What I Do, Part Two

(This is an another article directed more to people who are interested in a medical career than to those already involved.  Feel free to read along but I again offer my usual warning that there is nothing profound or exciting to follow and I cannot be held responsible for your boredom. I’m going to try to write this without jargon and I will clearly explain everything which is where the boredom is going to come in for those of you who are in the know. -PB)

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Because I am a second year Emergency Medicine Resident, at my program I carry the trauma pager which alerts us whenever a trauma or a seriously sick patient is on the way.  As part of my training I get “first crack” at all these difficult patients, those for whom a delay of immediate interventions or decisions could result in serious long-term disability or death.  Our attendings supervise us but they generally stand back and only correct us if we are doing something either completely wrong or not the way they want to handle things.  It is the attending’s patient, not mine, even if she just stands in the back with her hands folded across her chest looking bored.  As we gain proficiency our attendings stand around looking bored more but to start out we are supervised fairly closely.

We really don’t get as many of this kind of difficult patient as you might imagine.  We get plenty of really, really sick and injured people but in most cases, they are stable enough where a delay of five minutes or even a half hour might not have too many serious consequences.  Most trauma patients that we receive for example, even Level One traumas for which the entire trauma team is mobilized, are stable enough to be taken to the CT scanner before the decision is made by the trauma surgeons whether to operate.  (On the other hand sometimes the patient is so badly injured, particularly in the case of penetrating abdominal injuries, that they go straight to the operating room with barely a how-do-you-do in the trauma bay).

The trauma pager usually but not always alerts us that a critical patient is on the way and gives us time to prepare.  In this case, the terse message on the pager screen said “57 M SVT Chest Pain” which meant that the paramedics were bringing in a 57-year-old man with chest pain who the paramedics believed to be in Supraventricular Tachycardia.  Supraventricular tachycardia, as the name implies, is a fast heart rate with the pacemaker, a focus of electrically active cells in the heart, located above the ventricles in either the atria (the top chambers of the heart) or the atrioventricular node (the specialized cells between the top and bottom chambers of the heart that allows the transmission of electrical signals). A rapidly firing pacemaker in the atrioventricular node is more correctly called an accelerated junctional escape rythm but it looks somewhat like SVT on an EKG.  The heart has a normal physiological pacemaker in the right atrium called the sinoatrial (SA) node but this is not what is usuall driving the heart in SVT.

The heart itself is an electrically active muscle. Unlike skeletal muscle, and with the exception of the SA node, it is not innervated but instead receives its signals to contract via a wave of electrical current generated by the flow of ions into and out of individual heart muscle cells.  The SA node is not directly innervated (attached to nerves) but is modulated with neurotransmitters like acetylcholine released from nerve endings of the parasympathetic nervous system (of rest and digest fame) located close to the SA node. The wave of electrical current produces a progressive cascade of electrical depolarization and repolarization of individual muscle cells, sequentially opening and closing voltage-gated ion channels on the cell surface, that allows the flow of sodium, potassium, and calcium to power the cellular machinary that causes contraction and relaxation.  Usually, this process is initiated in the sinoatrial node which has a natural automaticity and, absent any external influences from the autonomic nervous system, paces the heart at anywhere from 60 to 100 beats per minute.  Every heart cell can pace on its own but since the SA node paces faster, its signals interrupt the pacing potential of the rest through something called overdrive suppression.

I am simplifying things considerably and once in medical school you will learn about the heart in great detail.  Like many things in nature, the mechanism of cardiac activity is wonderfully elegant and simple to understand but frightfully complex once you get into the details.  The important thing to remember is that measurable electric current flows in the heart. An EKG is a representation of this current as it flows towards an electrode (also called a lead) and is more specifically the magnitude of the vector component of the current (well, actually the electrical potential which is a voltage) coming towards or moving away from the electrode.  The EKG, either on a monitor or printed on paper, is a graph of time and voltage with time represented on the horizontal axis and voltage on the vertical axis.  By convention, a printed EKG uses twelve leads, looking at the heart from twelve different electrical points-of-view.   A cardiac monitor like you see over hospital beds or on a portable defibrillator of the kind carried by paramedics is just an EKG with two or three leads instead of twelve.

A normally functioning heart has a distinctive EKG pattern representing the flow of current in the heart.  Abnormalities of the heart cause their own distinctive pattern on the EKG.  A Q-wave, for example, is an abnormal downward deflection on the EKG caused by the lead “looking” through dead (and therefore electrically silent) heart tissue to the opposite side of the heart and is something that develops after a heart attack in many patients.

The patient finally arrived and was a reasonably fit-looking middle-aged man sitting up in the gurney who was awake, alert, and in no obvious distress except he was dripping with sweat.  His chest pain and sweating had started about fifteen minutes before while working in his home shop sweeping sawdust into a dust pan.   The nurses, who actually do most of the work of patient care, hooked the patient up to our monitor and established another intravenous line to complement the one placed by the paramedics as I listened to the rest of the report and looked at the “rhythm strip” printed from their defibrillator.  It showed a wide-complex, monomorphic tachycardia with a rate of 280 beats-per-minute, also known as Ventricular Tachycardia or “V-tach,” not SVT as originally advertised (an earlier strip showed what could have been SVT however).  A normal heart rate is, as we said, anywhere from 60 to 100 beats per minute with an EKG pattern showing that the beat originates in the SA node.  This was a rhyhtm originating in the ventricle and pacing the heart at a rate three to four times normal.  It was “wide complex” because the QRS complex, the pattern of electrical force from the ventricle as represented on the EKG, was of a longer duration than a normal QRS indicating that the normal conduction pathway of the left ventricle (which provides the power stroke of the cardiac pump that sends blood to the body) was being bypassed.

The patient’s medical history was unremarkable, at least from our point of view although I have no doubt that many of my physician friends in Europe would have considered him marvelously complex and lucky even to be alive as this kind of patient is a rarity over there.  The usual COPD (from emphysema), the usual coronary artery disease with a history of two stents (expanded wire cages in the arteries of his heart to open them up and allow blood flow), and the usual non-insulin dependent diabetes.  He was a very pleasant guy and despite his chest pain cracked a few jokes and expressed a little dismay at all the trouble he was causing.  Not twenty feet away in another room was a patient a third his age with no medical problems whatsoever and  complaining vociferously to everyone and anybody about the slow service in our department which is typical and shows how profound are the generational differences of our patients.   Except for his sweating and fast heart rate, the rest of the physical exam was unremarkable.  He was on the usual medications for a guy with his medical problems and had no allergies.

