Seize the Seizing

Tonight I am on call and while I was getting ready to admit a new patient with pneumonia I was reviewing the chart in the nursing station. All of a sudden the nurses began to panic and one of them yelled for a doctor and said that her patient was seizing. I continued to review my chart but soon realized that I was the closest thing to a doctor on the whole floor. The charge nurse realized this as well and said "doctor, you have to run a code!" 

I ran to the room and began to bark out orders and questions like "get me a crash cart", "Tell me what meds she is on", etc. The patient was writhing back and forth and moaning. The nurse said the patient was having a seizure and had a history of seizures. I did not think that this looked like a seizure so I did a sternal rub to see her response to pain and I noticed that she was guarding and trying to avoid the pain. Next I forced her eyes open with my fingers to see if her eyes had rolled back in her head and to see if her pupils where responsive. I immediately saw that her pupils were reactive and they were not rolled back. I quickly determined that this was not a seizure but rather she was malingering (faking). While holding her eyes open I looked her in the eyes and yelled "you are not having a seizure, knock it off". Almost immediately she sat up and quit the writhing and shortly after this she requested to use her cell phone. If she had been having a seizure she would have been postictal and would not have been able to function enough to request to make a phone call. The nurses were impressed and asked me how I knew she was not having a seizure. I explained how seizures work and described the methodology of determining if a patient is having a seizure. 

I returned to admitting my patient and enjoyed the effects of the adrenaline rush. The hospital is never boring.

This is my job?

Today after many  long hours of being on call I was finally finished and getting ready to go home and I realized that I was not in any rush to leave. I actually wanted to stay and keep seeing patients. I have never had a job where the major goal was not to get out and go home and do as little work as possible. It is odd to me that I get the privilege of doing this for my career. I enjoy it like I enjoy any of my other hobbies which is mind boggling as I have always held work and hobbies as 2 very different things.

I was excited to get home and get some sleep and see my kids and wife but it was great to have this feeling of "I love what I do" It makes it so much easier to do your job when you truly love what you do. I just never realized that it was actually a possibility. I was always skeptical of the idea of truly loving what you do for a career. I will see if this feeling continues or if I burn out at some point.  In the mean time, I am excited to go into my next shift.

On Call

Tonight I am on long call. I arrived at the hospital at 6:30 am this morning which requires me to leave home at 5:00 am. I will be on call through 3:00 - 4:00 pm tomorrow. All in all it is a 20 + hour shift. We have on call rooms where we can sleep at the the hospital. However taking care of the patients through the night takes priority over sleeping. When we are on call we get all new patients admitted to our service. We are responsible for anyone who comes into the hospital during the the time that we are on call. This is when we get new patients. 

You never know what you are going to get when you are on call. It could be a seizure, congestive heart failure, stroke, myocardial infarction, pulmonary embolism, COPD, pneumonia, etc. Sometimes you get a patient that has an unknown etiology and you have to try to figure it out. Often the patients will have multiple co-morbidities. When a patient gets admitted to our service my senior resident decides who is going to get the patient. My team is made up of 2 3rd year medical students, 1 4th year medical student, 2 interns and 1 senior resident. We take turns getting new patients. The senior resident will page me when it is my turn and give me a basic description.

For my 1st patient tonight the senior resident page me and when I returned the call she said; "you ready?" "this is a 66 year old male with a chief complaint of left lower extremity swelling who presented to the ER. He is in room 601." That is the info I get and I go from there to work the patient up and figure out what is going on. This patient had tripped and fallen about 2 1/2 weeks ago and noticed that he had some swelling near his groin. There was not much associated pain. He could walk fine. He did not want to mention it to his wife because he had a big hunting trip scheduled and he did not want her to not let him go. He went on the hunting trip which required a lot of driving and a lot of sitting waiting to shoot elk. Upon returning home he noticed that the swelling was still present, but he continued to wait hoping it would go away. He woke up this morning and noticed that the area was warm and the swelling had not resolved so he called his primary care physician who immediately instructed him to go to the hospital.

Even before I went to see this patient I had a basic diagnosis figured out. My basic thought was that the patient had either cellulitis (infection) or a deep vein thrombosis (DVT). Both can be very serious and both can result in death if not managed correctly. Upon seeing the patient I ordered a venous doppler ultrasound to see if a DVT had formed. Sure enough he had a massive DVT that most likely resulted from the fall he had over 2 weeks ago. This basically helped me rule out the cellulitis. I started the patient on lovenox which is an anticoagulant (blood thinner). I also had to adjust his other medications for his chronic conditions which include hypertension, diabetes, hyperlipidemia. Once I got the patient all worked up and "tucked in" I paged his primary care doctor and let him know what was going on. He was glad to hear that I had managed the patient correctly and he did not have anything to add or change. He will be in to see the patient in the morning. This is how it works. 

