Stuck between administration and the drug seeker

Doctor, I am in a lot of pain!!! The worst pain I have ever been in and I think I might die. I am allergic to ibuprofen, tylenol and anything else without opiates in it. Well the doctor has seen this drug seeking behavior 100's of times and it plays out in a similar fashion on a daily basis in the emergency department. The doctor can give the patient some morphine or other opiate and quickly get the patient discharged until they need another fix, but doctors generally do not like to enable these patients.

Now it get's complicated. If the doctor takes a firm stance and calls the drug seeker to the carpet the drug seeker can often (not always) become enraged and aggravated, yelling and causing a huge scene which requires a lot of other employees to get involved like security, nursing staff and others. Also emergency physicians have patient surveys that the patients fill out and describe how satisfied they were with their doctor. Was the doctor nice? Was the doctor non-judgemental? DId the doctor treat you with respect? There are other questions about patient satisfaction and a nice area for patients to write in their complaints or compliments.

You can imagine what the drug seeker writes on these surveys when he/she does not get their drug of choice. Sometimes it seems that the drug seekers who have been refused are the only patients who take the time to even fill out these surveys. As you can imagine the jilted drug seeker can get pretty creative in their complaints in these surveys. Who cares? Well, these surveys are filed in the doctor's employee file and at some hospitals tie the doctor's pay and bonus based on the patient satisfaction reports. These surveys can influence promotions or even lead to termination. A negative report / survey is filed as a negative report regardless of it credibility. The administration does not know the survey was filled out by a scorned drug seeker or a patient who was truly treated unfairly by the doctor. A negative survey is a negative survey.

What would you do? Give the patient the morphine or drug of choice? Call the patient out and refuse to enable the patient? Choice one gets the doctor out of having a negative survey and may even get him / her a positive survey and gets the patient out of the emergency department in a quick manner requiring less staff and less drama. Choice two gets an outraged often belligerent patient that requires lots of staff time and gets the doctor a negative survey and may even get the doctor in a meeting with the administration and disciplined for a negative survey in his / her file.

I see it play out every shift. Many of these same patients do not pay their bills and often are more likely to sue as well. Obviously I am making generalizations and there are many patients who truly are not drug seekers in similar scenarios but I am talking about the repeat patients that are easily identified as drug seekers not the patient's with a kidney stone in true need of pain control.

Here is a parody video that some ER doctor made and although funny I have seen this exact type of patient many times.

http://www.xtranormal.com/watch/5864157/

A Malpractice Solution

If you read my previous post then you know I promised that I would post about a possible solution for the malpractice issues that have mostly fueled the out of control costs of "defensive medicine". If you did not read my revious post then read it first here:

http://jjmedicalschool.blogspot.com/2009/12/medical-reform.html

Here is a thought: If a patient wants to sue a doctor the patient should have this right but if the patient's lawsuit is lost or deemed frivolous then the patient should be required to pay fr the associated costs that the doctor and the doctor's malpractice insurance has incurred in defending itself. I recently was in a meeting with some doctors and their malpractice insurance representative and they explained to me that in a recent frivolous lawsuit that was thrown out by the judge. However it cost the insurance company / doctor $200,000.00 to defend themselves. Even though the lawsuit was thrown out the doctors still pay to defend themselves. It costs the doctors lots of money even when they win the lawsuit just to defend themselves and this fuels more defensive / expensive medicine.

We all know that even if you required the patient who sues the doctor to pay the costs of the doctor's defense if the patient loses or the lawsuit is thrown out as frivolous that the patient will not have the funds to pay these costs and will ultimately not pay the costs. I imagine the number of frivolous lawsuits would decline if patients knew they would be responsible for all the associated costs if their lawsuit was lost.

We create a system of healthcare banks that specialize in funding a line of credit to patients who have a lawsuit against a hospital or doctor. These healthcare banks will have a comitee made up of doctors, attorneys, healthcare administrators, investment managers and patient advocates who approve or deny this line of credit. A patient with a lawsuit would not be allowed to file a lawsuit until a line of credit that was large enough to cover all associated costs of the lawsuit if the patient were to lose the case or the case was denied for being frivolous.

Let's look at how this could work. Example 1: "legitimate case". The patient suffers an amputation of the wrong leg and instead of losing 1 leg has to go back in and have the correct leg removed and is now legless and requires a wheelchair. This patient has tremendous mounting bills and will require many future medical costs due to this medical mistake. The patient now wants to sue the doctor. The patient will need a line of credit to file the lawsuit to assure all costs are paid for if the lawsuit is lost. The patient will present his case to the healthcare bank that will review the case with its committee of experts. They will see that this is in fact a legitimate case and a case that will most likely win a large settlement. It would make financial sense for the healthcare bank to provide the line of credit to this patient and when the patient wins the case the healthcare banks will make a small percentage for offering the line of credit to the patient. The line of credit is granted and the patient and his attorney file the lawsuit. The judge views the line of credit and allows the case to proceed. The malpractice insurance company for the doctor and the hospital realize that they are at fault and not going to win the case and decide to offer a settlement of $3 million. The healthcare bank gets a reasonable percentage for backing the case with a line of credit and the patient and his attorney get the rest of the funds. The case is closed.

The above case is an actual case that under our current system the patient was in a state that had lawsuit compensation caps and the patient was only awarded $250,000, the cap maximum. I am not sure if and how the associated medical bills were handled but the awarded amount was $250,000.

Example 2 "The frivolous case". The patient decides he wants to sue his doctor because he suffered a heart attack after smoking crack and claims his doctor never mentioned that crack cocaine could cause a heart attack. This doctor saw the patient one time for a cough in the emergency room over 1 year ago and as part of a standard medical history asked the patient about the use of illicit drugs like cocaine the patient denied ever using drugs. At that time the doctor treated the patients cough and told him to follow up with his regular doctor. The patient decides that he wants to sue this doctor and when he looks into suing the doctor he is told that in order to file a lawsuit he will need a line of credit to cover the costs of the case if the lawsuit is lost or deemed frivolous. This patient does not have the means to provide a line of credit so he would be referred to the healthcare bank. The committee at the healthcare bank reviews the case and quickly realizes that this would be a frivolous case and a bad case to back with a line of credit and denies the line of credit. The lawsuit is never filed.

The above case under our current system was a real case that never went to trial and was thrown out as frivolous but it cost $67,000.00 to defend and to get it thrown out. The malpractice insurance company pays these costs and the doctor pays with time and an increase in his / her future premiums and other intangible costs)

Obviously my suggestions above are filled with imperfections and needs a lot more thought put into it by qualified experts. It is nothing more than a naive concept by a medical student and others have probably thought of similar, if not better concepts, but I believe a variation of the idea could work in some degree. Lawsuit payout caps do not work because this leaves patients who really need large sums of money to pay for the care needed by the mistakes they suffered, out in the cold with insufficient funds even when they win their lawsuit. Some studies have shown that states with lawsuit reward caps have an increase in the number of lawsuits. The current system offers no protection to doctors even when they defeat a frivolous lawsuit because it still cost them (through higher premiums) and costs their insurance company to defend the bogus lawsuit.

This is just an idea. The system is broken and the true tragedy is that until hospitals and doctors lose the fear (whether real or not) that their ability to provide for their families is blowing in the breeze and ready to disintegrate at the next lawsuit you are going to have defensive medicine. The defensive medicine is a major chunk of the healthcare costs that are overburdening our system. It is easy to say "hey doctor XYZ do not run that unnecessary test that you know is not really needed!" and it is easy for doctor XYZ to think or say "it is not worth my license or livelihood to be the guy who has the rare case that would have been caught by the unnecessary test had I only performed it, so I am going to perform it because I am afraid that I will be sued if I don't and my career will be over!"

I am not saying the solution I proposed is perfect or even near perfect and a multitude of much more experienced and qualified individuals could tear it to pieces with the problems and holes it may have in it but it might be a start of some kind.

The bottom line is something has to be done about malpractice and all the issues around it both for the patients who really need compensation and for the doctors / hospitals / public who pay for the defensive medicine caused by a fear of the litigation. The problem is that all current "house policies" that I have read do not even mention any form of reform for our healthcare legal malpractice problems.

Medical Reform

I am sure that many people have many different opinions of the current state of our healthcare system. Most individuals probably base their opinions on how to fix or not fix our healthcare system based on what part of the system they have most often experienced. If you are a medicare patient and frustrated with the lack of doctors who will see medicare patients and the long delays to get an appointment you probably are frustrated with the inconvenience of trying to get an appointment with a doctor that will take medicare. If you are an HMO patient you are probably frustrated with all the rules and regulations that they are forced to follow and the lack of care they are allowed given all the HMO policies. I think you get the point.

Most people would agree that there needs to be some things addressed within our current healthcare system. I will briefly discuss 1 point today (there are many more); Malpractice.