Ordinarily we shock (or cardiovert) V-tach immediately if it is unstable.  Unstable arrhythmias are those producing symptoms; things like low blood pressure, altered mental status, obtundation (unconsciousness), chest pain, or sweating.  In our patient’s case, as he was somewhat stable (talking and perfectly alert) we decided to get everything we needed set up before attempting cardioversion which would certainly be required.  Nobody can maintain that kind of heart rate for long.  If he became unconscious, for example, maintaining an airway would be important so I set up for a possible endotracheal intubation (insertion of a breating tube through the vocal chords into the trachea) while the nurses drew up a couple of milligrams of Midazolam (Versed) for sedation before we jolted him.  I have had patients report that being cardioverted feels like being hit in the chest with a sledgehammer so sedation is the merciful thing to do for conscious patients.

No sooner had the Midazolam been injected into his intravenous line when he rolled his eyes and became limp and totally unresponsive.  The monitor still showed V-tach so now it was definitely time to shock him.  I set the defibrillator to 100 joules, was reminded by my attending to make sure the machine was set to synchronized cardioversion as shocking at the wrong place in the cardiac cycle can make the problem worse, pressed the charge button, and after checking that nobody was touching the patient, pressed the button with the lightning bolt on it and sent the charge into the pads that had been previously glued to his chest.   very satisfying jump from the patient (just like on TV) as every single cell in his heart depolarized, looked around at its neighbors, said “What the fuck?,” and waited for the regular signal coming from the SA node to resume a normal heart beat.

Which is exactly what happened.  After a brief period of asystole (or no electrical activity) the monitor showed a normal cardiac rhythm.  I made sure that the patient was still breathing and that he had a pulse and not thirty seconds later he opened his eyes and asked how he was doing.  In the meantime the cardiology fellow (an internist who is doing additional training to become a cardiologist) who we had previoulsy called arrived to evaluate the patient.   V-tach has many causes from electrolyte abnormalities to a tension pneumothorax (a collapsed lung with increasing pressure in the chest cavity compressing the heart) but in this case, given the presentation the most likely cause was cardiac ischemia which was confirmed by a post-cardioversion EKG showing unmistakable signs of myocardial infarction (a heart attack).   Ten minutes later and after starting an infusion of an antiarrhythmic agent the patient was on his way to the coronary catheterization lab for an emergent “heart cath.”

Total time in our department?  Ten minutes, fifteen at the most which made him both my quickest and most satisfying patient of the week and an official “Perfect Emergency Medicine Patient.”  By this I mean that he arrived with an unmistakable chief complaint, was able to give a good history, had solid physical exam findings, and responded to our intervention beautifully.  Not only that but he had a quick disposition and was taken off our hands early for definitive treatment.  We don’t get many of this kind of patient either.

My next patient was a 14-month-old with a fever, vomiting, and cough.  This is the worst kind of patient because while the child probably has nothing more serious than a cold or some self-limiting viral syndrome, the differential diagnosis is long and sometimes we keep a patient like this for hours and hours, eventually obtaining a perfectly normal lumbar puncture (where we stick a needle through the back to obtain spinal fluid to check for potentially deadly infections) before sending them home.

What I Do, Part Two

What I Do

(With a hat-tip to the Happy Hospitalist.Nothing new or profound here so my regular readers may, if they desire, ignores this article completely or read on and forgive the basic level of information presented. -PB)

A young reader writes, “Dear Dr. Bear, I am a senior in high school and am thinking about being a doctor. What does your job involve?”

I am a resident physician, meaning that I have graduated medical school and am now doing my specialty training, in my case in a specialty known as “Emergency Medicine.” Some people do not know that Emergency Medicine is a specialty but as you will see, its practice does involve some specialized training as well as an approach to medical care that is somewhat unique. I am a little more than halfway through what will turn out to be a four-year period of post-medical school training. Emergency Medicine training is typically three years but I did an intern year in Family Medicine after which, screaming in fright, I made the switch to Emergency Medicine. (I did not get “credit” for that year in my new residency program.)

No matter what specialty you pursue, you will have to do an intern year which will consist of exposure to all of the major medical specialties. You may perceive this to be of little value if you are, for example, going to do dermatology but since Emergency Medicine is a generalist field, every little thing we learn is useful and can be applied somehow. In other words, I have never been delivering a baby on an obstetrics rotation and said, “Man, this is bogus. I’ll never have to deliver a baby in my real job.”

Medical school itself lasts four years and in all but a few cases needs to be preceded by a four year (or however long it takes you) course of study at an accredited college that leads to a Bachelor’s degree. I have a Bachelor’s of Science in Civil Engineering and, unlike most physicians, did not go directly from college to medical school but instead worked as a Structural Engineer (the cool branch of Civil Engineering) for many years. This made me what is called a non-traditional student but if you’re sure you want to be a doctor there is no need to interrupt your journey and you may as well take your lumps when you are young. The process of applying to medical school and positioning yourself for acceptance is well described on the Student Doctor Network and to them I refer you to find all the information you could ever need. Take advantage of it because even ten years ago, when I was applying, this kind of thing either didn’t exist or was a spare sketch of the resource it has become. I think we now have the first generation of people who take the internet completely for granted.

So I am what is known as a Resident, a physician but one who practices under the supervision of other physicians who have finished residency and are fully-trained in their specialty. These doctors are known as “Attendings” or “Attending Physicians.” We are called residents because once, long ago, if you desired additional training past medical school (which was at one time not common or even felt necessary to practice) you lived in the hospital while you trained. While the hours are long in residency, we no longer live in the hospital but the name has stuck. Residents are also called “House Staff” at many hospitals, again with the implication that they belong to the “house.”

Just for your information, you can be a licensed physician and still be a resident. In other words, I occasionally have patients who insist on seeing a “real doctor,” not a resident. Leaving aside the debate as to whether you are a “real doctor” on the day you graduate medical school (you are), licensing in most states only requires that you complete an intern year and have passed all three steps of the United States Medical Licensing Exam. From a legal point of view, there is a basic level of knowledge and skill that every doctor should possess and this is the minimum for legal independent medical practice doing anything which you feel comfortable doing, can get insured to do unless you want to work without liability insurance, can convince hospitals to give you privileges to do, and can convince patients that you know how to do. Practically, however, you need to specialize and get additional training unless your ambition in life is to work at a low-level Urgent Care. I don’t have to tell you that medicine is very complex with a rapidly expanding body of knowledge that one person wouldn’t be able to assimilate in a hundred lifetimes. Specialization is a de facto necessity.