Update on the pancreas

It has been an interesting week. I have been treating the patient with the pancreatic pathology. It has been great for me because I have been assigned as the lead "doctor" on this case. So I work as the main contact for all the consulting physicians and the primary care doctor,  so they all page me for updates and to see what I have been doing for his condition. He had a procedure on thursday that was very cutting edge and not a common run of the mill surgery. The GI doctor used a scope to perforate the stomach to view the pancreas. Then he proceeded to asses and remove as much necrotic tissue as he could. He also made sure that previous stents that were placed were still functioning. It turned out that they were both clogged. So he drained both of the previous stents and placed 3 new stents. He also place a nasogastropancreatic tube to flush the pancreas with saline and antibiotics through out the upcoming weeks. The patient has a tube coming out of his nose. We will continue to flush the pancreas through this tube.

Unfortunately he could only remove 20% of the necrotic tissue which means there is going to have to be a surgery this week. So surgery will be called in to remove the pancreatic necrotic tissue. The good news is that there was no cancer found and there was some viable pancreatic tissue. The patient was feeling much better following the surgery so there is a small chance that his body could heal the pancreas on its own but the odds are rare given the large amount of necrotic tissue left. Following the procedure his hemoglobin was low which occurs from blood loss, when I noticed this I ordered a unit of blood to be transfused. We transfused him which brought his hemoglobin up.

I spent a lot of time with his family explaining what was going on and letting them know what to expect. They were very grateful and said that I was the only "doctor" that even talked with them and was honest with them. They said everyone else was aloof and very quick and would not stick around to answer questions. With my lower number of patients that I am managing I do have a little more time than their other doctors but I have noticed the general trend is to spend a little time as possible with the patients and try to get out of the room quickly. This leaves the family and the patient scared and in a cloud of confusion. I certainly do not want to give any false sense of hope or doom so I basically explain the full spectrum of possible outcomes in terms that the family can understand. I often have to simplify the terms but it gives the family and patient a sense of what is going on.

We are all feeling more optimistic this week regarding his condition. We were relieved that we could not find any cancer. Maybe the outcome will be better than we expected but he could still take a turn and decompensate quickly, so we are on guard. This case has been great for learning and I have learned a ton through managing this patient. I guess this is why we train in this manner, it is the best way to figure out how to be a doctor. We will see what this week brings.

Medical Formalities

An interesting aspect of the medical education process is all the formalities involved.  Those of you who know me are aware that I have never been one to like "formalities". If the rule says you need to wear a white shirt, I most likely am going to show up in any color but white. I know this is probably immature but I just can't help it. If these formalities are never questioned we would probably still be wearing fur loin cloths. 

Anyways  there are many rules involved in writing up and performing a physical or doing an exam. As a medical student we are required to do everything by the book which is a good idea because it forces us to learn everything the proper way and then later we can modify things to fit our style. I have spent a lot of time this year learning all the finite details in doing a medical presentation. There is an exact format and order to the way we are suppose to examine and then report on a patient. Ultimately this art cannot be mastered without lots of repetition. Like many other things in life it seems to be a daunting task at first, like learning a foreign language or learning how to play an instrument but soon enough you just get it down and without even thinking about it you have finally mastered the process. 

I am finally getting in my groove with all the formalities of doing physical exams, giving presentations, discussing patients with other doctors, etc. The nice thing about these rules / guidelines is that they provide a framework that help you to remember all the things you need to do and you become less likely to miss things in your exam or presentation. This is an aspect of medical education that I did not realize would require such effort. In talking to younger medical students there is no way to explain to them how or what they will need to do. The only way to really get it all down is lots and lots of real practice and interactions with patients which only comes with time and time takes time, you know.

Fragile Life

I had a patient admitted to my service a few days ago that has been weighing on my mind. This has been an interesting and tragic case. This is a 53 year old male who presented last a few months ago with painless jaundice which is very often a sign of pancreatic cancer. However at the time the patient did not have other symptoms and his cancer work up was negative. He was found to have a gallstone which had been pressing on his pancreas which had caused pancreatitis and ultimately shut the pancreas down. As a result of the pancreatitis the patient developed pancreatic insufficiency diabetes and had to be put on pancreatic enzyme replacement therapy. 

