Friday, November 6, 2015

the time I caught a hidden stroke

I was covering two different units, working with a lot of critically ill patients requiring sedation for trauma and illness.  I was getting a page every 5 minutes from nursing, 95% stuff that could be put off until the next shift..

I kept assessing an unstable, sick patient with a bad head injury while getting hammer paged and running around the different units dealing with half a dozen cases of refractory septic shock, coagulopathic surgery patients with low EFs..and then a nurse tells me that the patient with the head injury vomited.

I run, I go do a neuro exam, I think for a second.  The neuro exam is stone cold stable from previous multiple exams..but the patient vomited, this is new and there's a high chance of increased intracranial pressure.

I order the stat head CT and call neurosurgery stat.

There's a hemorrhage in the brain and the neurosurgeons rush the patient to the operating room for a stat crani.

I managed to save someone's brain because of vomit.

Monday, November 2, 2015

death, dying, and being an intern

I've had the "worse" months of intern year frontloaded and I can finally see the sun rising over the horizon.  I've had way too many goals of care discussions with families that are really emotional for everyone involved and that's been exhausting for everone.

I've had so many patients who have their prognosis described to them objectively by no less than 3 teams of experts from different specialties and the patient and family still want all heroic measures taken.

Many times the patient gets so sick and requiring so much medicine that they can't make decisions on their own, or their so elderly with severe dementia.  I've seen family members decide that it's somehow better for that family member to get a tracheostomy so they can stay connected to a ventilator and stay "living" when that patient can't even interact with them anymore.

I do my best by explaining what "full code" means to families and patients, and how it isn't a magic intervention without side effects like anoxic brain injury or becoming dialysis dependent from circulatory shock.  I'm also a little disappointed by neurology teams who have given families unrealistic prognoses.

I tell people CPR breaks ribs, can cause pneumothoraces, patients end up requiring ventilator support and sedation and dialysis, all because their body is too weak to run it's own life supporting processes.

I've seen way too many people die on ventilators in the middle of the night when their families aren't around.

I can tell you I don't want a tracheostomy and I don't want to be full code if I'm in my 80s with an incurable illness.  I want a good quality of my life for the remainder of my life.  At home.  With family.

Not in some dark hospital coding overnight, sedated on a ventilator with people lining up to crush my chest with chest compressions and then surgery getting paged to throw a chest tube in me and dying unable to interact with the world.

Life is a warm and beautiful thing.  There's nothing wrong with hospice or comfort care and passing away at your home.

Tuesday, October 27, 2015

going from student to doctor

I haven't been writing nearly as much.  I'd like to breathe new life into my blog and have it reach more people, so feel free to share it.

Anyway, the transition from student to physician is all too real.  You're always thinking about what's right for the patient, but there's a lot of playing it safe and being overly cautious because of the potential for unintentional harm to a patient.

You often get pressured by nursing staff and ancillary people to "put this order in" or "write for this" and you can get burned by doing that without thinking it through.  You get so busy that you don't always get to write orders in a timely fashion and you start feeling a little bit of friction.

I'm a little frustrated with nursing at this one hospital, because I want to know how much of X medicine someone got or how many fluids they got and I keep hearing "this is my first time with the patient," like it's somehow okay.  I get that nurses are busy doing tons of stuff, but you can jot things down here and there.  I wish nursing was more assertive about urine output and that they include us in their sign-out to each other instead of ignoring me when I'm right there.  I end up pushing myself into their report because it's my patient and I'm writing orders.

There has also been a lot of great nursing.  I wouldn't be happy having to move 300+ pound patients around, doing all the cleaning of urine and fecal matter and vomit for 12 hours a day, day in, day out.  A lot of the nurses around keep a good attitude and I have a few favourites I hope I get to work with the next day.  The hospital usually has the same nurse continue to follow the same patients over and over so there's some continuity, which is really helpful when you're tracking a patient's clinical status over time.

There are a lot of brave nurses who stick around a combative, agitated patient and who give great care to people coming off from cocaine and meth despite being in danger sometimes.

I'm going to miss a couple of the nurses in the unit once I leave, they've been there to talk me through orders or know what to call me for so we avoid crises.

Being a doctor is a great feeling (most of the time) but you're always under the microscope for everything you do and every word you write in your patient notes.

Then you get sucked into a lot of family drama and potential legal drama with families who make their frail actively dying loved one with say, several significant strokes, heart attack, metastatic cancer, renal and liver failure, maxed out on pressors and mechanical ventilation be full code and continue aggressive medical measures even though you explain to them over and over that their loved one is sick and will not recover.

It's hard.  It's rough being a doctor.  I wish I could be a student again sometimes, you know.

Saturday, October 17, 2015

The worst parts of intern year

I'm pretty sure I'll have more bad days as an intern because that's basically what this year is.

I had a month at one point where I'd come in at 5am everyday because it's a busy service and I'm paged and answering calls as soon as I arrive and the night intern is pushing tasks on me even though he's technically covering.  I do it anyway because I'm a team player.

I started one morning by getting called to the bedside to pronounce a patient dead.  It was emotionally terrible but I didn't have time to think about it because I had to do a mountain of paperwork and I was an hour behind in preparing for rounds and no one really cares what you have going on.

I typically answer a phone call every 20 minutes, spend more time writing patient notes for the purposes of billing and proving I'm not a fraud ( as in, hours writing patient notes..), and chase close to 200 data points a day, and get called to the bedside to talk to family while I field calls about crashing patients, go tend to them, then go back to the family and explain to them their loved one is sick and dying while being as understanding, polite, humanistic, and direct as I can be, providing constant emotional support.

I spell everything out as simple as possible for families who have loved ones who are sick and dying and getting worse.  They always tell me "Well, X years ago, they were perfectly fine!  I know they're going to get better," and they disregard my medical education and professional opinion that end-stage disease is end-stage and terminal.

It complicates things for sure, especially talks about code status.  This is a fictional example, but many times you have a patient who is 70+ years old with metastatic cancer, end-stage pulmonary or heart disease, in intolerable pain from said metastatic cancer, with dangerous cardiac conduction abnormalities, little to no renal function, and the family or patient wants everything done to save their life.  Even though you explain in detail about the patient's suffering and how there's the option of keeping the patient comfortable and having a good chance at a decent quality of life.

Then I see those patients go into cardiac arrest because they're so sick, people line up to do chest compressions, ribs are broken, a pneumothorax happens, surgery hurries in to put in a chest tube, and that same patient is on the ventilator unresponsive and they stay that way for weeks because the family still has hope that they'll fully recover even though they have so much going on and ACLS might have been going on for 45 minutes.

It's tragic.  Families start looking for tiny improvements in this lab value or this blood pressure in their loved one who is extremely frail and essentially on life support with no physical reserve left.

I need a break

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