I generally work 14 twelve-hour shifts in every 28-day block. I either work the 9 AM to 9 PM shift or the 9 PM to 9 AM shift, with seven consecutive days on one or the other. Next year I will work seven to seven instead of nine to nine which allows for some overlap between the third year and the second year residents. The most we ever work is three shifts in a row with at least two days off afterwards. Our schedule is set up so we work Friday, Saturday, and Sunday for two weekends in every block but get the other two off. It sounds like a pretty reasonable schedule and it is. We are allowed to trade shifts so if, for example, you need a bigger block of days off you can swap with another resident provided that you don’t violate the work-hour rules for Emergency Medicine.

During our first year we work mostly off-service (not in the Emergency Department) rotating on other specialties such as Trauma Surgery, Internal Medicine, Critical Care, Pediatrics, and Obstetrics to name a few. During second and third year we spend most of our time in the Department with a few months reserved for electives. Some programs mix it up a little more. The advantage of doing all the off-service training early is that by the start of second year, you are done with call forever. “Call” is the practice of spending the night in the hospital, in addition to your regular daytime duties, to take care of your existing patients, admit new patients, and handle emergencies. I did two intern years, approximately 150 nights of call, and got meaningful sleep on so few call nights that I can count them on the fingers of one hand. Considering that you may have call every fourth night for most of intern year and you cannot just go home in the morning afterwards but usually stay until one in the afternoon, you can imagine that intern year can wear you down.

But shift work isn’t too bad. You have to discipline yourself to sleep during the day or else the temptation to carry on as if nothing has happened can lead to a big sleep deficit which manifests as the subjective feeling of always being tired and falling asleep whenever you sit down. But if you can master the art of sleeping during the day you will always be well-rested for your shift, bright-eyed, bushy-tailed, and ready to go.

We also have conferences to attend during the month. Unlike other residencies that may have an hour of didactic training (lectures) every day, because of the nature of our work we throw them all into a once-a-week, five hour block. If you are just getting off of a shift you still have to go. Likewise if you are on a day off. No excuses. On the other hand conference sometimes runs concurrently with a shift and since conference is mandatory, you are excused. It all evens out. We also have a Trauma Conference once a month which is also mandatory as well as an occasional wild-card thing like Animal Lab where we practice procedures (chest tubes, internal pacers, surgical airways, for example) on live, anesthetized pigs or dogs (all of which are euthanize at the end of the lab). I love dogs (I have five of them) so it can be a grim business. On the other hand we rarely get the chance to do a surgical airway on human patients and if one day, the skills you learned on a poor dog help you save somebody’s toddler…well….it will have been worth it. No question about it.

So I mentioned that I am learning the field of Emergency Medicine which, as medical specialties go and despite what you have seen on television, covers a broad range of medical complaints. A “complaint,” by the way, is medical-speak for the problem that brought the patient to the Emergency Department. In Emergency Medicine, we can see patients with complaints that are so idiotic they transcend idiocy and achieve a sort of moronic nirvana (“My ass is sweating”). We also see patients with some of the most serious injuries and medical problems that you can imagine. Like that biker who you saw get hit by a truck when you were twelve who had big chunks of himself smeared across the road. You can bet that if he wasn’t dead at the scene, some Emergency Physician struggled mightily to keep him from dying long enough for the trauma surgeons to save his life.

So it’s a real mixed bag. Some nights you feel like a school nurse treating things that would have kept normal people home and some nights the trauma and serious medical complaints just keep rolling in and the minor complaints stew for hours complaining about the crappy sandwiches and the limited television stations.

The purpose of Emergency Medicine is two-fold. First, our job is to assess and stabilize injured or severely sick patients until they can receive definitive treatment. “Stabilize” means to keep them from dying by reversing or halting the processes that lead to death. Shock, for example, is a common presentation and as it is just brief rest stop on the road to death, a chance for the Grim Reaper to sip his latte and finish his bagel before he gets to you, we treat it aggressively. Now, as hospitals are somewhat crowded and we can not always get even extremely sick patients admitted quickly (and even if we can the admitted patient can wait in the Emergency Department a long time until a bed is available) we often not only stabilize but make the diagnosis and initiate the definitive treatment. Critical care (also known as intensive care) is a big part of our job and while most of us enjoy it, it sucks up huge amounts of time and detracts from our second job which is to see as many patients as possible in the shortest amount of time.

For a practicing Emergency Physician, this means seeing at least four patients an hour to be considered a guy who pulls his weight. It may not sound difficult but while many complaints are minor, some are not and almost every patient we see is completely new, a Rossetta stone who needs to be deciphered. In fact, it is not unusual to get a “drop off,” a severely demented (senile) patient from a nursing home who hasn’t spoken a word since the Clinton Adminstration and for whom you have only a sketchy medical history (if that) and a chief complaint of “altered mental status.” If you’re lucky you can elucidate a reasonable list of her many, many medical problems from the medication list (if it was sent with the patient) but sometimes you have nothing to go on at all. Sorting it out takes time.

On arriving at the beginning of my shift, I pick up a computer tablet, scan the list of patients waiting to be seen, and select the next one on the list. I do this for the next twelve hours, consulting with my attending to some level depending on the seriousness of the complaint. I am now carrying the trauma pager so when a trauma comes in I drop what I am doing (if it is not an emergency) and run the trauma with trauma surgery and the attending who usually just stands back until his resident scews something up (which happens a lot, it’s training you understand). Occasionally critical patients, those with potentially life-threatening problems, come in and I again drop everything to take care of them. All of this is done in cooperation with the nurses who do most of the actual patient care, the Unit Coordinators who keep the administrative life-blood flowing, and a team of allied health professionals which includes Physician Assistants, Respiratory Therapists, Phlebotomists, Radiology techs, and the like.

One of the biggest parts of our job is coordinating care which involves, among other things, arranging consults, calling on-call physicians to admit patients, talking to the medical examiner after a death, calling patient’s primary care physicians, and a myriad other tasks that keep us on the phone longer than any other specialty.

If you like multi-tasking you will like Emergency Medicine.

What I Do

Stealth Medicine and Other Topics

An Apology

I want to apologize to the distinguished elderly gentleman sitting on the hall bed. It was a little insensitive of me to stand at the coffee machine taking my time making a cup of coffee not five feet away from you and your wife while you waited to be seen by a doctor. When I walked around the corner to check the board, although you didn’t know it, I was still only five feet away and I heard every word of your verbal broadside delivered against lazy doctors making people wait in busy hallways while they took in-your-face coffee breaks. After I heard this I quietly asked the charge nurse how long you had been waiting and I was doubly ashamed. I don’t like to see people waiting in the department and I blush to think that on many occasions this is the result of my inefficiency as a resident.