Many people think that malpractice is a cost of healthcare but really only effects the doctors as they pay their higher insurance premiums and that very little costs trickle down to the patients or the system as a whole. However malpractice is probably the single largest cost and waste of money on the entire healthcare system. Doctors are going to get sued. We now have classes in medical school about how to cope with your first lawsuit. It is not an issue of if but more and issue of how often. So every doctor out there is trained early and often on how to practice "CYA" medicine (cover your ass). For example; if a child comes in who has a hit their head and it is a mild bump at best. The doctor knows the child does not really need an expensive CT scan but the doctor also knows that it is not worth a lawsuit to not scan the kids head and so the kid gets $1000.00+ of tests that the doctor would most likely not do on his own child in the same situation but because he knows of a case where 1 doctor got sued for blah, blah, blah... the tests are performed. This type of medicine is being practiced all day long in every hospital, clinic and surgery center throughout the USA. As you can imagine the CYA medicine singlehandedly cost the healthcare system billions of dollars in unnecessary tests and procedures.

I once spoke with an "ambulance chaser" type attorney and he told me that in order for him to make his $1,000,000.00 salary he needs to file 10 lawsuits against doctors and or hospitals / month. He explained that whether or not the case had any merit at all did not matter. He just knew he needed to convince 10 people to sue / month. He said it was easy to convince the people to sue because they had nothing to lose. The patient does not have to pay anything unless the case gets settled and if it did get settles the attorney took is 30 - 50% and the patient got their money. The attorney said the patients had noting to lose. "Why not sue" he said. So you go in for a procedure and are completely happy with your care and satisfied with the outcome, this attorney will take you case and find some area or way that he can create a complaint and then sue the doctor at no cost to you and then one day you get a call and he says guess what your case for the procedure you were happy with settled and you get a check for $50,000.00. I asked the attorney what would happen if they put payout caps on the malpractice lawsuits and he responded that instead of 10 lawsuits / month he would have to raise it to 30 lawsuits / month to keep his $1,000,000.00 salary and in the cases that really deserved a larger payout would no longer be eligible for a needed larger payout

This attorney actually said to me "you would be stupid not to sue, even if you are happy with the care because you may get a payout." This is why doctors have to practice "CYA" medicine. This kind of medicine is expensive! A CFO at a hospital I was rotating at explained to me that he estimates that they do $50 - $100 million in unnecessary tests and procedures / month in the name of CYA medicine. This is just 1 hospital is 1 community that has 7 other hospitals in the same community.

Ironically there is no mention of malpractice reform in any of the new healthcare reform policies. Many politicians, including our president are attorneys so it makes sense that this huge elephant in the room would be ignored in any new policies. There is big money in malpractice for the attorneys but if it were addressed properly it could literally reduce the need for most if not all of the other cost cutting solutions that have been proposed. Some of the other issues of course should and could be addressed but certainly the malpractice issue is being ignored completely.

What is the solution? I do not claim to have all the answers or maybe even any of the answers. I have an idea but you will have to wait until my next post to read about it. Rest assured though this malpractice and CYA medicine is most likely much bigger and more expensive than any other cost in our healthcare system and is not being addressed and may never be addressed, at least in the foreseeable future.

Finished up another emergency medicine rotation

Everyday I work in the emergency department I feel like at the end of the shift I have added more to my data base knowledge of disease and pathology. For example, the other day I show up on my shift and I had to perform a couple knee taps from traumatic knee injuries where the patients had bled into the joint space of their knee due to an injury from falling onto their knee. You have to drain the fluid and the blood if enough pressure builds up in the knee the you the patient will have their nerves and blood vessels pinched to the point of infarction. They can experience permanent damage if you do not remove the fluid.

You palpate the knee to find the fluid build up and then use a needle and syringe to evacuate the fluid. It can be hard to find the fluid filled space but once you get it and drain the fluid the patient immediately feels relief and is happy with your work. It is a great procedure.

So now I am comfortable with knee taps. I feel the whole education and training process is all about getting exposure to all the many different illnesses and procedures needed to be a good physician. Each time you perform a given procedure your skills improve and you knowledge advances. This part of the reason that the training requires so many years. It just takes a long time to get all of the procedures down. Some days I show up to work a shift with know real clinical knowledge of a given procedure other than reading about it and the by the time I leave I have performed the procedure and added it to my skill set.

It is amazing when you look back over a few months of many long shifts and realize how much learning has occurred and it keeps you going on the days when you feel like you are no where near the level that you need to be at to be a excellent physician. It is a day by day, hour by hour process and eventually you get there. I love it and enjoy the whole process. Even a bad day is great compared to some of my past jobs / careers.

More on the Match

This year the match day is set for Thursday March 18, 2010. All 4th year medical students get a letter 1 week prior to the match day that tells them if they did match or did not match. You hope that you get a notice stating that you matched. Then you have to wait a week to find out which of the programs on your rank list that you matched at and where you will be going. Following a week of torture all the 4th year medical students meet up at their schools on "Match Day" and everyone receives their envelopes and wait for the official signal and then tear into their letter to see where they and their family will be going. This occurs on Match Day at all of the medical schools across the country on the same day and at about the same time.

For most it will be a day of happiness and celebration but for some it will be a day of frustration and or panic as they find out they matched at a program that hey really did not want to go to or they do not match at all and have to enter the "scramble".

The residency programs get their list of new residents for the upcoming year (their program's match list) on the same day and they learn who they get at their program. This can be a happy or sad day for the residency programs as well. They may have a spot or 2 not filled or they may have drawn from the end of their match list and not matched the rockstar students they had hoped to get.

In the more competitive fields there are very few (if any) spots that go unmatched and there will be several applicants that do not match at all. These students will have to either scramble into a different (less competitive field) or take a 1 year general internship and reapply the following year. In the less competitive fields there will be several programs that do not fill all their spots and will have to try and fill the spots in the scramble or leave the spot unfilled.

Emergency medicine is more toward the competitive side on the scale of competitiveness but not as competitive as the super competitive specialties. Last year there were only 5 or 6 unfilled spots that were immediately filled before the scramble even really began. There were many applicants in emergency medicine that failed to match and had to change their specialty of choice or make a new plan. This year looks like it may even be more competitive as most of the emergency medicine program directors I have spoken with have said that they have seen at least a 10% increase in applications from last year. Some of the programs will get 800+ applications for 10 spots.

It should be interesting.

Residency and the Match

I am asked about how a medical student gets accepted to a residency program once they finish medical school. I will try to explain the complicated process here.

It is called the match. During the 3rd year of medical school you rotate through all of the required rotations for 1 - 2 months per rotation. The rotations include surgery, internal medicine, pediatrics, ob-gyn, family practice, psychiatry and some others. While doing these rotations you work as a "doctor in training" seeing patients and learning how to be a doctor. During these rotations you are supposed to figure out what kind of doctor you want to become.

The 4th year of medical school is about doing rotations in the specialty you want to go into and doing other electives that may relate to the specialty you want to pursue. There are some required rotations during 4th year as well. I want to go into emergency medicine so I have done several rotations in emergency medicine. Another strategy during 4th year is to do the rotations in your specialty of choice at programs that you are applying to so that the program can get to know you and you can see if you like the program as a potential place to train at for residency.

In the beginning of the 4th year you apply to programs in the specialty you have chosen and hope to get interviews. Depending on the specialty and how competitive it is, you may apply to a handful of programs or many programs. Once you have completed your applications you sit back and hope that you get several interviews. If a residency program is interested in an applicant they will offer an interview to the applicant. You go to the interviews and check out their residency and you try to impress the program.

Once you finish all of your interviews you submit a rank list in oder of where you want to do your residency. For example; if you have 10 interviews that you went to, you would rank these programs from 1 - 10 (1 being your top choice and 10 being your last choice. The residency programs rank the applicants that they interviewed. Often a program will interview 100 applicants and so they will rank the applicants from 1 - 100 (1 being their top choice and 100 for their last choice). On a certain date the all of the rank lists are due and processed by a computer program.

Then about half way through the 4th year of medical school there is a match day where you receive a letter with the rest of the nations medical students and you open it to find out if and where you matched. You can only match at 1 residency program and you are contractually obligated to train at the program you match at and they are obligated to take you as a resident. Every year there are many students (even competitive applicants) that do not match for one reason or another. There is a program called the scramble where residency programs who did not match all of their spots and unmatched applicants can call, fax, and email each other to try and get a spot or fill their residency program.

It is a rather complicated process but it has been used for years and seems to work well. Basically the program you rank the highest that ranks you high on their list as well will be where you match. The match day is a very exciting day because you find out where your next several years will be spent.

Healing Touch

There are certain cases that are such a joy to treat in the emergency department. One of those cases is called Nurse Maid's elbow. The reason it is a joy to treat is that you can take away the pain and restore the patient's pain free status. Ultimately the patients are very happy with their doctor. This usually occurs when a young child is tugged by the hand and causes a type of elbow joint dislocation. It can be very painful and only occurs in younger children because of their specific anatomy allows for this type of dislocation. Older children and adults have different shaped bones making this type of injury unlikely.

