Dying a Little Inside Every Day

Ok, so Geriatric medicine has me feeling suicidal. My mother told me that as long as I didn't have a plan, I was o.k. Thanks, mom.

I don't mind the work - going in and seeing patients every day, following up on their care, seeing their progress. Not too bad. It's the rounds. Rounds are where every patient is presented to the attending and a care plan is developed for each one.

On surgery, you start around 0630 with the senior resident and see all your patients by the time of the first OR case... usually around 0830 or 0900. You "pre-round" earlier and get all the information (vitals, labs, xray results, etc.) about your patients so that you can present them during rounds. At each patient's room, the resident or medical student following the patient presents the information to the senior resident. One person holds the patient's chart and writes orders as the care plan is developed. Depending on the amount of time and/or number of patients, some teaching is done about a particular topic or disease process. Later in the day, in between cases, you round with the attendings and give them an update on their patients.

In Geriatrics, rounds are scheduled to start at 0930. Our attending this week has been showing up around 1000. Then you sit in a room and talk about all the patients. In surgery, we used to call this the "card flip" in honor of a scene in the "House of God" where instead of physically going from room to room you quickly talk about all the patients. However, in Geri nothing happens quickly. We usually spend a good hour or two talking about the patients. Disease topics and social issues are brought up. Teaching is the primary focus.

THEN, you go see the patients on "walk rounds". You stand around while the attending performs their physical exam on your patient. I sometimes feel like an animal trainer at a dog show hoping that my patient will perform for my attending as well as they did for me earlier in the day. However, by now it's around 1300, and all you can think about is how that bagel and coffee you had at 0800 are long gone, and wondering when are you going to eat lunch. Of course, it's around this time the attending decides to start a diatribe on diabetes and wound care, and all the while my mind is drifting andgoing through the indications for an above the knee amputation vs a below the knee amputation. Several minutes later and thinking about the time I launched the bone saw across the OR, I look up to see that the team has already moved onto the next room; stomach grumbling and looking at the list to see how many more patients have to be seen, I follow them.

So, this happens every single day. After rounds, we grab patient charts, make sure we have orders for the next day, follow up on any consults that might have seen the patient during the morning/afternoon, and then get ready to sign out. Of course, that's if there isn't an afternoon lecture, or some other discussion group that you have to go to... uugghh..

Luckily, I had today off... which is good because I went out for dinner and drinks with colleagues from the MICU last night, and I woke up this morning with a bit of a headache and dry mouth. I also didn't sleep very well due to a new addition to the family.... yes, I went and did it.... I got a new cat. Her name is Lacey. She's about six months' old and was abandoned and picked up as a stray. She's really skinny, and needs a bath once the spaying wound heals, but she's lovely.



Right now there's a little bit of a war zone going on in the house, with everyone except for Lacey on edge. I kept her in my bedroom and the other cats are upset with not being able to sleep with me. There's a lot of hissing from Winston and skulking from Sophie. I've heard these things take time, so hopefully, soon, I'll be able to open doors and have the family all together....

Tomorrow, back for "weekend rounds" that are supposed to be short and efficient... we'll see.

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My Big Fluffy White Cloud

So, I don't know if I've ever talked about the "Cloud Theory" in this blog. Essentially residents come in two flavors: white clouds and black clouds. White clouds keep the badness away. Calls are lighter. Not too many admissions. Black clouds bring chaos. Everything goes wrong. Admissions are numerous.

I've always considered myself a white cloud. My calls are generally on the easier side. Other than the "Night of 13 Traumas" and the "Week of Deaths" my call nights have been mostly, well, boring. Last night, nay, this whole month, has been an example of that. I had one admission yesterday at around 10 in the morning... and that was it. After 10:30 p.m., the most important medical decision I had to make was ordering some nasal saline for a patient complaining of a dry nose from their oxygen. Twelve hours later I was on my way home. End of rotation.

So, what did I learn this month on the MICU service?
1. Take care of your body.
75% of our admission were complications due to patients not taking their meds or not taking care of themselves. The complications were further complicated by the fact that these patients smoked or drank in excess. When you need to have a breathing tube put in, because you're in acidosis (producing too much acid) because you decided to not take your insulin for several days, it's going to take a while to get you off the breathing tube because your 2 pack a day smoking habit has lead to COPD and emphysema, and your chronic pint a day habit is leading into withdrawals and DT's. So you stay in the MICU while we correct your acid imbalance, try to prevent you from getting a ventilator associated pneumonia, and keep you turning from side to side to prevent bed sores. Three weeks later, we might be able to get you well enough to make it to the ICLU (intermediate care level unit) with a tracheostomy, on hemodialysis, and several new holes in your skin.