In my defense however, my shift had ended almost an hour before I had that cup of coffee and I was just hanging around waiting for some lab results so I could get a disposition on a patient. I wouldn’t say I was “off the clock” because we don’t have a clock per se but I was certainly not picking up new charts. Even towards the end of a shift residents get kind of antsy about picking up a new patient because, while we sign out patients who will obviously be in the department for a long time, it is common to stay quite a while after the end of a shift tying up loose ends. We never know for sure if a new patient will turn out to be an easy disposition or a disaster who keeps you in the the department three hours past the end of the shift.

One day, towards the end of my shift and after some surrepetitious cherry-picking I selected a low-priority chart with a chief complaint of “headache” which I thought might be a chronic migraine patient and therefore an easy disposition. The patient turned out to have meningitis and required a lumbar puncture, central lines, intravenous antibiotics, intubation, a critical care admission and the kitchen sink. This is not the kind of patient who you sign out. Don’t get me wrong, it was a great patient and I don’t mind staying late for something as important as that but I do like to get home too. The point is that you definitely do not want to pick up an abdominal pain patient with only a half hour left. To much potential for badness.

But I digress. The real point is that long waits are the future of medicine. Not only are there not enough doctors to go around, especially in primary care, but we have an aging and incredibly sick population already making huge demands on our very finite medical capacity. Compounding the problem are diminishing reimbursements to physicians, madcap and increasingly byzantine bureacracy, a predatory legal environment, and the resulting complete lack of common sense that makes it increasingly impossible for physicians to adequately treat the patients they see now let alone the marauding horde of aging baby boomers about to despoil such capacity as we currently maintain. I don’t see how it is going to get any better and more importantly, I don’t see why you put up with it.

You see, I looked at your chart and your complaint, while not trivial, was not something that couldn’t have been addressed by your own doctor if he were so inclined which he wasn’t. Obviously when he factors all of the variables into whatever mental black box he uses to decide whether to fit you into his schedule, sending you to the Emergency Department was the easier choice. I know perfectly well that he is already swamped with patients, many of them horrifically complex, and I don’t envy him as he tries to fit them into his hectic clinic. There must come a point where the relatively small reimbursement he receives for the one extra patient is not worth the time it takes from his family. And that’s the problem in a nutshell with primary care, namely that the reimbursement for the time it takes to sort you out and customize a medical regimen is not enough to make it either economically or professionally appealing. If your doctor only gets a pittance to see you, he needs to see a lot of patients to make a living leaving less time for each one. He’s not a bad guy but he has the same finacial pressures on him as you once had before you retired and if you knew how little Medicare reimbursed him for his time, you could easily do the math and see that he’s not exactly as filthy rich as you imagine him to be.

So I ask again why you put up with it and the answer is simple. Because you have never considered paying a doctor with anything other than insurance and even your co-pay is given reluctantly. On one hand this is understandable. As a retiree you have paid into the Medicare system for your entire life, not to mention paying either directly or indirectly into a private health insurance scheme since you first started working. On the other hand it is also understandable that your doctor isn’t exactly jumping for joy at his reimbursement from either the government or your insurance company, two entities whose sole purpose seems to be playing a game of chicken with doctors, that is, seeing how little they can actually pay them before they throw up their hands and look for another way to make money. So far it’s the doctors who have swerved off the road but eventually this is going to change. I have talked to many primary care physicians who are getting seriously fed up with the way things are going. Like you, they are locked into the insurance mindset but it will only be a matter of time before medical doctors realize that many American retirees are not poor, need fairly detailed primary care, and might be willing to pay for it if they preceived good value for the money. By this I mean the ability to have timely access to their physician with appointments that are long enough to address their many medical problems. When physicians and patients realize that each can provide value to the other, a good service for fair compensation, both of you will finally break free from the insurance prison that has been built around you.

This sort of practice is called “boutique” or “concierge” medicine by its detractors, especially by those who demonstrate their compassion by giving away other people’s time and money as if it were theirs, and they act as if it some completely alien economic model thought up by a zany college professor when it is instead the economic model that governs almost every other transaction between buyers and sellers.

As a patient, you’re locked into medicare and it may gall you to have to pay for a service that you expect to be free. But there you are sitting in the hallway of an urban Emergency Department rubbing elbows with the usual drunks because your primary care doctor did not have time to see you. If access is worth it you’ll pay, if not stand by for longer waits.

Stealth Medicine

To be a chiropractor in America is to lead a double life, trying to fit in with the world of real medicine while at the same time practicing a form of medical therapy based on a thoroughly discredited treatment modality. Officially, chiropractors have backed away from some of their more outrageous claims instead deciding to settle on the huge chronic musculoskeletal pain market of which chronic low back pain alone would seem to provide the potential for rich provender from now until such a time as the sea shall give up her dead. We’ve reformed, they proclaim. All of that hokey subluxation stuff? That’s so ninteenth century. No more relevant than the real medical profession’s use of bleeding back in the Bad Old Days before we got all scientific. Indeed, you’d be hard pressed to find a chiropractor claiming to be anything other than a hard-workin’, back crackin’, pain relievin’, dutiful member of the health care team doing his bit and making sure to refer to appropriate specialist when he gets in over his head.

Nobody here but us super-powered physical therapists. Move along. Nothing to see.

And yet it cannot have escaped your attention that the latest frontier of chiropractors is pediatrics where they hope to make inroads into a population that is not exactly suffering from a lot of chronic musculoskeletal pain. That most kids are fairly healthy is an axiom of pediatrics and the diseases that they acquire are usually fairly benign and self-limiting. They certainly do not have the kind of vague low back pain that is the bane of the Emergency Physician but the delight of the chiropractor. What, then, are the chiropractors proposing to treat in your children? Certainly not real pediatric diseases as the International Chiropractic Pediatric Association is quick to point out. Whatsamatta’? Don’t you read? “The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Apparently chiropracty can resolve asthma, ear infections, colic, allergies, and headaches to name just a few. What then, exactly, are pediatric chiropractors doing if it’s not treating conditions or diseases…or is your poor Uncle Panda, lumbering asian bear-mammal as he is, just lost in the semantics? In their mealy-mouthed way, chiropractors are trying to make an end-run around the ridiculousness of their profession to become your child’s pediatrician, a job for which they are singularly unqualified for many reasons the most important of which is that they have no training in pediatrics (the real kind, I mean).

