Too much specialization?

One thing I have noticed on this neurology rotation and other rotations with specialists is that the attending physicians become hyper focused on their one area and often become blind to anything that falls out of their expertise. This would be fine if human illness was confined to given organ systems and never overlapped with other pathologies. Unfortunately nearly every illness impacts and is impacted by multiple systems within the body. I think in certain situations this type of focused care can lead to inability to diagnose and treat the real cause of a given illness. 

For example; today I was working with an extremely well versed neurologist. We had a 54 year old women with a history of gastric bypass in 2005 who was referred to us for unexplained episodes of a warm sensation starting in her gut and spreading throughout her body followed by shortness of breath, hyperventilation, and tingling. During the episodes she has to sit down and try to relax until it passes which usually takes 10 to 15 minutes. The neurologist grilled us on all the possible neurological causes. He went over every possible nerve involved and thought about it for quite some time. Never once did he even hint at the possibility that this may be something caused by something other than a neurologic pathology.

The patient seemed very anxious too and had a history of depression and just seemed like the type of patient to me that is constantly anxious. Immediately I thought that these episodes sounded like panic attacks. I also considered possible GI issues. These seemed more likely to me than a neurologic syndrome. This particular neurologist is not the type who wants to be second guessed. So I kept my mouth shut and just hoped he would come to a similiar conclusion but he never did. Ultimately the patient was told "we do not know why this is happening". She was told to try to see is anything provoked the episodes and to see if anything made the episodes better. I think many of these specialists have focused their work and studies so sharply that they are often blinded and miss a very simple diagnosis because they make it too complicated. Later in the day I asked the neurologist about this patient and I said "is there anyway this could have been a panic attack?" He responded with "you know, I never even thought of that...."

It would have been very easy to have the patient try a benzodiazepine at the onset of the next episode and see if that helped ease or end the episode. Also many different GI drugs and tests could have been used to rule out GI causes. Hopefully this patient will stumble into a GI specialists office or a psychiatrist or other doctor who recognizes panic attacks. I have seen many patients with specialists who have had there symptoms molded and manipulated until they fit awkwardly into an explanation within the specialist's field. I think this may be common. An excellent primary care doctor can prevent a lot of this by guiding the patient in the right direction or diagnosing the symptoms correctly before having to get a specialist involved. 

Trigger points / Nerve blocks

I have to admit that I like doing procedures.  That is what I liked about surgery and the ER. Today was great because we were running the neurology pain clinic. We had lots of patients who suffer from chronic pain. Many of the patients we saw were in a lot of pain and others symptoms / pain was questionable. You always have to be alert for drug seeking behavior. The cool part about today is that I was able to do several nerve blocks. I also got to do a few botox injections in the neck and other muscles to ease pain due to spasms. 

The coolest case was a 65 year old man who had open heart surgery 18 months ago. Following the surgery he notices that he had intense pain in his chest wall. He had sen multiple doctors regarding the pain. AT first everyone told him that it was pain from having his chest cracked open. However after 6 months the pain persisted and was very intense. He was not able to lie down for more than 10 - 15 minutes before the pain became unbearable and he had to stand up and walk around. He could not remember the last time he had more than 2 hours of sleep in a given night. It seemed like living torture. After multiple visits to multiple  doctors someone final thought that the pain must be neurological in nature and they referred him to a neurologist. 

He came to us in desperation. You could tell that the pain was real, hew was not malingering. he could barely tolerate any pressure on it even when we distracted him while palpating the chest wall. He winced and actually had what is called the chandelier sign which is when the doctor touches the painful area evoking so much pain the patient reaches for the chandelier. He was dripping in sweat just from us trying to localize the pain. We were able to determine that he most likely had a nerve caught in or under the wiring used to close his sternum following the heart surgery. After open heart surgery actual wires are used to reconnect the sternum. Usually these wires are left in fore life. We had lots of cadavers in anatomy lab that had these wires in their sternum as remnants of their surgery. 

Once we had our diagnosis we used lidocaine derivative with a longer half life to numb the nerves in the area. The idea is, if the numbing medication gets rid of the pain then you can localize the pain to the nerves in that area. If you inject and get no pain relief then the pain could be from a different source. My attending physician allowed me to do the injections under his guidance and supervision. The last thing you want to do is go between 2 ribs and inject the heart. It was such a great feeling to see this great big guy who had been suffering from pain so long he was nearly suicidal, get such relief from these injections that he started to cry tears of joy and say "thank you doctor" over and over again. "I haven't felt this way in 18 months, I forgot what it is like to be pain free!" he blurted out.