I had a young patient brought in by the parents. They were shopping at a big department store and the father was holding hands with the child and they were looking at some ornaments on a tree. The child was trying to grab some of the ornaments off the tree and the father tugged the child away from the tree. The parents heard a popping sound and their child began crying out in excruciating pain. The parents were scared and the father felt guilty.

I entered the room and the crying child began to cry even more and shouted out to me "go away, go away, go away now!" The parents were embarrassed and told the child to not be rude. Then the child blurted out "you are stupid!!" I smiled and carefully approached the child and explained the diagnosis to the parents and eased their concerns and fears. I also explained the cure / maneuver to reduce the injury and relieve the pain. The father while holding the screaming child gave me the indication to proceed with the maneuver and I took the child's arm and moved it in a fashion that restored its proper position. It takes a lot of force and the child usually screeches even louder but only for a second or two and then slumps in relief as the pain subsides. I performed the maneuver successfully.

You relief and thankfulness was palpable and auditory as the parents verbalized their thanks. I told them to wait for five minutes or so and that I would return to make sure that the arm / elbow was back to normal and check to see if there was any nerve damage from the injury which can occur in some occasions. I returned and completed the proper examination of the child's arm and all of the neuro functions were intact and appeared to be normal. The child was smiling and happy playing with a toy and the parents were beaming with a sense of relief.

I explained that the nurse would be in shortly to discharge them and then turned to leave the room when the child said "doctor, I am sorry I said you were stupid" I kneeled down to the child's so we were looking at each other eye to eye and said "I understand that you were in a lot of pain and scared. Thank you for apologizing that makes me feel so much better and now my feelings are not hurt anymore." The child smiled and said "thank you." Then as I left the room the mother stood up and before I knew it she gave me a big embrace and said "thanks for fixing our little baby and thanks for not ruining a teaching opportunity by telling our child that it was ok to call you stupid."

I smiled and said "thanks" Now I can fix your child but your husband needs more help than I can offer so you are going to have to fix him." We all laughed, especially the husband as he confirmed my diagnosis. I said to the mother "don't worry about it, my wife has the same task with me and it is a life long process to fix a husband." We shook hands and I left the room. I walked towards the room of my next patient, a 55 year old man with chest pain and I smiled and thought to myself "I love this job!"

This is why doctors have certain diseases or problems they like to treat or fix.

Time of Death

Most people I imagine do not think about the concept of "time of death". While working in the emergency department you have to have this "time" in the back of your mind at all times. Immediate death is what we are trying to prevent in the emergency department which is a different approach than many other fields of medicine.

This week I have had the sorrow of having to declare the time of death on 2 patients. The patients keep coming and you must keep working. Often you do not even have time to reflect on the whole process of declaring someone dead until well after your shift while lying in bed or while driving home and then a flood of emotions enter your mind. You work like crazy to save a patient who is dying and you when that effort fails, you declare the time of death. This is just a technicality that society requires doctors to do. It is not like the patient actually died at the exact time the doctor declared the time the death. Often we do not know when exactly or technically the patient has died.

This week I had an older individual that had a heart attack right in front of all of his family visiting for Thanksgiving. We could not save him. He most likely died well before his arrival to the emergency department even though he arrived to us with a weak pulse it is hard to say that he was actually still living. We gave it every effort. My other patient was a young patient involved in a motor vehicle accident and that was a tough case. It was especially difficulty telling the family that they just lost their child. Again we tried everything to save the patient but finally I had to declare the time of death.

All in a days work...... I guess.

Another EM Rotation Done

I finished up another rotation in emergency medicine. This time I worked at a large government hospital where no one has to pay for any care. It was an extremely frustrating experience to say the least. There was so much "red tape" and "hoops" to jump through that it was nearly impossible to practice good medicine. The supplies and equipment were sub par and non existent. The excuse was always "we do not have the funding". The technology and equipment that was there was outdated and not comparable to any modern hospital. The employees complete lack of desire and motivation to do any work made treating patients difficult. Emergency medicine is certainly a team sport and when a large portion of the team does not care enough to put any effort in, you can imagine how inefficient the process becomes.

I am glad that I did my rotation here because it confirmed that this is not the kind of program that I would want to train at for residency. The average wait for patients to be seen by a doctor was often more than 18 hours. Once the patient was seen by the doctor it seemed that the entire goal was to do the least amount of work possible and then get the patient out of the ED to be someone else's problem. Then the patient was shuffled around by the other services in the hospital. It was truly unbelievable. I think anyone who is a proponent of socialized medicine in America should come and witness the disaster that is called medical care at government hospitals. Even when the doctors at these hospitals are top notch as many of them are, they are handicapped by the ancillary services that are inefficient or even worthless.

For example we had a patient that we needed to get a test done immediately so that we could make the correct diagnosis and start the proper treatment. Without the test we could not begin treatment or it would be dangerous for the patient. I make the call to the department that handles the test and I explained that we needed the test ASAP. They responded that they were on a mandatory break and could not perform the test at that time. I begged and further pleaded my case only to be hung up on. Ultimately this case turned out ok because I was able to work around the given test but it certainly delayed treatment. This kind of scenario is a daily frustration and many times the end results are not favorable.

Also this hospital is hemorrhaging money and continuing to use up tax dollars to provide subpar services. The medical system is in need of fixing but the idea that the government can somehow run it seems unlikely given my many experiences working at multiple government hospitals. I certainly do not claim to have the perfect solution but I think the solution should not include anything that resembles the VA and County hospitals that are scattered throughout the USA. The patients do not pay with money but they do pay and it can be far more costly than any amount of money.

Great Night

I like working overnight. There is a certain buzz in the air from midnight into the early hours of the morning. None of the administrative heads are there so the staff seems a little more laid back and not on edge. It is less formal. The individuals that work nights are also a little more interesting so all the nurses and ancillary staff have a different vibe. I like the night.

Last night I worked from 11:00 pm to 8:00 am and my most interesting case was a 54 y/o alcoholic male who was found on the street in a pool of blood. After cleaning him up and looking for the source of the blood we were able to determine that it was coming from his GI tract. Ultimately he became fatigued with his breathing and I watched as he struggled know that we were going to have to intubate him.

I was able to go to the head of the bed and with the senior resident helping I intubated the patient. First you pre-oxygenate the patient by giving 100% oxygen. This helps his body build up reserves so that he won't crash while you are trying to get the breathing tube in and he is getting no oxygen. Then you administer a few medications to paralyze and knock the patient out. Once the patient is out you use an instrument to expose the airway through the mouth. Once you see the vocal cords you know you are there. You slip the tube between the cords and push it down the trachea. Once in place you supply oxygen and listen to both lung fields to make sure you are in the correct place. You also check placement with a chest xray.

Following successful intubation the patient is hooked up to a ventilator and remains in a sedated state while the various health problems are addressed and hopefully fixed so that the patient can be weened from the ventilator. Intubation can be a stressful procedure because the clock is ticking and many times due to anatomy or other factors it can be difficult to find and get an airway. While you are attempting to intubate the patient is not receiving oxygen so you have to be quick. There are also a handful of complications that can occur as well which also add to the stress of the procedure.

I love it. It was a great night. The patient lived.

How many pillows do you sleep on?

A 51 y/o African American female presented with shortness of breath. She had noticed that about 1 week ago it became difficult to do anything without becoming winded or worn out. She thought that maybe it was asthma or something. Tonight it had become worse and she was starting to have chest pain as well so her husband drove her to the hospital.

I entered her room and looked at her propped up on several pillows and struggling to get oxygen. She was an obese women who claimed to have no past illnesses. She was not taking any medications. Either she was very healthy or had not been to her doctor in a long time. I worried that she may be having a myocardial infarction and ordered an EKG.

I asked her if she found that she woke up in the night and felt like she could not breath. SHe said "How did you know?" She was waking up 2 - 4 times a night and would stand by the open window to catch her breath. I examined her legs and she had pitting edema. I asked her how many pillows she was sleeping on. She told me she sleeps on 4 pillows to prop herself up.

Her EKG came back unremarkable and her cardiac enzymes were negative which suggested that she was not having an MI. We ultimately determined that she had congestive heart failure (CHF) and admitted her to observe her and pull some of the excess fluid out of her. I explained to her and her husband what CHF was and how we treat it. I then admitted her to the hospital and talked with the hospitalist who would manage her for the next day or so.

CHF patients suffer from their heart just not cutting it anymore and they become congested has fluid backs up into the lungs. This makes it difficult to breath and they often have to prop themselves up on several pillows when they sleep to get enough oxygen. If they lay flat on their back their lungs become more congested due to gravity making it even harder to breath. Often a classic diagnostic question will be "How many pillows do you sleep on?" There are a few different ways to treat CHF all of which entail helping the heart to better do its job.

18 hours, for what?