Look at it this way. For the sake of the argument lets say that all chiropractors decide that subluxation theory is idiotic and henceforth devote their lives to evidence-based physical therapy. That’s kind of the angle the so-called “reform” chiropractors take in opposition to their “straight” brethren who ascribe almost every pathology including infectious diseases to subluxations. Would you take your child to a Physical Therapist for routine health maintenance, well child checks, or even something as serious as asthma? Of course not. And no Physical Therapist would touch your child in this capacity for the same reason I don’t perform abdominal surgery, namely that it is well outside of my training and my legitimate scope of practice.

Pediatrics is not surgery. The risks are generally low which is why chiropracters believe they can move into it safely. It’s hard to screw up on a kid after all, even as a legitimate pediatrician but especially as a pretend one. Adjust a few spines, twist a few bones, and marvel that most of your patients never seem to get any diseases despite not being vaccinated. But you’re playing with fire. Eventually you are going to get the childhood leukemia or the cystic fibrosis patient and you, in the full flower of your ignorance, are going to keep adjusting the spine oblivious to the depth of your folly.

Stealth Medicine and Other Topics

Emergency Medicine Residency (Part 2: Event Horizon)

(Once again, a caveat: I am a resident in a medium-sized Emergency Medicine program in an academic setting. Not as academic as Duke or USC but we have most of the players. I have never worked in private practice in Emergency Medicine so while I welcome the comments of those who have, I am describing my views of residency, not private practice. -PB)

The Spice of Life

The other night I was sitting at our PACS workstation (for viewing imaging studies) discussing a fracture with one of the orthopaedic surgery residents. In front of me were the ultrasound pictures of another patient, a woman who I was working up for a possible ectopic pregnancy. I had three charts on the table; one a lower GI bleed, one a headache (cough…drug seeker…cough), and the other a totally lame alleged intentional overdose of Seroquel. I had just discharged a four-year-old who was perfectly healthy requiring only maternal reassurance and I was keeping an eye on one of our habitual drunks signed out to me by one of my fellow residents, to be discharged when he could walk or obtain a ride home.

In no particular order, my other patients on that shift were a minor laceration to the forehead, a couple of nebulous abdominal pains, a few chest pains only one of which would probably pan out (although all were admitted), a possible meningitis requiring a lumbar puncture, a septic shock requiring the works (intubation, lines), a constipation, and a couple of drunks with whom I am on a first name basis.

That’s how I spent my night and that’s pretty typical. An occasional flat-out, full-throttle emergency, a couple of really sick people who might have become real emergencies if they had waited another few hours, some acute but non-life threatening complaints, and a whole bunch of patients who make you scratch your head and wonder what could possibly induce a reasonable human being to leave the comfort of their bed at 2AM to sit in the hall of our department eating cold turkey sammiches’. I mean, without giving too much away, let me just say that I have had vague abdominal pains at one time or another but I have never even considered calling an ambulance to take me to the Emergency Department.

So you see, while Emergency Medicine is a specialty, most of your time is going to be spent on general medical complaints, not actual emergencies. Still more of your time is going to be spent coordinating care; either referring, consulting, or admitting and a surprising amount of working up and treatment goes on before we get to that point. It is hard to get specialists and consultants to come in or admit so one likes to have a rock-solid case before calling. Not to mention that the Emergency Department has become a miniature hospital-within-the-hospital complete with admitted patients and even critical care. Consequently, the consultants and admitting physicians expect us to do a lot before we actually call, sometimes to the point of doing essentially everything for the work-up of a complicated patient including definitive care. When they start asking me the results of C-ANCA studies maybe it’s time for them to admit the patient.
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A typical shift, like March, starts like a lion but goes out like a lamb. On arriving, I grab the first chart on the rack and start the work-up on my first patient. This is the easy part. There is nothing to starting a patient’s work-up. You either have a pretty good idea what’s wrong or you can temporize by ordering studies, a tactic that will buy you anywhere from twenty minutes to an hour (one of our Emergency Departments, if you can believe it, does not have a “stat” lab and the only fast thing you can get are a few lab values off of the ABG on a critical patient). With the first patient comfortably simmering on the back burner, I pick up the next chart and repeat the process. Eventually I have a bolus of six or seven patients waiting for studies and disposition and then things slow down considerably. At a certain point you start getting close to the resident Event Horizon, that point in the space-time continuum where your efficiency drops to zero; as does your ability to see new patients without falling unacceptably behind on the ones you are following. It is surprisingly difficult to keep track of a large number of patients at various stages of their work-up.

Moving patients is complicated by the structure of residency. Our attendings, who see patients themselves, need to lay eyes on every one of our patients and approve the plan. They are as busy as anyone else so while every patient to be discharged or admitted needs their blessing, coordinating this can be difficult, particularly as our attendings are not only seeing their patients but also supervising a couple of other residents.

So if you look at a graph of my productivity, you’d probably see what looks like a huge effort towards the beginning of the shift tapering off to nothing by the last few hours. In other words, while I’m seeing my required quota of patients, once I get a certain number I lose efficiency rapidly. We typically don’t pick up charts on the last hours of our shift but by that time it’s academic anyways as most of our effort is now spent frantically trying to get rid of the ones we have. Another one of the skills our attendings try to teach us is to keep the patients moving through the pipeline without that kind of bottleneck.

Some bottlenecks, however, are unavoidable. Procedures, things like suturing or doing a lumbar puncture, can eat up a considerable amount of time if you a) are not very good at doing them and b) don’t coordinate with your nurse. Coordination is important. The nurses want to move patients as much as you do and if, for example, they have the patient moved to the OB-Gyn room for a pelvic, you need to plan to be available to do the exam when they are ready. You also need to stay on top of the labs and imaging. The sooner you can make a decision the better.
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The other unavoidable bottlenecks are critical patients and trauma, both of which can suck up large amounts of time. Critical care patients in particular, because they are not likely to be taken off your hands by surgery any time soon, can easily set you back an hour, something that many patients in with minor complaints do not understand. Reason number 1024 not to come to the Emergency Department for a minor complaint. It might seem like a good idea when you breeze through triage on a slow night but invariably there will be delays.

Contrary to the popular belief among critics and sour-grapers of Emergency Medicine, although we see some minor complaints (“I couldn’t urinate for an hour but now I can”) we do not do primary care. Oh sure, patients make attempts to get us to manage their chronic problems but you need to avoid the temptation. You cannot do decent primary care on a patient who you have never seen and will probably never see again and certainly not within the confines of an Emergency Department visit. We do not do drive-by pap smears, in other words.