Unfortunately the pain relief would only last 6 - 8 hours but we now had a concrete diagnosis and we could try a couple different treatments and ultimately have the wires removed if needed. This case was very rewarding and kept us going most of the day. 

I included an x-ray that shows some of the wiring used to close the sternum following surgery. If you look in the middle of the chest in the upper 1/2 and slightly to the left side you will see the wiring holding the sternum together. 

MS or a Stroke

Today I saw and examined many patients with neurologic complaints. Just to name a few of the complaints: short term memory loss, numbness and weakness of distal lower extremities (feet), burning sensation in left upper extremity, numb toes, right sided paralysis, new onset seizures, head aches, etc. This was all in clinic. Some of the patients were new patients with first time complaints and some were follow up patients with chronic pathology.

What does a neurologist do? The main goal of a neurologist is to localize the affected part of the nervous system which will lead to treatment. First you need to find out the history of the patient. What other diseases and problems exist? What familial medical issues exist? How did your parents die or what diseases do they have? Do you smoke? Do you drink? Do you use illicit drugs? Are you sexually active with men, women or both? Do you use protection? You basically want to gather any and all pertinent information that could play any role in the neurologic complaints. Then you will ask lots of questions about the complaint. When did the pain start? What does the pain feel like, is it sharp, stabbing dull? What makes the pain worse? What makes the pain go away? How long have you had the pain, etc? Next you will do a focused neurological exam to help pinpoint the problem. You look for weaknesses, decreased sensations, decreased reflexes, etc. Hopefully by the time you finish your history and physical you have a good idea of what pathology / disease you are dealing with. Then you order laboratory and diagnostic tests to help solidify your diagnosis or rule out certain pathologies.

The most common diagnostic tests in neurology are MRI of the brain and spinal cord, CT of the head and spinal cord, EEG (measure nerve impulses), EMG (measures nerve impulses in the muscles). 

Hopefully by the time you have finished all the laboratory and diagnostic tests you will have a firm diagnosis for the patient. Then depending on the disease or syndrome you will recommend treatment which could be short term or long term pharmacologic intervention. Surgery will be an option for some of the diseases. In general neurologic diseases are not mild in nature and will require some life changing interventions. On the mild side you have carpal tunnel syndrome and on the severe side you have hemorrhagic strokes leading to brain death or severe impairment. Sadly for many of the diseases there is no curative treatments and the existing treatments do not offer much help. 

Government and medicine

I started neurology at a government facility. It was a long day to say the least. I have had a few rotations now that are at government hospitals and one thing I have noticed is that those facilities are run horribly. There is no organization, unbelievable laziness of the staff and poor follow through on anything. It is amazing that anything gets done and that more people do not die. 

Here is an example. I was told to be at the human resources at 8:00 to meet the HR director and have my paper work processed and be cleared to work in the neurology department. Upon arrival I find the office is closed and no one is there. After waiting 1 hour someone finally shows up and I explain that I am supposed to meet the HR director and when I tell them the name of the person I am supposed to meet they inform me that she has not worked there for 6 months. They have no idea what to do with me. After asking many questions and getting no answers they tell me to go home.  Rather than going home I decide to go to the neurology department because they must be expecting me. 

I went to the neurology clinic and found an attending neurologist and explained that I was the new rotating medical student. He said that the chief of neurology was out of town until next Monday and had left no instructions. The  secretary of the neurology department finally told me to go back to HR and have them make me an ID. I arrive at the ID center at 11:00 am and when I explain that I am there for an ID I am told that they have met their quota of 25 IDs and will not do anymore. She explained that if you do not get there by 9:00 am then you can't get an ID because they will have already hit their quota. I asked her if she did anything else besides the IDs. She said that was her only job and that she works from 8:00 - 4:00 but once quota is met she just hangs out until she clocks out at 4:00. She explained this was they way it has always been. Usually from 9:00 to 4:00 she does nothing. I asked her about the quota and she did not know why they had a quota.

I was told that without an ID I could not work and that I should go home. Rather than going home I went back to the neurology clinic and just started seeing patients and presenting them to the attending physician once I had worked them up. 