2. Learn when to give up the fight.
I was lucky this month to have attendings who know when care has become futile. I have heard of attendings who "flog" their patients until the end. The ones I had this month acknowledged that there was a time to fight, and a time to pull back and let nature take over. Luckily, they also had the personal skills to be able to help families with the making these very hard decisions.

3. Even different disciplines can work together when you've got the right group.
I am an emergency medicine intern. We had a family medicine & neurosurgery intern as well. All of us mixed in with the three medicine interns. One of our senior residents is a medicine-pediatrics resident. And, we worked as a team. No one complained. Everyone did the work. We gave each other breaks, and helped each other out. No one took advantage of the situation. Toward the end, the three of us "non-medicine" interns began to focus on our up-coming rotations outside of the MICU, but we still got the work done.

Of course, in every group there has to be someone who doesn't quite fit in. That was, unfortunately, one of the medicine interns. Early in the year, you figure out who "gets it" and who's having some problems. By this point in the year, you hope that everyone has pretty much caught on to how things work. You worry about those that haven't. This person is in the "hasn't quite gotten it yet" group. Which is scary.

It's the end of the year. In a month, this intern is going to become a resident and be in charge of interns and running the unit. The senior residents tried to limit their patient care, and the rest of us tried to keep them from managing our patients as much as possible.

And, again, unfortunately, a lot of the lighter times in the unit came at their expense (these are funny to those in the medical profession, let me know if you need an explanation):
- asked if it was possible to put a drain into a brain abscess to help with the infection. Um, the answer to that would be no.
- when asked to check a heme-occult on a patient with a falling hemoglobin, they came out of the room and said no blood noted on exam. When asked what the card showed, they answered first, "what card?" and then answered that since the stool was brown, there couldn't be any blood in it.
- was asked to go to the floor to evaluate a patient for possible admission to the MICU. They came back an hour later, and when the resident asked about the patient's condition that required admission to the ICU, the intern stated that they had spent the last hour explaining to the family about Do Not Resuscitate and Do Not Intubate orders because it hadn't properly been explained to them. When asked about the patient, they stated they hadn't examined the patient.

These are just a few examples. Again, scary. I am just wondering when they are going to be scheduled in the emergency department as second year medicine residents do a rotation through the E.D. We already heard about an OB-gyn intern that was asked to leave in the middle of a shift because of incompetence. I am just wondering if I will be working the E.D. when this intern comes through. Like I said, scary.

OK, have to be going to bed. Tomorrow I start the geriatric medicine service. My last rotation of my own personal intern year. We'll see what the new morning brings, and if white clouds will continue to color my sky.

Where's the Story?

It's been a week since I've last written, and, seriously, not a whole lot has happened. I honestly thought the MICU would have a bit more... um... drama? Live and Death battling over patients while we do our best to heal our patients. For the most part, it's been trying to find placement in a full hospital and boarding well patients while occasionally needing to make room for a sicker patient.

We've had one very awesome save. A woman who came in with fulminant sepsis. Coded just as she arrived on the MICU. Got CPR, intubation, multiple drugs, and was able to leave to the floor 5 days later completely intact. No brain, heart, kidney or other damage.

We've had some patients that we've been able to make comfort care and ease their transition into the next life. Patients that the best medicine we could provide was to allow nature to take its course.

We've seen alcoholics in withdrawal, psych patients testing the limits of the nursing staff, many many non-compliant diabetics in diabetic ketoacidosis, and many septic patients that eventually get better or die. I think we're about 50/50. The "Surviving Sepsis" campaign is barely reaching Buffalo. I was implementing it 3 years ago in Minneapolis on the surgical ICU. As the system improves, I am sure the survival rate will too.

As for now, I am counting down the last week of this service and looking forward to the future. A month of geriatrics, followed by a pediatric ED month, and then the official start of my second year. I will be working on a protocol to make post-cardiac arrest patients hypothermic (low temperature) in order to protect brain cells. I will be working on my EMS requirements. And, hopefully, I will take my first helicopter ride.

Now it's off to the unit to see what has come in overnight, and how my patients have done. We can only wait to see what the rest of the day will bring.

Making Sacrifices...

I think if I was to stop and think about the power that I have sometimes, I wouldn't be able to handle it. I haven't been writing lately as the patients haven't been that interesting; the stories maybe not so dramatic. Life for me in the MICU is simple: patients come in, patients go out, new patients come in.

Based on what I've heard, it seems that we're not as busy as some of my colleagues have been. At most, I've carried about 3 patients. Most of them have been DKA (diabetic ketoacidosis), septic infection, or a mixture of problems. I've discharged patients straight from the unit to home, and we've had one patient with a series of misadventures who died within 8 hours of being transferred from another hospital. Tomorrow I'll see if I can find out how the Guillain Barre patient is doing.