Imagine how things would slow down if we did.

Emergency Medicine Residency (Part 2: Event Horizon)

Just a Few Random Things

Fast Freddie Johnson and the Man

The patient, a young black man, eyed me suspiciously. Apart from telling me that his name was Kareem, he had said very little during the initial assessment in the trauma bay and had made it to the CT scanner and back without saying more than ten words, total, to anybody. His GCS was 15 and he was hemodynamically stable so this was initially attributed to pain and fear. Other than the obviously fractured tibia, he was uninjured but as the pain medication kicked in and things settled down he still seemed reluctant to give us any information.

A group of his friends were in the hallway outside the trauma bay and they, too, were noncommittal even in regard to his last name. They eyed the two police officers from whom their friend had been fleeing before he smashed his stolen car into a tree and elected to plead the fifth in regard to their alleged friend.

“Come on,” said one of the cops, “You hang out with this guy and you don’t even know his last name?”

Shrugs all around. They had the police in check.

“Kareem,” I said, “I’m Doctor Bear, one of the residents on the trauma service. We’re going to get the orthopedic surgeons to look at you and I imagine they’ll be taking you to the operating room to fix your fracture.

“Kareem?” said the patient’s mother who had pushed her way into the trauma bay, “His name ain’t Kareem, it’s Freddie, Freddie Johnson …Baby, why you be tellin’ them yo’ name is Kareem?”

Mr. Johnson, demoted and revealed, shot his mother an angry look and I fully expected her to deny knowing her son.

The police left after we assured them that Mr. Johnson wouldn’t be going anywhere for awhile which was probably a mistake as only one day after an ORIF (Open Reduction, Internal Fixation) of his tibia, the taciturn Mr. Johnson limped out of the hospital on his crutches and we never saw him again. I guess we underestimated his desire to evade the law. Although we never really had a conversation and he glowered at me whenever I went into his room, I can’t find it in my heart to dislike Mr. Johnson. If you have to leave Against Medical Advice (AMA) this is the best way to do it, avoiding as it does the usual song and dance, the cajoling and stroking, that these things usually entail. I have often found myself earnestly trying to persuade a recalcitrant and unappreciative patient to stay when my heart yearns to say, “Hey, if you want to leave before I can arrange to have home IV antibiotics then don’t let the door give you a staph infection as it hits you on your ass on the way out.”

Of course you can’t really say something like that.

Residency and Call Revisited.

I despise call. And I don’t care to justify my dislike for it by claiming that patient care suffers if the residents are tired. I don’t even know if I really buy into the notion that tired residents make a lot of mistakes, and frankly, I don’t care. It certainly seems like a difficult hypothesis to test and I would hate to have my sleep dictated by the results of some pointy-headed geek’s study.

No, I dislike call for the more visceral but just as legitimate reason that it is inhumane to deprive a person of sleep for anything short of combat operations or genuine medical emergencies. The problem is that everything nowadays is an emergency, even things that aren’t.

“Call” is a misnomer by the way. It’s not “call,” it’s “work.” Attendings have call. They get to go about their business until called in for an actual emergency. Otherwise they take a phone report from the resident on call and say, “Okay, admit the patient and I’ll see him in the morning.” Residents on call generally work nonstop from the early evening until they are allowed to go home the next day. If it’s not an admission in the Emergency Department it’s an issue regarding one of the many patients they are cross-covering.

There was a time, many years ago, when the whole crazy system began when resident call did not mean a sleepless night every third or fourth day. Because people routinely died from the first major illness they acquired instead of collecting them over the years and living longer thanks to medical advances, hospitals were a lot slower-paced then they are today with a more stable census for a service (as hospital stays used to stretch for weeks for things that are treated as an outpatient today) and fewer acute issues that needed to be managed. As a result, the house staff in the fifties may have stayed overnight in the hospital often but I guarantee they slept a lot more than we do today.

But, as I said, today everything is an Emergency and has to be done right away. Not only are we dealing with an older and sicker population but expectations of the public are a lot higher than they used to be. Fifty years ago it was recognized that some diseases were death sentences and the priest and the undertaker were more likely to be called than the doctor. Today, we never say die and we routinely admit, treat, and discharge people who fifty years ago could not possibly have lived long enough to acquire so many comorbid conditions. The combination, for example, of congestive heart failure, diabetes, emphysema, chronic renal failure, morbid obesity, and ischemic heart disease (any one of which was fatal a generation ago) is so common that I’m thinking of having a stamp made so I don’t have to keep writing it on the chart.

So there is very little down-time on a typical medicine or surgery service and you can count on a steady stream of admissions from the Emergency Department to keep you occupied through the night. The Emergency Department, for it’s part, is turning into a miniature and almost self-contained hospital complete with a census of admitted patients who linger in the department waiting for a bed.

What to do about it? Who knows. I only mention it because, with the exception of one month next year, this month is officially my last call month in my medical career. Nothing but shift work from here on out. Emergency Medicine, Baby!

No point, just wanted to gloat.

Letter to A Patient’s Husband
(With a nod to Scalpelorsword for the idea-PB)

Dear Mr. Jones,

I know you accused me of not caring and, on the surface, it may appear that way but I assure you the reality is more complex than that. I know your wife is morbidly obese. I know she suffers from a host of serious and eventually lethal medical conditions. I realize she was in a car accident last week but other than a few bruises, she is all right and while I can understand your reluctance to take her home, you must because she can’t stay here.

Yes, she is a big woman. In fact, she could barely fit into the CT scanner. Yes, she has trouble walking. I have had physical therapy working with here and they inform me that they have done all that they can do. I also am well aware that he has trouble breathing. This is a combination of her emphysema, her current smoking habit, and obstructive sleep apnea from her obesity. I also realize that she seems tired but as you probably noticed, she’s not getting a lot of sleep at night, particularly because she refuses to wear her CPAP mask.

Yes, I understand it’s uncomfortable. I’d hate to have to wear it myself but it’s all I’ve got in my bag of tricks.

I am sorry. We can’t keep her. She came to us in poor health after an automobile accident and she’s going to leave in the same condition that we got her because there is nothing more that we can do about her chronic medical conditions. We took great pains to rule out any occult injuries to her brain and spinal cord and she has been in the hospital on our service many, many days longer than we typically keep uninjured trauma patients, many of who we discharge from the Emergency Department after a few hours of observation.