This is how the entire hospital runs, including patient care. Tests and labs can't get processed timely or properly. Patients are given the run around on everything. Tons of time is wasted away. Often life saving exams like ECG that could dictate treatment when ordered are not processed with the explanation that the tech has reached his/her quota. The while waiting for the test at a later date the patient decompensates and can ultimately die as everyone just watches with a "there is nothing I can do" look on their face.

The rotations I have done at private hospitals are run the polar opposite when compared to the government hospitals. They are lean and efficient. You order the exam and the tech is there before you even hang up the phone. Very little time is wasted and the patients are respected and treated like customers. Why do people even go to the government facilities? The answer is simple; it is free. The public aid patients and the veterans get the care (if you can call it that) for free, nada, zip, $0. This is what makes many people afraid of socialized medicine. The government gets involved and everything becomes a bureaucratic nightmare and inefficient. There is no incentive to provide efficient and quality care so it simply is not offered. Hopefully if we ever turn to a socialized model it will not be run like the government hospitals are run in today's healthcare world. This kind of healthcare is dangerous.

Good bye to the kids.

I finished my rotation in pediatrics and took my exam this past Friday. The rotation was fine and I learned a lot but it confirmed my dislike for pediatric medicine. Every field in medicine has its unique problems and difficulties. Pediatrics in today's world is overrun with managed care making it difficult to even make a decent living. The pediatricians work long hours and make the least of all the specialties. Not the money is the most important aspect but you have to be able to make a decent living without working 60+ hours after all of this training.

Also as I have mentioned before, the parents you have to deal with in pediatrics make the specialty unique. In today's world every mom / dad gets on the internet and is suddenly a demanding expert on wants to run the show. You get these type of patients in other fields as well but the moms and dads tend to be much more dramatic about their kids they they would even be for themselves. You get the mom telling you why vaccines cause autism because she read blah, blah, blah. All of it is based on know real knowledge but plenty of conviction and it makes this field a little intense at times. People are passionate about their kids. I am too, so I can understand the passion but having to deal with pseudo-knowledge passion can be tough to say the least. 

Another downside for me is that the bulk of the day is dealt with treating healthy kids and really just reassuring the parents that the "ear ache" will go away and there is no need for antibiotics. Occasionally you get some sick cases which makes it exciting but you pretty much deal with a healthy population. Many doctors would count this as a strength and maybe years down the road I will say it is a strength as well but right now it is not very challenging or exciting. You are mostly seeing strep throat, otitis media, and some flu and then being told by the parents how you should be treating it. 

However I did enjoy this rotation and felt I did pretty well with it. My last 2 weeks of clinic were all in spanish as my attending was from Mexico and all of his patients were spanish speaking. It was amazing how many of the parents spoke no english. I liked it because I was able to use my spanish and it was great practice. This population was also very poor and not very educated for the most part. This patient population is actually very nice to work with. They are extremely humble and very grateful for the doctor and his / her help. They tend to complain a lot less and statistics show that they sue way less than other populations. It was very rewarding working with these patients and they were very happy that you helped their child and would hug you and express their gratitude. It was truly rewarding and I enjoyed my time with them. I could see going on medical missions and working with these under served populations when I finish my training. I came home each night feeling fulfilled and happy. I enjoyed going in each day. Also my attending let me practice with a lot of autonomy which always helps you learn much more than just watching. 

On Tuesday I start neurology which should be interesting but I am not too interested in this field. I am going in with an open mind and going to try and learn as much as I can about the diseases of the nervous system. Who knows? Maybe I will love it.

Strange faces

Today I had a very interesting case present. When I walked in the room I could not help noticing the father was very odd looking. The patient was a 3 year old female who was slightly abnormal looking. The patient was a regular patient of my attending so he was aware of the syndrome and I think he wanted to test me a see if I could diagnose the syndrome. The patient was visiting because of an ear infection and not for the syndrome. 

I am aware of a handful of genetic disorders that manifest with craniofacial abnormalities. This patient looking like she had an enlarged forehead and exophthalmos (bulging eyes) sometimes seen in Grave's disease. After I examined the girl I verified there was an ear infection I grabbed a book on genetic disorders and thumb through the section on facial disorders and quickly came across some pictures that looked like this patient. 