He was followed in clinic throughout the fall. However he has not been well enough to return to his high profile executive job or to drive his car. His wife and older children have been supportive and concerned for his health. Then earlier this week while climbing some stairs he experienced shortness of breath and did not feel well. He knew something was not right. His wife brought him to the ER where he was worked up and admitted as my patient. I am in charge of his day to day work up and care, thankfully I have a deep team of support to help me and more importantly watch my management of the patient to make sure that I am not missing anything or doing something incorrectly. I have my Intern, senior resident, teaching attending physician and the patient's primary care doctor all looking over my shoulder. I also consulted GI, surgery and interventional radiology on the case. I kind of work as the main point of contact with the patient and the family and I keep all the physicians on the case informed.

This case has taken everyone by surprise. The patient has no past medical issues and really no risk factors. He does not smoke, drink or use drugs. He is health conscious and was not over weight. He exercised and ate very well. His case is serious and he has been decompensating over the last week. He continues to have pancreatitis and his mental status has declined and other organ systems are starting to become affected. If he continues at this rate he will die within 7 to 10 days. We are trying to figure out what exactly is going on. We know that his pancreas has failed but his other symptoms are atypical. He has a pseudocyst in his pancreas which will need to be either drained or surgically removed. We should have this addressed by tomorrow. This case has been like an episode of House (the tv show). Right now we are stumped.

My main theory now is that he must have pancreatic cancer that has metastasized and the cancer must have been in the very beginning stages and not detectable in August when he was first seen Tomorrow we are going to work him up again for cancer and see if we can find anything. Hopefully it is not cancer but we can find a less ominous illness. If in fact he does have pancreatic cancer his prognosis will be terminal. 

In July this was a healthy successful father, husband and friend and today he is hanging on for his life. There has been a large number of people that this has impacted. HIs children, his wife, friends are all devastated. Everyone is still hopeful but I think the outlook is grim.

Inpatient care and the hospitalist

I am about halfway through my internal medicine rotation which is one of the main required core rotations required for all medical students. I feel like I am getting the hang of how to manage the fairly sick hospitalized patients. There is of course a lot more to learn and master but I feel like I can make sense of what is going on. I am not sure if I would want to have a career as an internal medicine doctor but I like it much more than I thought I would.

Internists usually divide their practice between seeing patients in clinic for routine outpatient issues and then seeing their hospitalized patients in the hospital. Recently many internists have found that the hospital work is not as appealing or as lucrative as outpatient clinic and so many have hired hospitalists to manage their hospitalized patients. A new field is growing in medicine because of this trend. Now there are jobs available as a hospitalist where as an internist you focus only on hospitalized patients. The job consists of seeing hospitalized patients for community internal medicine doctors who no longer want to manage hospitalized patients. 

I have been working as a hospitalists throughout this entire rotation. I am only seeing hospitalized patients who have a community internal medicine doctor as their regular physician. I could actually see doing this as a job. I like the complex cases and there is a great deal of interaction with the patient and their family. It is usually a stressful time for the patient and their family and they are grateful for all the help they can get. So many doctors fail at even elementary forms of communication, that it does not take much to make the family feel comfortable and happy. Simply taking the extra time to explain to them a diagnosis or a test or their given illness brings so much comfort to them that it is rewarding to interact with them and try to help them.

These patients are fairly sick and take quite a bit of intervention to help them recover and in some cases there is no hope for recovery. I find it rewarding to deal with people during these stressful moments. It is easy to connect and have an impact on their lives and often it also has a great impact on my life. Watching someone watch their loved one die is a unique opportunity that one gets as a doctor and much can be learned from these observations. Fortunately in today's world we are often successful and helping the patient return back to health but this is not always the case. This job also makes you ponder your own and your loved ones' mortality. I find myself wondering what it will be like when I die or when one of my close family members die. For some reason i did not think about these things when I was selling mattresses or when I worked at one of my numerous past jobs / careers. Discuss...

Too old to be gay?

2 days ago we were on long call so I was staying overnight at the hospital and getting new patients admitted to my care. I got a call from the ER with a new patient that I would be responsible for, she was an 83 year old woman who had come in via ambulance after experiencing a fall and some mental confusion. She also had hypertensive urgency / emergency  that needed to be controlled. 

The case its self seemed rather boring and before I had even hung up the phone I was pretty sure of my diagnosis. I was pretty sure that she had a Transient Ischemic Attack (TIA) and it turned out that she had a history of TIA's. This is not an interesting story because of the diagnosis or medical mystery. 

I went into the patient's room to introduce myself and perform a complete exam. This is how we handle every new patient. Part of the exam includes a ton of questions that many seasoned doctors do not bother to ask but as a medical student I am required to be very thorough. This lady was adorable. She was feeling fine and had quite the personality. She told me, she was ready to get home and did not know why she even had to stay. SHe had a friend there with her who had witnessed the TIA and was able to answer many of the questions I had regarding the event. Her friend was also in her 80's and was surprised how well she knew the patient's medical history. When I asked the patient about medications or past surgeries, she would often reply with "I do not remember or I do not know" but her friend would fill in all the gaps and tell me exactly what I wanted to know.