I can understand your reluctance to take her home. I believe you when you tell me that all she does is sit on the coach and watch TV except when she struggles out of it to use the bathroom. I wish that we could send her to a skilled nursing facility but as she has no insurance and you can’t afford it, this is not an option. She may or may not qualify for Medicaid but we can’t keep her here waiting for the decision. You will just have to take her home.

How will you get her up the steps? You have two sons. I saw them here yesterday. They may live a couple of hours away but they’re just going to have to drive back to town and help their mother. She is your responsibility and theirs. That’s why they call it a family. In fact, the stability of our world depends on families acting as self-supporting units. Break the bond of family and you have either a decaying European-style welfare society dying a selfish and lingering death or a catastrophe like the former Soviet Union which proved that if everybody is responsible for everyone else, no one is.

I’m sorry to place the whole burden of Western civilization on your shoulders, what with you living in a trailer with nothing but basic cable, but there it is. She is your burden. We need this bed for the never ending backlog of patients, some even sicker than your wife, many of whom are sitting in hall beds in the Emergency Department as we speak.

So you see, it’s not that I don’t care, it’s that I can’t care. I can’t take her home with me and assign my wife as her nurse. We can’t keep her in a scarce hospital bed for the rest of her life with her own private nurses and therapists to assist her. Despite what you may have heard, we are not magicians and I we cannot cure what afflicts your wife. I’m not even sure that we could help her if she wanted our help which she apparently does not. I can’t, for example, hold the CPAP mask on her face all night against her will or force her to take insulin shots. She could have me arrested for assault. She’s an adult. We all lay in the beds we make. We’re not doing a thing for her but catering to her whims, something you might want to stop doing by the way.

She can get up if motivated. I have seen her, just this morning, heave out of her bed and transfer to the bedside commode. I suggest if she asks you for some food you tell her to get it herself.

You asked if I am sending her home to die. Of course not. But she is going to die. I’d say her chances of being alive five years from now are zero as she is a setup for all kinds of medical badness. But, like I said, we can’t keep her here for the next year or two hoping to preempt the next medical crisis. Call the ambulance if there is any sudden change in her condition.

You were right about one thing. In the end, hiring a nurse to help you at home would be a lot cheaper than the inevitable hospital costs your wife will incur over the next five years as her health continues to deteriorate and fruitless regular hospital admissions turn into fruitless and spectacularly expensive ICU admissions. But I’m just a resident. I don’t make public policy. Even if I did, while your idea makes sense economically, I’m not sure I’d want to structure society to completely remove the burden of individual responsibility.

Good Luck. I wish I could do more but I can’t.

Sincerely,

Dr. Bear

Just a Few Random Things

Barking Mad

Psychiatric Ward

Inpatient psychiatry wasn’t as fun as I thought it would be. The people locked up on the tenth floor of our hospital were just a little too crazy to really be interesting. A little insanity, like a little spice, adds flavor to a patient’s personality. Too much of it and it overpowers everything. After all, a patient can only cut his scrotum open with a razor blade a couple of times before everybody just yawns and moves on to the next sensation.

It’s not that I don’t appreciate odd behavior. I am as mean-spirited as anybody and take the usual guilty pleasure in other people’s misfortunes, particularly when they are the result of some absolutely inexplicable but voluntary lapse of common sense.

It’s like slapstick comedy. We shouldn’t laugh but we do.

The truly insane, however, are directed by impulses so remote from the normal as to be both chilling and profoundly boring at the same time. If you’ve heard one patient explain how the television has commanded him to kill you’ve heard them all. If it’s not the television it’s the lawnmower, the dog, or the dead people next door. Just some variation of minds so out of whack that there isn’t even any guilty fun to be had. We don’t laugh and point at a diabetic. It’s the same with insanity.

Now if someone claimed that his cat was hissing dark commands in his head, instructing him to take night courses at the local community college towards a degree in medical coding, well, that would be unusual. I’d settle for his dead mother screaming at him about the benefits of good dental hygiene, something you almost never see in the insane.

What is your job as a medical student working on the psych ward? In essence, nothing. Oh sure, you will follow patients but except that you may have extraordinary conversational skills, you might as well just sit and stare at each other for all the good it will do. They’re schizophrenic. Their brains hear and see things that are internally generated but perceived as absolute external reality. Maybe they can be talked out of it but it will require someone skilled in the black arts of psychotherapy, not little old you casually rotating through. All the talk in the world probably isn’t going to make a difference anyways. The voices will not listen to reason and have to be silenced with psychiatry’s ever-expanding arsenal of medications.

So you will round on your patients and write your notes. Unlike, say, a surgery rotation where you can state proudly on your progress note that the patient “has had a bowel movement and is tolerating a soft diet on post-op day three of his bowel resection,” in psychiatry progress is hard to measure and most of your notes might as well conclude that “The patient is still as crazy as a shithouse rat…but we’re going to discharge him today because he is not a threat to himself or others…for now.”

About all you can do is be a little familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, the fourth and current edition) which is the Bible, Koran, and Vedic Texts of psychiatry rolled into one hard to digest bolus. When I say to become familiar with the DSM-IV I mean to get a review book, preferably one that will fit in your pocket. The DSM-IV is a large reference text and therefore highly unreadable except on the idiot savant level.

The DSM was developed to standardize the language of psychiatry between different mental health professionals in different countries and psychiatric traditions. This was necessary because as you can imagine, psychiatry is one of the most subjective medical specialties and has previously been very flexible even in the objective description of psychiatric pathology. The DSM also sets forth criteria for the diagnosis of discrete disorders as well as providing a framework for completely describing a patient for the purposes of psychiatric diagnosis and treatment by the use of five categories or “Axis.”

Axis I, for example, describes major disorders like schizophrenia or bipolar.

Axis II is for underlying or pervasive personality disorders or things like mental retardation.

Axis III is a “gimme” or a “freebie” for most medical students and residents who are not interested in psychiatry because while it is technically a description of other medical conditions that may contribute to the disorder, in practice it is the non-psychiatric past medical history. It gives you something to grab a hold of on an otherwise mystifying patient. Here, at last, are conditions that we can treat definitively, or at least definitively know we can’t treat.

Axis IV describes psychosocial factors, things like homelessness, unemployment, or poor family support. Axis V is the Global Assessment of Function (GAF) and is a numeric score from 0 to 100. Most of us function at around 90 to 100 which is considered normal. Someone lower than 60 probably needs to be committed except our society has unfortunately moved away from institutionalizing the mentally ill. That’s a subject for a different day but it would freeze your blood if you knew some of the truly unhinged characters standing in line with you at Wal Mart.