On an earlier post, I wrote about talking to families about making the decision to withdraw care and "let nature take its course." It's a powerful position to be in. In essence, we make a clinical decision that a patient's outlook is grim or continued treatment is futile - we feel that it would be in the best interest of the patient to stop medical treatment. Primum non nocere - first do no harm.

In medical school, the first time I thought about my actions leading directly to a death was in the "Dog Lab" during physiology. My medical school still had a live dog lab where we studied the cardiovascular system en vivo by giving various cardiac medications to sedated and intubated dogs. I was the one giving the medications. After a time, you stopped thinking about the dog and focused on the beating heart lying in front of you; watching the various effects the drugs had.

One of the last things we did was give a medication that would cause ventricular fibrillation "a bag of worms." We all reached into the chest and felt the irregular heart beat. We then shocked the heart and watched it slowly return to a normal rhythm. The final medication I gave was potassium chloride. This would stop the heart... for good.

I didn't think about it as I reached for the syringe and started giving the medication. We all just peered into the chestto watch the heart give several strong contractions and then suddenly stop. We were all thinking about the physiology: cardiac monocytes being flooded with potassium leading to a contraction with no release. Then I took a step back to cap my needle and realized I had just killed a dog. (We say "sacrificed" in research.)

On days like today I feel the same as I did on that day. I talk to the family who look to me to do "what I need to do for my patient." I talk to them and guide them to the decision to withdraw care. And then I write the orders: morphine bolus, morphine drip "titrate to agonal breathing," d/c (discontinue) all medications (including the ones currently keeping the heart going), d/c lab draws, d/c ventilator support. These are the "comfort measures" orders, but as I write them, I feel like I am back in medical school, pushing the syringe.

Tomorrow is Grand Rounds Wednesday, and I will be helping the medical students learn how to intubate in the evening. We'll see what the morning brings.

The Farmer and the Cowman

I titled my entry today based on the great song in the musical "Oklahoma!" It has to do with the conflict that existed on the open range between farmers building fences to keep their cattle in and the cowmen who pushed their cattle across the open spaces. Both are raising cattle, just in their own way. So too surgeons and medicine doctors, or internists, treat patients, but in their own way.

Which brings me to one of my favorite episodes of "Scrubs" where the main character and his best friend (a medicine intern and a surgical intern) play out the dichotomy between medicine and surgery ala "West Side Story."

Anyway, the reason I bring this up is because part of what is driving me crazy in the MICU is the way the medical interns approach patients. I know in part my prior training is affecting my perception, but seriously, I am suicidal most day on rounds. I just want to know: what is wrong, what are we going to be doing about it, and how soon will they be able to transfer out of the ICU? I don't think about their clinic visits, what their medications were six months ago and 3 hospitalizations earlier, or if they eat beets on Thursdays.

Facts, that's all I want to know. Now, medical people will say the most important part of the exam is the history. In fact, I had a professor in medical school that said that 80% of the time you could make the diagnosis based on history alone. I guess I have to work on my patience... and, dealing with some of the medicine residents, I am going to need a lot of it.

My patients:

an alcoholic, diabetic admitted for leg ulcers who we admitted to the MICU for management of their alcohol withdrawal. They were intubated because we had to sedate them before they went into DT's.

a patient with knee pain who has been taking a LOT of Alleve over the last 2 weeks. So much that they gave themselves an ulcer. In fact, several since I saw the endoscopy while the GI doc did it. Ortho will be coming to see the offending knee tomorrow.

a patient who smoked for a long time, now has emphysema and came in with shortness of breath. They were having a CT scan to look for a pneumonia or possible mass when I was leaving. I wonder if they'll be off of the bipap mask tomorrow.

That's about it. I really don't have a lot going on. It seems like I pick up patients and send them out. I actually picked up a patient that was admitted overnight and discharged them to home this morning. Maybe things will pick up next weekend when I am on-call. Until then, I will be enjoying the attending we have now who also was a surgical resident before changing to anesthesia.... at least I have someone, along with the neurosurgery intern that I can roll my eyes with during rounds... the long, slow painful part of my day.

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The Honeymoon Book

The Honeymoon Book : Seriously, nothing much happening in the MICU. It's actually been... shhhh.. very quiet! I have had a patient or two, and I actually went two days with no patients of my own. Just at sign-out tonight (around 1600) things started getting a little crazy, and the intern on-call tonight is a bit of a black cloud... we'll see what he brings in over night and what I'll pick up in the afternoon after my Grand Rounds Wednesday... until then, enjoy the entry I placed in my photo blog...!

In Case of Emergency...

I had fun today. While most people wouldn't consider it fun, I thought it was great. As part of my EMS (emergency medical services) focus, I got to participate in a disaster drill.