It is called Crouzon Syndrome also called craniofacial dysostosis which is a genetic syndrome. Basically the bones in the skull and face fuse too early and then can't expand. This causes abnormal bone growth and deformities of the face. This is a fairly rare disorder (1 in 25,000) so I was lucky to see a case. The father had a very profound case and never had any intervention. The girl's case was fairly mild. The treatment involves surgery to prevent the closure of the sutures. If there is no intervention there is a high risk of brain damage and mental retardation because the brain can't grow correctly. I think that the father had some developmental delay but he was not fully retarded. The patient's mother was normal. The patient is scheduled for surgery in the next year. 

I have included some pictures of patients with Crouzon Syndrome.

There is a Rat in the Kitchen

The other day I have this mother bring in her 5 kids which are all under the age of 8. All the kids look fine. As I walk into the room to start the exam I pick up the chart and it says "strange marks all over the body". The patient was the youngest child a 9 month old male. I had the mother place the baby on the exam table and I began to undress the infant and ask the mother questions. She began to explain to me in spanish that the baby was bitten by rats.

It was unbelievable. I had the baby lying there just in his diapers and he was covered in soars. I counted 35 in all. They looked like little bite marks. The mother  explained that their house is infested with rats and that she has talked with the landlord many times but nothing ever gets done. I explained all of this to my attending and he came in and looked and was not too surprised. He later explained that he has seen this a handful of times. We admitted the baby to the hospital and started him on rabies prophylaxis. 

The attending told her that they have to get rid of the rats. The mother explained that they had tried everything but they could not get rid of the rats and that they are trying to save money so that they can afford to move to a better place. He told her that in the meantime they need to feed the rats so that the leave the baby alone and that they need to sleep with the baby to assure that no rats can get to him. 

Wow!

On to out patient

I have now finished working in the inpatient unit, the nursery, the NICU. Tomorrow I start on the pediatric outpatient service. This entails working in a clinic near the hospital. I will see patients in the clinic from 7:00 am until 6:00 pm or so and I will also be responsible to round on any patients admitted into the hospital under my attending physician. If a community pediatrician has a patient of his / her show up to the hospital through the ER or a direct admit, the doctor has 24 hours to see the patient in the hospital and will then see the patient each day they are in the hospital. I am at a teaching hospital so the residents will also see these hospitalized patients like I did during my inpatient rotation.

Outpatient clinic is what most people think of when they think of their child's pediatrician. Most of the patients are in for ear infections, soar throats, abdominal pain, well child physicals and school physicals. Fortunately most of the patients seen in the clinic are fairly healthy and will not need to be hospitalized. The biggest role of the pediatrician in today's world is to determine the severity of the child's condition and make a diagnosis then reassure the parents that the child is ok. It is also a big challenge to try to convince the parents that antibiotics are not necessary in most instances. Many parents come in and demand antibiotics or feel cheated if their kid doesn't get antibiotics. Often parents will find a doctor that will give them antibiotics if their current doctor refuses. Most illnesses in kids are in fact viral and do not require antibiotics and on the contrary the antibiotics are dangerous for the child due to resistance build up. Furthermore even when the illness is caused by bacteria studies have shown that they will often heal without any antibiotics which explains why many kids who never see a doctor do not have chronic infections.

Most pediatricians complain about this antibiotic issue. It is a daily battle for them. There is a concern of the rare instances when a bacterial pharyngitis goes untreated and then later causes an auto immune response in the heart or the kidneys. This is very rare and also not completely proven to be caused by an untreated infection. The incidence is rare and when it does occur it is often in patients who have other autoimmune diseases and predisposed for these types of illnesses. Rheumatic fever has a similar mechanism. Also physicians do not want  to miss a meningitis. Liability also plays into the overuse of antibiotics. Doctors do not want to get sued and will practice defensive medicine and give antibiotics "just in case".  

Why is the overuse of antibiotics a bad thing? The problem is called resistance. Basically bacteria get exposed to antibiotics and have the ability to learn how the antibiotic works and then the bacteria mutates to avoid destruction by the antibiotic in future generations. If we can limit the exposure of antibiotics to bacteria we can hold off resistance. Given America's predilection to overprescribe many of our antibiotics have become ineffective. The resistance that everyone knows about is MRSA = Methicillin Resistant Staphyloccus Aureus. This pathogen is a direct result from overuse of antibiotics. 

In Europe they do not use antibiotics for Otitis Media (Ear infection) where we here in America give antibiotics like candy for Otitis Media whether they are needed or not. In Europe they have determined that the vast majority of ear infections resolve without antibiotics and they will hold off on using them until it is apparent that a child is not getting better on their own which is actually a very small %. In Europe they have less bacterial resistance.