures to them and personally tell them their new study/imaging findings.  I try to comfort them, I ask if they're scared or worried and I do my best to help them.

Sometimes those patients don't make it.  Sometimes it's me who calls time of death and says a few words to the family about how they're resting and with a God who loves them.

Losing patients crushes me.

It takes a special person to be an ICU physician.  I just couldn't do it as a career.

Wednesday, September 16, 2015

Med School Memories

I'm going to try to record a lot of memories of medical school before I forget them.

I remember how cheesy orientation was.  We went on a retreat to "build team spirit" or something and it was pretty boring.  I think most team building happens over drinks or in crises.  I prefer team building over drinks.

Anyway, I remember first year being exciting and stressful.  Mostly stressful.  I literally memorized textbooks of biochemistry, anatomy, physiology, pathophysiology, pathology, embryology, and pharmacology.  I'd study from 5am to 11pm on weekends, and I drank probably 6 cups of coffee a day.

I made some friends during first year, mostly kids who seemed to belong to a "cool" group of kids into music and art.  They were pretty laid back but I think closer with each other than with me for some reason.  I never really was into groups in med school because I felt like studying was less efficient for me and I never really craved attention or the need to be around someone all the time.

I noticed a lot of different coping mechanisms first year, among people and myself.  I buckled down and studied hard by myself, putting on my favourite music and making playlists with the occasional youtube break.

Some people clustered into groups that remained tight through basic sciences and you'd always see them posting photos of themselves hanging out on facebook.  Others never went to class and just viewed recorded online lectures and only showed up for exams.   They were sort of the med school ghosts.

Anatomy lab was my favourite, as challenging as it was to memorize all of these insertions/origins/actions of basically every component in the body down to which locations of the inner ear are potassium rich and literally microscopic details about the basilar membrane and cochlear hair cells.  I liked being in scrubs and using a scalpel to dissect through tissue, never forgetting my "teacher" was once someone living who donated their physical body for the education of young students who would one day touch lives and struggle with the toll of being in charge of saving someone's life.

First year was definitely stressful, especially around exam season.  I remember taking my favourite track jackets to wear in the study center because it was always noxiously cold.  I remember watching the sun rise from the student center and watching it set without ever really leaving because I had so much to study.  

I never did the crazy all nighter thing though, nor did I stay overnight in the library studying.  I did my best to take care of myself and I think that carried into clinical rotations.

I saw colleagues fail out of medical school, some of who were good friends of mine.  I saw people the next year but as underclassmen since they had to take leaves of absence for various reasons.  

First year was pretty memorable and a lot like high school in the sense you're around a relatively small group of people for much of the time.  I saw people date and break up and start sitting at opposite corners from each other in the auditorium for lecture.  I went on a few dates myself with girls a year ahead of me but it never really amounted to much.  I did most of my dating outside of medical school.

Being a medical student wasn't really impressive to anyone I dated, lol.  I was so busy for such long stretches of time that it was difficult to date anyway.  

Autumn was the best season to be a medical student since I found the cold and changes in foilage to be comforting.  It was a time to just really withdraw from the world at times and study and keep warm.

I did burn out pretty badly once, though.  I felt overwhelmed and almost dissintersted in biochemical pathways and having to do all these small group sessions that were pretty "low yield" just made me wish I could be catching up with all the studying I needed to do before my next exam.

I remember having so many meals on campus, too.  Pretty bad, bland stuff.  But I was close to family and had decent meals every once in a while.  I definitely got to know the restaurant scene as well, and kind of grew into a gentleman with more refined taste in food and drink.

You go through so much in medical school that you do spoil yourself a little every now and then, and I think that's normal.  It's a great morale boost to go out to eat here or drink this or go on a vacation somewhere.  

First year was a daily grind that always consisted of setting up camp in the study hall after lecture, but I almost miss it.  Going from a bookworm to someone who is keeping cirrhotic ESRD patients in septic shock alive is a really big change.  

The only thing I regret from my medical undergraduate education was so much emphasis on biochemistry and not a single lecture on fluid management and acid base balance on elderly patients with septic shock who have just finished a course of chemotherapy.

There's room for improvement in medical education.