The scenario was a mass casualty incident (think Katrina) where the local hospitals are either destroyed or overwhelmed, and patients need to be shipped out. We, Buffalo/Erie County, were on the receiving end of a group of patients that had been evacuated.

A C-130 from the NY National Guard flew in the patients. It was amazing being on the tarmac on the opposite side of where I usually am in the terminal.


the c-130 landing, people in the terminal had posted signs that there was a drill going on so they wouldn't panic at all the uniforms and flashing lights

The patients had been previously triaged (arranged in order of severity). Our people then performed a second triage as patients were brought off the plane:

"patients" being unloaded off the airplane

We then brought them to our staging area where we evaluated them and re-triaged them for transport to local hospitals:


Most of the patients didn't change from their original diagnoses, but some patient became worse or got better, and we needed to re-evaluate them. We then got them all on ambulances and "discharged them" from our triage center.

After this, we had a chance to check out the plane and some of the other equipment. The airport firefighters were very nice and let me climb up on their fire truck:


And, then they let us explore the plane a bit:

the plane is able to carry about 244 patients stacked 5 high on gurneys


a view from the cockpit



All in all a very interesting day. I have no patients of my own in the ICU, and I covered someone else's patients on Friday. Tomorrow I am on "short call" meaning all day until 2100 but not overnight, so we'll see if I pick up any admissions then...

For now, a little souvenir, and the truck I will be driving in August when I do my EMS rotation. If you want to see all the photos of the drill, they are on my Facebook page on the following link: http://www.facebook.com/album.php?aid=36038&l=9b58b&id=715126579

Enjoy!

Small Victories

My Guillain Barre patient took a breath today. Just a small one. Well, maybe half of one, but it's a big thing! Even she was surprised. So excited she tried another breath and was able to do it. It all started this morning when I noted that she was able to flex her fingers, ever so slightly.

We decided to do a "nif" (negative inspiratory flow) test. It tests how much pressure a patient can create when inhaling. You and I, normal lungs, we can generate a high pressure, greater than 40 or 50. My patient inhaled to an 8 or 9. But this is HUGE considering that she has been on a ventilator for over a week, not able to move anything below her neck during this time.

She finished her last session of plasmapheresis and was being transferred back to Children's Hospital as I was leaving this afternoon. Of note, her primary caretakers since her admission have been my fellow Emergency Medicine residents. One of my colleagues evaluated her in the Emergency Department. He then sent her to the Pediatric Intensive Care Unit (PICU) where a 2nd year EM resident intubated her and took care of her. When she was transferred to BGH, another of my colleagues admitted her to the ICU and then transferred her care to me when I started. We're hoping the 2nd year EM resident on service in the PICU tomorrow will be able to take care of her... kinda like keeping it in the family.

Other than that, the most I can comment on is other patients in the unit. My fluffy white cloud is following me around, and as I left this afternoon my second patient was being transferred out. I picked up no patients during the day, and tomorrow I will round on one of the other intern's patients as she will be taking the day off. We'll see if I get any patients after rounds tomorrow from the overnight service.

So, these are some of the other patients in the unit:

- a schizophrenic patient intubated with pneumonia. They are literally "crazy" and won't be easy to extubate. We'll have to see how they do.

- a patient with severe aortic stenosis (heart valve that is blocked) who is not eligible for surgery and who needs to remain on the ventilator to keep their lungs from filling with fluid. The attending is trying to talk to the family about placing a tracheostomy versus extubating the patient and "letting nature take its course."

- a patient that pulled their own endotrachial tube out and actually seems to be doing ok despite the fact that they were near death about 3 days ago. Still touch and go, but holding their own right now.

- a patient with lung cancer who has multiple complications and abscesses. They are end-stage, so for the most part we're doing palliative care. They were too sick to be in the cancer institute so we are trying to get them stable enough to be transferred back.

- a patient who developed severe sepsis, almost died and needed to be intubated within a few minutes of arriving in the ICU, who is unable to clot their blood and who had the misfortune of having a venous line placed into a non-compressible artery. They were headed for a procedure to try to safely remove the line when I was leaving.

- a patient who ate something bad (not sure if at a restaurant or some old hamburger meat) and was infected with e.coli 0157:h7 which causes a severe bloody diarrhea. Unfortunately, this patient developed sepsis and is now in multi-organ system failure. I will have to see if they are still alive when I go back in the morning.

finally, the GI bleeder with a "spurting" artery at the base of a massive stomach ulcer. I placed an NG (nasogastric - nose to stomach) into him when he came back from the endoscopy suite, and he was being wheeled to interventional radiology/surgery when I was leaving.

Funny, I keep saying, "as I was leaving" but that's how my day went. Everything happened in the afternoon, as I was leaving. That's what's been interesting about this rotation, not knowing what I am going to find when I step in the door in the morning...