During an exam we have a section called a social history. During this portion we ask questions about tobacco use, alcohol use, illicit drugs, sexual behaviors and history. We also ask about living circumstances, marital status, number of children etc. When I go to this section of my exam, I said to the patient "do you have any grand children?" Usually when I ask an elderly person about their grandkids they get a big smile and begin to tell me all about their wonderful grandchildren and their latest adventures. This patient simply replied with "I never had any children so I do not have any grandkids but I do have some nieces and nephews that I spoil." I asked "are you married" she replied "no, I never got married". I asked her is she lived alone and she said no and pointed to her friend and said we have lived together for more than 45 years and she continued to explain how wonderful their life had been and that they have each other and they are both very happy. The patient's friend added more details about the spectacular life they have had together. 

As we continued the exam it became more and more clear to me how connected these 2 ladies were and it also became apparent how much they loved each other. So I finished up my physical exam and before I left the room to go run some labs I looked at the 2 ladies and said "Do you want to know the secret of your happiness and the success of your relationship?" The smiled and said sure tell us why we are so happy. I said with a smile "it is because you never involved a man, they tend to just screw things up" They both turned a little red and laughed and laughed and then the patient said "well, we could of told you that!"

New group of residents and grades

Sunday I was on long call and it was my last day / night with my residents. Today we got a new group who I will be with for the next 4 weeks. It is always interesting and challenging to figure out how he different residents work, what they like and what they hate. They are my boss so until I figure them out it can be a little tense. For example, you may have 1 resident who wants you to write up a patient and present a patient in a specific way and you get used to doing it their way, then another resident may be completely annoyed by this method and get all over your case for the  charting / presenting method that the other resident wants you to do. You have to be flexible and able to adapt to keep both residents happy. I am working with 3 residents and I am sure they want things done in their own special way. Once I figure their individual likes and dislikes I am pretty good and keep everyone happy. 

My main job is to make my residents look good and do their job better. So many medical students are completely clueless with how to go about doing this and furthermore they are annoyed and feel that they are above this task. They are forced to learn the hard way when they get poor reviews despite their good clinical knowledge. It is just like life where it is about keeping those around you happy, whether it is your spouse or your boss or the cop that pulls you over for speeding. If you can keep these people genuinely happy you do well and your life ends up being being happy and you have less problems.

The grades from 3rd year are arguably the most important aspect of getting you a good residency. The grades are based largely upon your evaluations that you get from the residents and attending physicians that you work with. Many med students who do very well (all A's) during their first 2 years of basic science are frustrated with their poor performance during 3rd year. The grading is subjective unlike the objective grading of the first 2 years. I have always been a fan of the subjective grading and tend to do well where you are graded based on how people like you. When you are applying for residency the resident directors realize that they are going to have to deal with you for the next 3 - 6 years and they want someone that is easy to get along with and someone who works hard. Many residency directors have said that they would take a student with stellar 3rd year grades / evaluations and poor to mediocre clinical science grades over someone who has mediocre 3rd year evaluations but straight A's and great grades test scores from their clinical science years. The perfect candidate would excel in both areas but interestingly enough those that do really well the first 2 years do not do as well during their 3rd and 4th years and often a mediocre student in the clinical sciences will excel 3rd and 4th year.

My patient who died

I had a patient on my service who was in her early 70's. She had been living with her family and had been getting progressively more depressed. She felt that she was a huge burden on her family and recently had said that she would be better off dead. She had also been complaining about a diffuse rash that had spread over most of her body that was accompanied with pain. Her family was skeptical of the pain and even the rash at first. The rash was originally hard to see and she had been so depressed that they did not think that the pain was anything to be worried about. 

She presented to the Emergency Room 3 days ago and became my patient. I did a complete work up and ultimately concluded that she had sarcoidosis which is a not so common disease and we do not completely understand what causes it. It usually affects younger people and causes granulomas to grow in various areas on the body. Usually the lungs are affected but the granulomas can form anywhere. Often this condition will grow slowly over time and can ultimately lead to organ failure and death but it can also appear and grow rapidly.

My patient had signs of neurological involvement which would mean that the sarcoid had spread to the brain which would explain her recent depression and atypical behavior. We decided to have her get an MRI today. I was paged this afternoon and told that while she was getting ready for the MRI she began to decompensate and died. I had to go and verify the death and call the time of death. 