I have had some interesting cases this week in the ED. The first case was a 33 year old female who came in to the ER with complaint of a rapid onset of shortness of breath and cough. She described it as not being able to breath and that she was sure she was going to die to the triage nurse. The nurse measure her oxygen saturation and determined that the patient was not in immediate danger of expiring. In fact her oxygen levels were normal. SHe was sent to the waiting room to wait her turn with the other non-emergent emergencies.

She waited 18 hours to see me. The ER was completely out of control with multiple emergencies and non-emergent cases so the wait was extra long. I look in the computer to read about her case and then make my way to the bed 47 to she how she was breathing. The patient was in no acute distress and seemed to be fine. I asked about her shortness of breath and her cough. She said "oh doc it is really bad! I can't even breathe. I listened and fully examined her and there seemed to be nothing wrong. She asked me "hey doc did you run a pregnancy test on me?" I explained that it was common procedure to run a pregnancy test on every women of childbearing age, she was obviously aware of this procedure. I told her that her pregnancy test was negative and she immediately stood up and began removing her gown and putting her street cloths back on.

I asked her what she was doing and she said that her cough was gone and that she felt all better. She was on her way out when I said "you know that you can buy a pregnancy test for a few dollars and not have to wait 18 hours for the results." She did not reply and headed for the exit.

Back in the saddle

It is good to be back in action. I worked yesterday and today and saw all kinds of crazy pathology in the emergency department. I walked into the emergency department and felt like I was at home. It is where I belong.

Today I had a patient that was complaining of a strange rash on his palms of his hands and soles of his feet. There are not a lot of diseases that manifest with this kind of rash. Usually it is either Rocky Mountain Spotted Fever or Syphilis. Sometimes scabies can present with marks on the palms but usually scabies presents in the webs of the fingers and toes. I worked the patient up and figured that it was pretty certain he had syphilis.

I ran a couple of syphilis tests and sure enough they all came back positive. We do not see a lot of syphilis anymore because of active use of antibiotics. If we see syphilis at all it usually is primary syphilis which presents as a lesion on the genitals. If the patient goes untreated they can progress to secondary syphilis which presents as a rash, often on the palms and soles. If secondary syphilis goes untreated it can ultimately lead to tertiary syphilis which presents with neurological signs and the patient can go crazy. It is almost unheard of in the modern world to see tertiary syphilis but I imagine it still occurs in certain populations. Even secondary syphilis is fairly rare.

Given the population I am seeing in this emergency department I will see all kinds of rare and weird pathology.

Catch up with Updates

Ok! Maybe it took longer than a month. I have been crazy with my studies and teaching a class to 1st and 2nd year medical students.

I took my exam yesterday. It was the USMLE Step 2CK (CK = clinical skills). This exam is required of all medical students in the USA and is normally taken during your final year of medical school. It covers all the clinical knowledge you are supposed to know by the time you graduate. It is a 10 hour exam and pretty tricky. It gives residency programs a good idea of where each applicant stands as far as their clinical knowledge.

I finished the exam which is a great feeling. I will not have my results for 3 - 6 weeks. It is hard to predict how you did. Everyone leaves the test feeling like they got kick in the gut no matter how well they end up doing on the exam. I will have to wait and see.

I have been studying over the past couple of months and more intensely this past month. I started a rotation at my school where I get credit for helping to teach a class called Essentials of Clinical Reasoning. I teach 1st and 2nd year medical students how to do physical exams on patients. I also write test questions for the exam. I really like doing this and enjoy the interaction with the students and the doctors who actually teach the course. I never really imagined that I would enjoy teaching but I guess I do.

I do not think I will choose a career in academia but you never really escape teaching as a doctor. You always have a student or resident or nurse or someone else asking questions and you end up doing some form of teaching throughout your career. It is convenient that I enjoy it. As a student I always like working with doctors who enjoy teaching because they make the work / rotation so much more interesting and worthwhile. Often you work with a doctor who does not like teaching and then you get the bare minimum of instruction and a lot of learning opportunities are missed.

I have also been busy applying for residency. I have applied for a residency in Emergency Medicine. So I will be an ER doctor. I will write more about this application process and the match in another post. It is worthy of a dedicated post.

My last day of this rotation / course is tomorrow and I will be teaching how to do a neurological exam. It should be fun. Then on Monday I start a rotation at a big teaching hospital in emergency medicine. This rotation will be like a tryout or audition because I have applied there for residency. It should be intense and exciting all in one. I think they see about 2 gunshot wounds / day on average. That makes for a great learning environment. They also will have me manage most of my patients on my own. Basically as a 4th year medical student going into emergency medicine they will treat me like an intern and give me the same responsibilities to see how I perform. Obviously I will have an attending physician watching out for me to answer my questions and to be my safety net. Hopefully I will not need to rely on my attending physician too much.

This rotation will be stressful because it will be like a month long job interview. On the other hand it will give me the opportunity to see if I would want to go there for residency. It is kind of like a test drive for both the residency and the applicant. I am sure I will have a lot to write about.

Have you waited long enough? Part 2

This is the continuation from the August 4th blog. Sorry for the long delay. I have been preparing for my next board exam. It is in 2 weeks and I have been locked down studying. Here we go..

I held tight to the IV that I had worked so hard to get into the vein. The patient continued to heave while I secured the IV. I looked up at the nurse and she apologized with a smile as I looked at my once freshly pressed white coat now stained with blood. I handed the IV port to the nurse so she could begin siphoning off the blood that was needed for all the lab tests we were about to order. I took my stained lab coat off and threw it in the biohazard bin. This coat was too far gone with 40 - 50% 3rd degree stains there was no saving this coat. I washed my hands and arms in the exam room sink while the nurse continued to get the blood samples.

The patient slumped back on the exam table and moaned interrupted occasionally by surging dry heaves. I asked the husband several questions about his wife and her condition. He explained how they had been enjoying a nice evening when his wife became violently ill. He seemed oblivious to the fact that his wife looked as though she had been covered in yellow highlighter which told me that she had been yellow for a while and the onset was insidious. I asked about her drinking and he boldly denied that there was an issue with alcohol. "we only drink socially" he said. I quietly thought to myself, they must be pretty social people because her condition screams 30 years of being extremely social.

I returned to the moaning patient to examine her and continue my quest for clues. The dry heaving had subsided and I needed to get a nasogastric tube in her nose and to her stomach so that I could determine if she was actively bleeding. Many alcoholics will have a gastric bleed that can be life threatening if it is not stopped. I put on new gloves and grabbed the tube. I knew this was going to be a wrestling match to get the tube placed. The nurse helped secure the patient as I prepared the tube and numbed the patient's nose and throat with some lidocaine gel. I inserted the tube in the patient's nose and she bucked and kicked. I asked here to swallow and told her it would all be over soon if she cooperated. To everyone's surprise she swallowed without any issue and I was able to pass the tube all the way into her stomach.

I hooked the other end of the tube up to the suction and flipped the switch. I watched as a blackish red fluid began to flow from the patient's stomach up her esophagus and out through her nose. This fluid started to fill up the bucket that was attached to the tube. I had several spare buckets ready to go. I continued to push saline into her belly at the same time. This process requires that you continue to fill the patient's belly with saline and then suction the stomach until all you see is clear fluid coming from the stomach. If you do not get clear fluid and it remains red then you know you are dealing with an active bleed. Alcoholics bleed.

I leaned against the wall and watched as the fluid continued to come out. I hoped that the color would begin to fade from black red to clear. I looked at her nervous husband and could tell he loved this women and I wondered what their life had been like. How many kids did they have? What kind of work did he do? What kind of work did she do? Did they have any grand kids? How did they meet?

My thoughts were interrupted when I noticed that the patient's hand began to flap. It was like she was trying to clap with one hand. I had seen this before and knew what it was, this was asterixis.......

To be continued.... (It won't take a month this time)

Emergency Reflections

I have been finished with my recent Emergency Medicine rotation for a couple of weeks now and have not had the opportunity to write much lately. So I thought I would post about a cases I had in the emergency department. I am going to post it in first person story form. 

It was about 1:00 am when a older looking women carried by a man was violently heaving blood into a metal kitchen usually used to cook a Sunday dinner. I glanced up from the chart I was working on and I was nearly blinded by the bright yellow glow exuding from her skin. I have seen jaundice many times but this was a bright yellow and her eyes were also taxi cab yellow. The pot was filled with bright red blood. She continued to purge blood from her innards into the pot and the bright red blood popped against her bright yellow skin. It was actually a beautiful combination of colors, like a modern painting. 

This women is sick, I thought to myself as I helped move her onto the bed in the resuscitation  room. As I looked at the bright colors I quickly ran down the differential diagnosis in my brain. What is wrong with this lady?  I looked her up and down and looked at the man who had carried her here and I assumed that he must be her husband. The yellow skin and eyes was a sure sign of liver involvement. Liver pathology in America often means alcohol. I was quickly cataloging and searching in the file cabinet in my brain for everything I knew about the liver and liver disease. I was flooded with information and experiences that I have gathered over last few years. 

As I questioned the patient and began stabilizing her and talked to her husband the clues began to accumulate. The most helpful and telling clue was the stench of alcohol that filled the air. The nurse was struggling with the IV, she could not get it in and we needed access to the patient's blood. The nurse looked at me and said "doc, can you help me with this?" I wondered if this patient had hepatitis or AIDS. I had gloves on at this point and I grabbed the IV from the nurse and began feeling and looking for a vessel to exploit on the patients arm. It was small but I was confident. I began inserting the IV and all was going smoothly when the patient began surging and I knew what would happen next. I had realized I was in the vein and I did not want to loose this IV so I held on strong as the patient heaved blood all over my arm. My lab coat was speckled with bright red blood. 

I got the IV in......

To be continued.

Goals in the ED

When I walk into a patient's room in the emergency department (ED) I have 3 questions in my mind. 1) What diseases / pathology can kill this patient given their presentation? 2) What can I do for this patient while here in the ED? 3) Where is this patient going, following my treatment? 

It is important to make sure that I do not miss something that could kill the patient if missed. Fortunately I have lots of back up at this point in my training to make sure I do not miss something. In order to rule out things that may kill the patient I may need to do a thorough history and physical exam. I may also need to order certain imaging and lab studies. Eventually when I have ruled out things that could kill the patient and in the process narrowed down their diagnosis I can start a treatment plan. Finally I figure out where the patient needs to go. I could discharge the patient home, admit for observation, admit to the ICU, send the patient to the OR for surgery or several other options. Then I need to make this happen which may include getting a specialist involved or talking to the patients family. 

This is a very basic outline of some of the ED physician responsibilities. It can be easy to assume the patient is fine and just discharge the patient without worrying about some of the other things but this is a rookie mistake and will eventually get the ED doctor in trouble. 

These are just a few of the thoughts that go through my head as I meet a new patient and their family. 

Inside Emergency Medicine

I am really getting the whole idea of what it means to be an emergency medicine physician. Every specialty in medicine / surgery has their own niche in the medical world. As you finish medical school and pick the specialty you want to pursue you have to have a paradigm shift. Medical school is all about general broad level learning. You have to learn a good amount about a lot of areas of medicine. During residency you focus the learning to know a lot about your area of expertise. I am starting see what will be necessary to learn / master in order to be an excellent emergency physician. 

The unique thing about emergency medicine (EM) is that it requires a broad knowledge on a ton of subjects within medicine and surgery. You basically never know what is going to come through the door. It can be a trauma to any given area of the body, fracture, delivery of a baby, heart attack, stroke, seizure, pediatric diseases, gun shot wounds, suicide attempts, etc. You have to be prepared to see every area of medicine. You mostly focus on the acute treatment of these pathologies. You are not there to treat the chronic pathology although you are forced to treat some chronic condition for those who use the ED as primary care. It can be overwhelming because you have to know a lot about a lot.

You will end up admitting about 30 - 40% of the patients you treat into the hospital which means the remaining 60 - 70% you treat and send home and you are the patients only contact with a physician for the given problem. You are the frontline of medicine and often your diagnosis and starting the treatment will guide the rest of the care for those patients you treat. This means you have to get it right because the doctors who will go on to treat the chronic side of the pathology will rely on your diagnosis. If you get it wrong then the remaining care is often wrong as well. You have the potential to get everyone on the wrong path or steer them onto the correct path to wellness.

There is a lot of liability and lawsuits in EM. You have to juggle many complex patients at the same time. While you are delivering a preterm infant you have a patient in respiratory collapse in the next room and blunt trauma from a car accident in the trauma bay and you have to manage all of the cases, particularly if you are the only doctor working the ED that shift. Another frustrating aspect of EM is that it is always easy for others to see your mistakes in hindsight. The critics always forget that you are working under extreme time pressures and with many other patients and generally without a diagnosis. You have to simultaneously diagnose and treat all at the same time. 

EM can be fairly demanding and thankless to a certain degree. You either love it or hate it. So far I seem to love it.

My Play Ground, The Emergency Department

I finished up my first week in the emergency medicine. I have seen so many wild cases. I have had 3 gun shot wounds, 2 stabbing, car accidents, trauma, liver failure, drug overdoses, diabetic keto acidosis, drownings and a bunch of seemingly more boring cases. In the ED you get your hands dirty and you get to do lots of procedures. I never know what I am going to see prior to each shift which makes it exciting and never boring. I will try to document some interesting cases over the next few weeks.

My attending shouted across the room and said "will you go see the patient in room 11 and I will take care of room 8". I yelled back "no problem" and quickly made my way to a computer to see if I could see what was waiting for me in room 11. I scanned the computer screen and saw the words spider bite on the screen. "Easy enough" I thought to myself. The patient had been here for 3.5 hours so if it had been too bad or poisonous I am sure we would have already treated the patient. I opened the curtain and saw a large African American male with a baseball cap on backwards and arms covered in gang tattoos. I introduced myself and asked "what brings you here today?" He glanced up and replied "doc I think I got bit by a spider or something and it hurts!"

I looked at his arm where the alleged spider bite was supposed to be and sure enough he had a large bulging bump on his forearm. I began to examine the bump and ask the patient about when, where and how this happened. It did not look like a spider bite to me. It looked more like an abscess and I noticed a "head" in the middle of the bump. I began to ask him all about his medical history and his life to see if I could piece together an explanation. He explained that he never saw or felt a spider bite him. He just assumed by looking at it that it must be a spider bite. He explained that he worked as a barber and as I looked closer at the bump it looked a lot more like folliculitis (infected ingrown hair). It certainly was infected which meant it needed to be opened up an drained and packed. 

I left the room t present the case to my attending physician and get the supplies to fix the abscess. The attending physician poke his head in and looked briefly at the abscess and told me that he agreed with my findings and to "just take care of it". I returned with all the tools and medication to fix it. I injected the lidocaine to numb the area and then made a small incision to avoid any important structures in the arm. The pus began to flow like a river out of the abscess.

As the pus flowed I realized that there were a few small hairs in the middle of the abscess and I cut them out. It looked like the source of the problem. I showed the patient and explained to him the pathology behind  his abscess. 

I nursed as much fluid out as I could and then used forceps to break apart the abscess and proceeded to clean it out completely. The patient could not watch the action and continued to look away. Finally I packed the wound and bandaged it up. He felt a lot better because I had relieved most of the pressure when I cut it open and drained it. 

The patient thanked me and I sent him out. I am not so sure that this was an emergency but we took care of it anyways. 

Emergency Medicine (EM)

Life is good in the Emergency Department (ED). They do not like it when you call it ER or emergency room (whatever). I am in the middle of a month long rotation at an inner city emergency department. I am using this rotation to hopefully "wow" them so they consider my application when I apply. It is like a month long interview. This makes the experience a little more intense because you are on edge and trying to impress everyone. I really do like EM. It feels like I was born to do this. 

I just completed the first week of the rotation. I have had so much exposure and hands on experience. The attending physicians tend to give you more respect and trust you slightly more as a 4th year medical student. During my 1st shift I was talking to the head doctor of the ED and he basically told me that I have free reign and can do as much as I would like and the only way I would get in any trouble is if I get in over my head and do not ask for help. My first couple of shifts they watched me closely to make sure that they could trust me and also evaluate my abilities / knowledge. This of course was not openly discussed but by my third shift I felt that I had gained their trust and the "set me free" to work like a resident which is still under supervision but I was able to do and see a lot more.

I like the excitement and the constantly changing environment of the ED. You never know what is going to come through the door. It could be a gun shot wound (GSW), a laceration, MI, stroke, motor vehicle accident (MVA) or a headache. You see it all. It is fast paced and always changing. You either love it or hate it. I guess I fall into the "love it" category". It is never boring. Another great thing about the ED is that you get to do lots of procedures, put in central lines, laceration repairs, intubate, cardioversion, set broken bones, chest tubes, nasogastric tubes, ultrasound guided procedures, etc. So far this week I have done several wound repairs with sutures and staples, paracentesis (draining fluid out of the belly), chest tube for a collapsed lung, several nasogastric tubes, chest compressions, set fractured bones, fix a dislocated shoulder and it has only bee 1 week. 

4th year! I am in my last year.

I have officially finished my 3rd year of medical school and I am no longer a junior medical student but now I am a senior medical student. As a 4th year student you receive less of a beating from superiors but you are also expected to know more and be able to do things. 

What is the difference between 3rd year and 4th year? During 3rd year you are required to complete all of the required core rotations. These include rotations in pediatrics, internal medicine, surgery, etc. Generally you are there to learn the basics and you are not required to have a ton of responsibilities. You do get grilled a lot on the basics. During 3rd year ideally you should figure out what you want to specialize in and what residency you want to pursue.