I also had to notify the family and to a certain degree they were relieved that at least she had a diagnosis and there was an explanation for her recent behavior. It is difficult to see a loved one deteriorate mentally and the families are always relieved when there is an explanation for the behavior. 

It was an interesting day and a unique case. Every time I have a new case and patient it is like my database of clinical knowledge grows a little. The hands on learning in the hospital is much more effective than just reading about a disease or case. No wonder the training takes so many years, there is so much to learn. 

Medicine Patient

Here is how I would present one of my patients from today.

48 year old hispanic male presents with a history of a recent MVA (motor vehicle accident) resulting in a spinal injury causing quadriplegia. The patient is in respiratory failure and ventilator dependent. The patient also has a sacral decubitus that was being managed with a wound vac at the nursing home. He also suffers. from depression The patient presents with a fever of 40.1 degrees of unknown origin possibly secondary to pneumonia or UTI.

5 days ago the patient began spiking fevers at the nursing home where he lives. The fever was refractory to acetaminophen so he presented to the emergency department. Chest Xray showed evidence of pleural effusion bilaterally, right side > left. Urine was cloudy with occult blood, traces of protein and leukocyte positive. Urine culture showed subclinical pseudomonas aeruginosa susceptible to tobramycin. 

On physical exam the patients lungs had anterior coarse rhonchi bilaterally more prominent on the right side. The sacral decubitus does not appear to be infected and shows granulation tissue and signs of healing. 

Patient was started on imipenum + vancomycin for pneumonia and IV tobramycin for UTI. We will continue to monitor the patient. We have sent for blood and sputum cultures. We are continuing his lexapro for depression and will have wound control look at his sacral decubitus and possible continue the wound vac

This is a very abridged example of a presentation I may give on rounds. This is a patient that I admitted today and I am currently managing. Most likely this patient has a UTI and or pneumonia which is causing the fever. Given his comorbidities this patient will be managed in the hospital until we can get him afebrile and rid him of any infection. He is actually a good example of the type of patients that I have been managing. 

This case is sad because this guy was a normal healthy man in February until he was hit by a drunk driver which left him a quadriplegic. His wife and family have basically abandoned him in a nursing home. He is mentally aware and just trapped in his broken body. He is severely depressed and miserable. He is just waiting to die.

Internal Medicine Patients

I am actually really enjoying my rotation in internal medicine. I like the challenge. It is kind of like the TV show House. I will get a new patient which is admitted to my service that I have complete responsibility for working up. So I have to come up with the diagnosis and the treatment plan. I certainly have a lot of more experienced residents and attending physicians that I can look to for help and they will also check my work to make sure that I am not missing anything. There is a great deal of satisfaction that comes from figuring out the diagnosis and then treating the patient and ultimately seeing the patient become healthy again.

I do not find it very stressful which may be one of the reasons why I like it. Currently I cover 2 - 4 patients at a time. I suppose if I had 10 - 15 patients it could be more hectic / stressful. I get to see a whole variety of patients. I have had MRSA cellulitis patients and patients with atrial fibrillation, pancreatic cancer, pneumonia, heart attacks, etc. Most of the patients are elderly. Some patients die due to their conditions which can be sad. This requires working with the family members of the patients. This can be very interesting because many times the family members are at odds with the situation or not prepared for the decisions that they need to make.

Internal Medicine

So I started internal medicine at a new hospital. The hospital has a much different demographic than the city hospital where I was doing surgery. What is internal medicine? Internal medicine is basically adult medicine. An internist is the doctor that takes care of adults for most health issues. The training is a 3 year residency. I would say that most adults see internists. They differ from family practice doctors in that they do not see children and they tend to see sicker patients. Often internists will manage adult patients that are hospitalized. 

This rotation is 100% inpatient. I do not see any patients in clinic. All of my patients have been admitted into the hospital where I am involved in managing their treatment while they are in the hospital. Most of my patients are fairly sick. I will see patients that are end stage renal failure or have serious pneumonia, or other illnesses requiring hospitalization.

I am on this rotation for 2 months. I just finished my first week and I actually really like it. It is interesting trying to figure out all of the patient's health issues. It is like a mystery and it feels great to figure out what is wrong and then treat the patient and get them well enough to go back home. I have had some really interesting cases thus far. I am on call  every 3 days. I alternate between long call and short call. Long call is overnight, so I come in at 6:00 am and will stay through the day and overnight and then leave the next day at about 1:00 pm. It is a 32 - 34 hour shift. Short call starts at 6:00 am and goes until about 8:00 pm the same day so it is a 14 - 16 hour shift. The hours can be long.