4th year is all about doing electives in the area of medicine that you want to pursue. You can use these rotations as an extended interview to showcase your abilities at programs that you want to apply to for residency. Also during 4th year you apply to residency. You have to submit all of your applications to residency programs. If a program likes you application you are then offered an interview which are done October - February. Then in March you find out where and if you matched at a residency program. During 4th year you also have a little more free time and the attending physicians are easier on you because they know that next year you are going to get slammed during your intern year. 

This week I started my first 4th year rotation. I am doing a month long rotation in emergency medicine at a teaching hospital. I have only had a couple of shifts so far but I love it so far. 

I shrunk the fetus.

So I was on the MFM service the other day and the attending physician who is very well respected and a talented clinician was supervising my work. I had worked a couple of shifts with him and I was slowly proving to him that I was not completely inept. However I still had a long way to go. This doctor is well known among the students and the residents for having a very "in your face" style of medicine. You had to have thick skin and realize that this is just how he taught. He likes to ask you progressively more difficult questions and when you miss one he goes overboard; "doctor you have disappointed me!", "Unacceptable, how do you not even know the very basics?", "you are a danger to the medical community", "did you read anything?" "what is wrong with you?",  "You do not know anything!" Following his hoopla he begins to teach you like no other can. He has vast amounts of experience and really knows medicine from every angle. More importantly he takes the time to teach you and he really does care about your learning and knowledge.

He gives you a lot of autonomy to perform the ultrasounds and make all the measurements of the fetus. Of course, he checks your work and determines if you are doing the ultrasound correctly. Many students become nervous on their own and while taking measurements / pictures with the ultrasound they can back into the numbers by figuring out how old the fetus is and what the fetus's measurements should be. Students can "cheat" this way and everything will be correct if the fetus has progressed normally. If you have a fetus and according to your ultrasound the fetus is measuring small for it's age you can adjust or re-measure and try to get normal measurements. If you report that the fetus is small according to your ultrasound measurements and when he checks the measurements he finds the fetus to be normal size you are going to get an earful about not knowing / understanding how to do ultrasounds. Many students will "fudge" their numbers. 

I had a 22 week pregnant mother who presented to have her baby measured and evaluated via the ultrasound. She had had a normal pregnancy up until this point. I made several different measurements and they kept coming up small. I looked in the chart and saw that the fetus had normal measurements 10 weeks ago. I continued to work the ultrsound and finally had confidence in my measurements and recorded my findings. I stepped out of the exam room and found the attending physician and explained that the fetus was small. The doctor immediately squawked "you have no idea of what you are doing! I am sure the fetus is normal, go remeasure it!" I replied; "actually I think that this fetus has asymmetric intrauterine growth retardation (IUGR)and I am confident with my measurements." In a huff he ran to my exam room and began to ultrasound the patient and her fetus. As he was doing this he continued to explain that I do not know what is going on and I need more practice / experience. I noticed as he was measuring he kept getting similar measurements to what I had found. He would quickly remeasure and check again. Finally after realizing my measurements were accurate he blurted out: "Doctor you have shrunk the fetus! What did you do?" This baby has asymmetric IUGR. 

On his way out of the room he said "good job doctor! at least I know you do not cheat with your measurements, which is more than I can say for a lot of the residents! Nice catch!" "Now get back to work!"

Maternal Fetal Medicine

This week I have been on the Maternal Fetal Medicine (MFM) service. MFM is a specialty fellowship that some OB/GYN doctors do to get specialized training in the management of high risk / complicated pregnancies. These pregnancies include many different scenarios. For example they manage complicated multiples, drug addicted pregnancies, pre-eclampsia, pre-term labor pregnancies, maternal disease / illness pregnancies, etc. If a pregnant women is being cared for by her regular OB/GYN and he/she determines that there are or will be complications in the pregnancy then they will refer the mother to a MFM specialists. Some regular OB/GYN's may continue to manage high-risk pregnancies but usually when it becomes too complicated they will refer out. MFM doctors spend all of their time managing difficult pregnancies with complications. 

I liked this service because most of the cases were interesting. The mothers I saw and helped with their treatment would have lost their pregnancies 20 years ago. However because of advances is knowledge and technology we are now able to help a lot of these patients have successful births. I would see women in the MFM clinic all day that were either regular MFM patients that we were monitoring or they were new patients referred to MFM to be evaluated. I would  ultrasound the mother's fetus and measure the amount of amniotic fluid, check the cervix and then make management discussions based on the findings. I would present my findings to the MFM attending physician and he would check my work to make sure I had the correct measurements and interpretations.

I saw pregnant drug abusers, diabetics, cancer patients, pre-eclampsia, seizure disorders, triplets, quadruplets, heart failure, kidney disease, and many other diseases. All of these patients had one extra complication; they were pregnant. With the proper management many of these mothers will go on to have a fairly normal birth. However there were also many who would end up with fetal demise or severe complications that would affect the mother and the fetus. MFM believes that you treat the mother first and then the infant. This is a complicated and controversial. Some of these cases were sad and involved difficult scenarios where entire families were involved and concerned. 

I did some many ultrasound evaluations this past week that I feel pretty confident in using an ultrasound to evaluate pregnant patients. I can determine the age of the fetus, the sex of the fetus and many irregularities with ultrasound. I am glad I had this opportunity and the attending physician gave me a lot of autonomy to learn by doing. 

Labor and Delivery Nights

Last week I was on L & D nights which started at about 5:00 pm and went until 9:00 am the next morning. I had some long nights but I really liked the work. I hated being away from home and when I was home I had to sleep while everyone was up. That part was not fun and I think it gave me a taste of what some of my residency will be like. Basically, with a long schedule like that you pretty much just work at the hospital and sleep with no time to do anything else. 

Like I said, I did enjoy the work. I was in charge of evaluating any new patient sent to L & D by their private doctor or by the Emergency Department. Many of the patients were in real labor and showed up to deliver. There was also a large group of patients who were in false labor and finally we had many who were in preterm labor with complications. I would examine each of these patients, I would take a detailed OB history asking about their number of pregnancies last menstrual period, Expected due date, related problems, past medical / OB history, etc. Then I would do a cervical exam to determine the status of the cervix, I would see if the cervix was dilated. I would also take samples of fluid to test for certain infection like gonorrhea and chlamydia. I also would test the fluid to determine if it was amniotic fluid. You put the fluid on a slide and let it dry and then look at it under the microscope and if you saw "ferning" you could figure that there membrane had ruptured (water broke). A second test for ruptured membranes that I also did was nitrazine paper test. If the nitrazine paper turned blue when exposed to the fluid, it also indicated membrane rupture. The nitrazine test reacts to the pH of the vaginal fluid. Amniotic fluid has a more alkaline pH compared to the normal vaginal fluid. 

If the patient had premature rupture of membranes then we had to manage them according to how far the pregnancy had progressed.  Following these tests / exams I would do an ultrasound to determine how the fetus was doing and look for any complications. I also would hook the patient up to a fetal monitor and check the fetal heart tones and monitor contractions. By the end of the week I could go through these exams fairly quickly and determine if the patient needed to be admitted or discharged. This was a good rotation for me because these skills will be required in my residency and practice after residency. 

I also saw lots of complications of pregnancy; drug abuse, premature delivery, fetal demise, preeclampsia, eclampsia, and the list could continue. I had my fare share of normal deliveries and was able to help in some c-sections. We made every attempt to deliver the babies vaginally but in some cases a c-section was ultimately required. I really enjoyed delivering the babies. I had some very sad cases where the baby was born dead due to various problems and these cases where always difficult. The family was always devastated and there was not much that could comfort them. Fortunately I did not have too many of these cases. The drug abusers were also difficult cases because it was hard to see these innocent babies born with addiction and into that kind of environment. It was hard to have hope for those children given their environment and inept parents. 

It was a great week. I am tired. 

Learning the details

L & D (Labor and Delivery) has been long, long hours but I have liked the work. I miss the time at home with the family. It stinks to not be at home much but at least I enjoy the work. 

I have been on nights this week. The overnight shift is a whole new world and is different than working the days. You do not have all the back up staff and specialists available but you do have the basics like anesthesia and other needed staff. The cool part about nights is that I get to be more involved and play a more active role. I have come a long way on doing ultrasounds to check out the fetus. I can now do them completely on my own and actually make all the proper measurements and interpret the findings as well. I run my work by the chief resident to make sure everything is good and done properly. I also have become adept at doing pelvic exams to determine cervical status. It is really great to have the opportunity to learn all these things. I am fairly comfortable with most births at this point and how to do / manage the birth. I also can do the proper repairs if the mother tears. 

Regardless of the specialty I go into, I think that this information and skill set will be handy to know. You can use these skills in the ER and in various situations as a doctor if needed. I enjoy the whole process. The families are usually happy and there is a good feeling in the air at the births. Occasionally it can be devastating if there are problems with the fetus but fortunately a lot of the births are healthy. It is a great feeling and pretty cool to be involved and part of the lives of these parents / families. They will take pictures with you and remember you as part of their process for a while at least. 

My last shift is Saturday night / Sunday morning. There is something miraculous about birth no matter how many times I am involved in the process I find it amazing every time. 

Crack pipe mommy.

I just totaled up my hours for the week and all I can say is; wow. It has been a long week but I have learned a ton and loved the things I have been able to see and do. I am on labor and delivery and I have assisted, done / participated in many new lives making their debut into this world. I have become very comfortable with how to deliver a baby in normal conditions and how to precede in emergency / difficult situations. 

The patient population I am dealing with are poor and living in some difficult situations. Many of these mother do not have any prenatal care and they show up to the hospital for the first time when the contractions start or their water breaks.  I have had several mothers who drink, smoke and use drugs regularly during their pregnancy making it difficult for the fetus to grow and develop properly. It is hard to see these situations and not become frustrated or angry. I try to remind myself that I am not there to judge and I have no idea what their lives are like or the kind of problems they have had. I am there to provide treatment and care for the mother and the fetus.

Last night I had the emergency department (ED) ob/gyn pager and at about 6:00 pm I was paged to the ED for a trauma that involved a pregnant women. I grabbed the ultrasound machine and a senior resident and we went down to the ED to assess the mother's condition and see how the fetus was doing. All we knew about the case was that she was 6 months along in her pregnancy and had been involved in a fire where she had 3rd degree burns over her head, neck, chest and abdomen. As we approached the trauma room we could hear the high pitched screams of a female ringing out. It sounded painful. I could not imagine what I was in for as I entered the trauma bay. There was a 27 y/o African American girl lying on an exam table screaming as several other doctors and healthcare personnel scurried around trying to do their specific tasks to care for her. Someone was putting in an IV and administering her pain medication and IV fluids while others were cleaning the burns and deriding the melted flesh. My senior resident announced our presence and who we were and we started in on our job. I began firing up the ultrasound and asking her questions about her pregnancy.

"How far along are you?" "I do not know" was her response. "Have you had any prenatal care up to this point?" "No" she muttered. I continued to ask her questions while y senior resident started a vaginal ultrasound to assess the fetus. We were able to determine that this was her 7th pregnancy and all the other babies had been with different fathers and were now in the custody of the state. She did not know who the father of this baby was and did not want the baby. She had been using marijuana, cocaine, heroine, tobacco, alcohol and some other drugs throughout this entire pregnancy. The fire was caused when here crack pipe exploded setting her chest on fire. It did not sound like a suicide attempt but rather an accident while smoking crack.

We were able to determine that she was 26 weeks into her pregnancy and that the fetus was alive. We hooked her up to a fetal monitor that we could monitor from the L&D floor while they finished taking care of her burns. It did not look like she was in risk of going into early labor. We monitored her the rest of the shift and the doctors on the next shift were introduced and continued to monitor her and the fetus. 

I have had several drug abusing mothers who are pregnant and continue to use their drugs. It is always a sad situation. I have to remain focused on patient care and education while trying to not judge the patient. This patient will most likely live for now and will go onto to deliver an infant who has brain damage and other abnormalities due to the exposure to drugs while developing. The most common drug and often the most dangerous and damaging of these substances is alcohol. 

There is not a lot of time to worry about the controversies of hysterectomies while working like this and trying to care for these patients. 

Labor and Delivery

This whole week I have been working on the Labor and Delivery during the day shift which runs from 6:00 am to 8:00 pm and it usually takes a while to sign out to the night team. My job is to basically assist the residents and attending doctors get things done. As I was able to demonstrate my competence in certain procedures I was allowed to take on a more active role. The director of the L&D unit is a big proponent for vaginal delivery and we work to do all deliveries vaginally if it can be done safely. So I was able to help in many vaginal deliveries and I actually got to deliver several babies this past week. I was also able to assist in a handful of c-sections that were considered necessary or emergent. The c-section vs vaginal delivery is another point of controversy in the field of ob/gyn. 

We had one patient this week who presented at 22 weeks with a complaint that she no longer felt the fetus moving. Upon ultrasound we were able to determine that the fetus was not going to survive and the mother was going into labor. I sat with the mother her husband and her mother to discuss the diagnosis and they of course were devastated at their loss and overcome with grief. I answered all of their questions and provided them with as much information as possible. Later in the day we had an active drug abuser mother at 39 weeks start to push and go into the final phases of delivery and everyone quickly scrubbed in to deliver the baby. Another student was allowed to scrub and assist in the delivery so I was not directly involved. The delivery became complicated and more physicians were paged to come and help with the delivery with the hopes of avoiding a c-section. It became very intense and complicated and one of the doctors asked me to page for some back up blood. I left the room to take care of the back up blood. 

On my way back to the room where the delivery was occurring the grandmother of the the women who had the 22 week old dead fetus came into the hall way and yelled to me please come quick my daughter wants to push. I yelled to a nurse to get one of the physicians to come and meet me. I entered the room and the mother was starting to push out the fetus. I tried to tell her to wait and stop pushing as I quickly put some gloves on but she kept pushing. I arrived in time to catch the entire placental sac and fetus. I kept it guarded from the mother as she had said she did not want to see it. Once I got it completely out I took it to the adjoinging room with the infant warmer and cut the sac to deliver the fetus. At this point a bunch of physicians had arrived to take over and run the show. I was able to follow all of my training but I was certain upon seeing the fetus that it was dead and had been dead prior to the delivery.

It happened so quickly that I did not have any time to process it. The family was of course very upset and crying and as the other doctors took over I was able to go back to the family and sit with them and try to comfort them. They wanted to know the sex of the fetus but did not want to see it. I told them it was a boy. 

What an intense experience and it did not hit me until I was driving home late that night. I nearly broke down as I thought about how difficult it was and how fragile life is. 

Comments on Hysterectomies

So my little blog recently exploded with hits and web traffic after I posted about hysterectomies. If you have been following this blog I am sure you are aware of the recent comments and discussion that occurred. It has been extremely interesting to say the least. However controversy and medicine is not a new phenomenon. There are many different issues that spark religious like passion and discussion. Just to name a few; immunizations, silicon breast implants, psychiatric medications, blood transfusions, hysterectomies and I could go on. 

I decided to sit down with the chief of ob/gyn at my training center and discuss hysterectomies and and the history of ob/gyn. Needless to say it was very enlightening and interesting. I had forwarded him my blog address so that he could read the comments prior to our meeting. He has been practicing ob/gyn since 1974 and has served in many leadership roles and faculty positions with in the community of women's health initiatives. He was able to shine some light on many aspects of ob/gyn and women's health. 

One of his interesting and profound statements that he made was that as a doctor you can't focus on anything other than the patient you are treating at the moment. You have to put aside your views, your opinions, your ideals and really focus on what is best for that patient. Any time you make blanket statements or decisions you will run into trouble. For example you can't think "Every women with disease X should get procedure Y". You also can't say patient X had a bad outcome with treatment Y so this treatment should be thrown out and noone should ever get treatment Y again. Every patient is so different and unique that they have to be approached in an individual custom process.

I asked him about his opinion of hysterectomies and the controversy around the procedure. He said that it is his policy that surgical intervention should be the last option after all other options have been attempted. He said his biggest challenge is that he spends much of his time trying to talk patients out of getting a hysterectomy but that many patients have friends and relatives who loved their results and they want instant gratification and really push for the procedure. He said he has had several patients that he tried to sway from a surgical procedure ultimately go to a different doctor and twist their arm to do the procedure until they were able to get it done. He also said that there is definitely a need for hysterectomies in the right patient. He explained that there are certain patients with disease that would benefit from hysterectomy and if the physician failed to offer the procedure he would be negligent. 

He explained that he has never lost a law suit and has been sued very few times compared to the normal ob/gyn doctor. He said he has been sued 4 times for not performing a hysterectomy and has never been sued for performing a hysterectomy. It has been his experience that this is a common phenomenon. An ob/gyn is more likely to be sued for not performing a hysterectomy than for performing a hysterectomy. He also explained that because reimbursement is dropping that ultimately a physician is better compensated for managing the patient medically than performing the surgery. Many of his patients will try medical management but ultimately give up with frustration and ask for the hysterectomy. We chatted for a long time on this issue and I do not have time to include all of the information. It is a complicated issue that involves many aspects. 

He will allow me to call any of his patients and ask them about their experience with their hysterectomy for the purpose of my learning. I am developing a survey to use for this purpose.

Thanks to all for your comments.  

Edit after some comments: There is no way I have time to list and write out everything that was discussed at my meeting with the chief or ob/gyne and the other doctors and patients I have talked with at length however I can tell you we discussed everything that your comments have mentioned. I also have the copy of our consent forms and I am not allowed to post them I can tell you they cover many of the issues mentioned like loss of orgasm in some woman and loss of libido in others and the health risks. 

The Dark Side of Hysterectomies.

I have had a ton of comments and emails sent my way from various readers who are mostly upset. Rather than reply individually to each one I thought I would make a post to make some general responses. For some reason some of the comments are not showing up o the blog but I am getting them via email so I will try to address those comments as well.

First of all let me start off by saying I am not pro-hysterectomy or trying to push hysterectomy on anyone. All of the procedures I have been involved with have been part of my training and would have been done wether I was there or not. I certainly did not have the lead role but mostly an observatory role and some minor responsibilities like suturing etc. 

What are the comments? Many angry, upset individuals have emailed me with their concerns about hysterectomies. These are patients who expressed their feelings that they were mislead by their doctors and forced into getting a hysterectomy. Now they suffer the side effects and are upset with the results. Most of the complaints have been focused on the sexual side effects and they compare it or call it castration. I certainly feel bad for any person in this type of situation and I do not support or condone mistreatment or patients of any kind and would never willingly participate in any such activities.

Currently I am training at a non-profit center that is subsidized and no doctors are paid on an incentive base plan. This means that the doctors get paid the same wether they do 1 surgery or 10 surgeries in a day. All of the patients are considered charity cases and none of them are asked to pay for these services. Some may have public aid that will pay in some cases a very small fee if any payment at all. I can definitely say that the doctors I am working at are not doing hysterectomies to make extra money as they do not get paid extra for doing extra cases and 90% of the cases are done free of charge. Most of the funds to keep this center open come from donated funds, subsidies and volunteered time by service doctors and nurses

I chose to train at this incredible center knowing that it was mostly service oriented medicine. The patients are very grateful for the treatment they get and have ended up at this center after years of not being able to get treatment anywhere. Many of my days during this rotation are spent on running a free pap clinic, STD screening clinic and Breast clinic. We work 15 + hour days in these clinics as part of our training and truly enjoy it and feel grateful for the opportunity and experience.

I had the opportunity to sit in on several consent meetings for the hysterectomies. In the cases I was involved with, these meetings took at least 30 minutes and involved walking through the risks and answering the patient's and the patient's family's questions. At some point during the meetings there was a doctor, nurse, social worker and a  patient advocate whose sole job is to present the negative aspects of the surgery and assure and document that the doctor and others fully explained the side effects. The average amount of time that the patients I saw had been waiting for this procedure was 4.5 years. Given the nature of this "free" center you can imagine the back up of cases. Working with volunteer healthcare workers and limited resources makes the process a lengthy ordeal. In the cases I saw these patients were literally begging for the procedure. One case had to be postponed and the patient wept hysterically and believed she would never get the chance to have the procedure done. The cases I saw were all had debilitating cases and or had premalignant or malignant cells on pathology or progressed to the point where the pain was so bad that the patient was on disability and not working. All of these cases had received multiple years of non-invasive medical treatments prior to this surgery. I am not saying that this is how all the centers work or operate or denying claims made in any of the comments.

I am not claiming that the cases presented in some of the comments do not occur. I am just saying they are not occurring at the center in the few cases that I have seen or been involved with. 

I also have seen and treated several cases at this center on my gyn oncology rotation of stage 4 terminal ovarian, cervical uterine cancers that were in patients who were never able to get a hysterectomy or had a partial hysterectomy and left the ovaries behind. In most of these cases a hysterectomy had been offered at some point in the patients lives and refused for a number of different reasons. I held the hand of a dying mother and her son's hand as she died in his arms. She had ovarian cancer that had formed in her ovaries that had been left behind at her request from a previous hysterectomy. The son is filing a lawsuit on the doctor who left the ovaries behind for not "forcing" (his words) his mother to have the ovaries removed. 

I have no intention to become an OB/GYN doctor. Mostly for personal reasons it is not the field I will ultimately go into. 

My blog is a blog intended for my families and friends who want to read about my training process. It is not a political statement of any kind. There is no intention to sell or preach any given procedure or medical ideal. My long term goal is to ultimately serve medical missions inside and outside of the United States.

Thank you for all of your comments and sharing of information. Certainly the kind comments were better received. Comments like the one provided by the president of the HERS Foundation are informative and appreciated. The accusatory and angry comments by some that can be read under the comments on my blog, come across cheapened and fanatical even if the information was good. The tone of some of the comments (not all) clouds the message and discredits the author. I understand this is an emotional topic for those involved. 

I will gladly provide educational material about the negative sides of hysterectomies and other medical procedures. I feel it is my duty to do so and serve as apatient advocate.

I encourage all to read the comments and will more than happy to post relevant information. If people have trouble accessing the comments I can post them as well. Many came to me through email but did not show up on the blog. However the comments that did show up are a good representation of many of the comments I received. There were a handful of death threats and over the top angry comments that were not posted as well as they came directly rather than appearing on the blog.

Another option for hysterectomy

I had a really long day on Friday. I was in surgery so that was exciting. We did 3 vaginal hysterectomies. These are difficult because you have to operate through such a small area. The nice part for the patient is that they do not have any surgical scars when the operation is finished and the recover time is significantly less given the non-invasive procedure. 

The downside for the doctor is that it takes a long time, much longer than an open hysterectomy and there is an increase risk of cutting a ureter given the lack of space makes it difficult to see all the anatomy clearly. 

I arrived at the hospital at 5:00 am and left at 9:00 pm with a 1.5 hour commute each way it was a 3:30 am - 10:30 pm work day = 19 hours. Talk about tired. Fortunately you have so much adrenaline going during surgery that you do not feel the tiredness during the procedures. However about half way home the fatigue hits me like a brick wall and I have to hang on until I get home before collapsing. I should have studied for the exam at the end of the rotation but there was no way to do any studying in the dismal state of fatigue.

Gynecology = Surgery.

Friday I was able to help with surgeries all day long. I like the operating room. There seems to be no concept of time in the OR. You are not watching the clock, you forget about hunger or using the bathroom. When you finally do glance at the clock you realize several hours have passed in what seems to be a blink of your eye. There is this unexplainable sense of confidence in the air. That being said there is also the long hours and the unpredictability that goes hand in hand with surgery specialties. Sure you get to be the big man / woman in the OR but that is about the only place. You are a stranger at home, a memory to your children, and an ex-husband or ex-wife to your former significant other. 

I was able to help on a laparoscopic hysterectomy with preservation of the ovaries. It was a sad case. The patient was a 39 year old female (obviously) who never had a chance to have children. She had symptomatic uterine fibroids that had plagued her most of her menstruating life. Finally she had had enough and wanted the surgery. In this surgery 3 small holes are made in the abdomen / pelvic area. Through these incisions a camera and surgical instruments are passed to perform all of the work. You also have to fill the abdomen with air to open up the space so you can see and have room to work. 

The biggest risk with the removal of the uterus is the potential for massive hemorrhage. When a woman dies in birth it often was caused by massive hemorrhage of the uterus. The uterus has a large number of vessels that vascularize it and keep it healthy and well nourished. Most of the surgery is spent cauterizing vessels feeding the uterus. You do not want to miss any because this can cause serious bleeding when you pull the uterus out. My job was to hold and maneuver the uterus to help the other 2 doctors to find, cut and cauterize all the vessels. I accessed the uterus through the vagina. It was demanding to hold the uterus in the correct position and if you were to let it slip you run the risk of tearing a vessel that had not been cauterized which would cause massive hemorrhage. By maneuvering the uterus I could expose certain vessels that could then be cut. The patient's uterus was so diseased it was very large, about the size of a 16 week pregnant uterus. 

It took several hours to tie off all the vessels and then remove the uterus and cervix through the vagina. It was so big it seemed like delivering a small baby. This was a fascinating surgery. Many surgeons do this surgery open, meaning they cut the abdomen are completely open to expose the uterus. An open surgery is quicker and easier to preform but leaves the patient with a long recovery time and weakened abdominal muscles and a large scar. Laparoscopic is the way to go if possible. 

We did another surgery where we used a CO2 laser to ablate non-cancerous lesions off of a patients cervix. It was cool to use laser technology and the surgery was fairly simple and done with only an epidural and no general anesthesia. So the patient was awake through the entire surgery. There was no cutting involved. We simply exposed the cervix through the vaginal opening and removed the lesions with the laser. We had to wear protective goggles to avoid damaging our eyes if they accidentally entered the path of the laser. 

The final surgery we did was an open abdominal hysterectomy where the entire tract was removed; cervix, uterus, fallopian tubes and ovaries. It took less time than the laparoscopic surgery. It was also easier to see all the anatomy which meant the attending grilled me with a ton of questions. "What is this structure?" "What never innervates this structure?" etc. Some attendings will kick you out of the OR if you miss too many of the questions. Fortunately I had brushed up on the anatomy so I was ready for the pimping! 

Pimping is a term medical students use to describe the process of being asked questions in a quiz/test like manner by residents and or attendings. It is a common practice in our training and a crucial part of our learning. Some dislike being put on the spot in front of everyone but I think it makes you prepare more thoroughly. SOe doctors will continue to ask harder and harder questions until you finally miss one and then tell you that you do not know anything and are a disappointment. You can't take it personally and have to understand it is just part of the process. Other doctors are very nice about it and do on the spot teaching with each question.