If you know a handful of common psychiatric presentations and can fit them into the five axis you will do all right.

Your psych ward patients will be a mixed bag (of nuts), ranging from the homeless guy claiming suicidal intentions for “three hots and a cot” to the raving but mostly non-violent schizophrenic. It is unlikely that you will rotate, as a medical student, on a ward for the criminally insane which would definitely kick things up a notch in the fear department. Students are occasionally attacked but this is not as common as you imagine. Just make sure to never let the patient get between you and the door, never wear a tie, and don’t get into a pissing contest with a lunatic. With a little common sense you will be fine.

My favorite patients are the bums who have the system figured out. They typically draw a disability check every month and use most of it for booze and drugs. By good economy and thrift they may manage to get almost to the end of the month at which point, malnourished, hung over, withdrawing, and cold they present to the Emergency Department, the 24-hour representative of “The Man” and claim they want to kill themselves. This buys them a stay in the psych ward where they can get a shower, hot food, and some rest in the bosom of the system. The only price to pay is being interviewed every day by an earnest medical student trying to cure them. Most of them actually have underlying psychiatric disorders that contribute to their situation but this disorder by itself is usually not serious enough to warrant inpatient care.

The bipolar patients are probably the most interesting. They will talk for hours in response to one question when they are manic. Even their medications can’t completely suppress this. I’d hate to be friends with a person like that but if you’ve got nothing better to do (and you won’t) you might as well listen to somebody who has everything figured out all the time. Beginners try to faithfully record everything the patient says in their progress note, often scribbling away furiously as the patient talks. Eventually you realize that it doesn’t really matter what the patient says and you condense your description of thirty minutes of frenzied speech to “Expansive mood, inflated self-esteem, and grandiosity.”

When they’re depressed, and you can sometimes follow the same patient long enough to see both sides of the disease, they can be almost catatonic and you will miss your chatty buddy from the previous week.

Will you like inpatient psychiatry? It is an easy rotation. You don’t really do anything but talk and there are no procedural or physical exam skills to learn. The hours are generally pretty good. You see your patients, present them, and maybe sit in a group therapy session and listen to the patients try to one-up each other. It can be frustrating, on the other hand, to write notes that nobody even reads, see patients for whom you don’t even have the usual medical student pretend-responsibility, and get the same tired story from the same patient day after day after day until somebody decides that, mirabile dictu, they are well enough to be discharged.

Barking Mad

Sound and Fury

Family and Community Medicine

Latravia Kell was my favorite patient. I can’t think of one bad hand that life hadn’t dealt her but she was unfailingly cheerful, polite, and compliant with all of her treatments. I met her on my first day of family medicine clinic and saw her at least every month afterwards. I didn’t do too much for her. She had a small platoon of specialists following her various medical conditions. Rheumatology had dominion over her SLE, Orthopedics claimed her osteopenia, Infectious Disease had suzerainty over her HIV and OB/Gyn was following her for various pelvic irregularities. In fact she seemed to have all of her bets covered and I was not sure what she needed from me.

“I’m here for my Depot shot,” she said on her first visit, “All you have to do is sign the form and the nurse will give it to me.”

“Well hell, we can do that,” I said, a little relieved because she seemed a monstrously complicated patient to inflict on an intern. “Is there anything else I can do?”

“No, not really. I’m good.”

Although we later became friends and she hugged me and cried on my last day at Duke, on her first visit I think even my brief physical exam annoyed her.

Later I had to dictate our standard clinic note hitting all of the high points of the chief complaint, history of present illness, and review of systems even though these were completely incidental to the purpose of her visit. I suppose this was to give the illusion that we were actually doing something besides routing her to the shot nurse but it seemed like a lot of sound and fury for nothing. My assessment and plan was basically a list of who was following her for what condition.

But that’s family medicine, at least at a big academic medical center.

I had other regular patients. It’s not as much fun as they make it out to be and occasionally you look at your panel for the day and hope that particular patients decide to skip their appointments.

Like Mrs. Ribitz. I knew that she was old and sickly. I was aware that her bones were fragile sticks and that she had recently fallen and broken her hip and her arm. I knew that ortho had pinned and casted her and that she was in a lot of pain. Hell, she looked terrible. And she smelled like the crappy nursing home where she lived which is not a nice smell as it is basically the smell of stale urine and dried food stains.

But my God could that woman complain. About everything and everyone. After the obligatory “What can I do for you today” she would stare at me malignantly for a few seconds and then launch into a tale of pain and suffering that would have made stones weep if it was anybody but Mrs. Ribitz telling it.

And then she would cough, gasp for air, and take a rest while sucking air through her nasal cannula. Her emphysema didn’t deter her from smoking and my eyes watered in the small examination room from the fumes that permeated her clothing.

“Well, Mrs. Ribitz,” I began while her coughs subsided, “I’m sorry to hear that things aren’t going well but if you had to pick one problem to address today, what would it be?”

“My feet are swelling,” she said curtly, “And my back hurts.”

I took off her slippers and urine-stained socks to examine her feet which were indeed swollen and pulseless, an alarming finding except they has been like that since I started seeing her and no combination of medications or therapies had been able to make a dent in the problem. I threw the Doppler on her and was able to hear the faint, plaintive sound of her tired blood struggling to supply her foot with blood. It was all peripheral vascular disease and poor medical compliance (which sounds nicer on the note than saying, “Patient is an idiot.”) She had already lost three toes to gangrene and I noted that most of the rest were heading that way. There was nothing to do as Mrs. Ribitz was the poster-girl for poor surgical candidates. I confirmed her next appointment with vascular surgery but that was the extent of what I could do for her.

“Tell me about your back pain,” I said with profound regret.

The floodgates opened and I heard, for the tenth time, the story of her chronic pain (from vertebral compression fractures) which was untouched by enough narcotics to drop a small herd of elephants, after which we both looked warily at each other. A physical exam to assess her pain was out of the question. She would probably have a heart attack from the exertion of standing up, which she couldn’t do anyways because of her hip.

“I’m out of Percocet.” A statement. “I need another prescription.”

At one time Mrs. Ribitz had a pain contract but I believe by the time she had exhausted two residents the clinic surrendered and just gave her what she wanted.

“I’ll just write you a prescription and you can be on your way.”

Mrs. Ribitz grunted in satisfaction. I verified the dates of her next appointment with ortho, checked her vitals and stood up to let the nurse wheel her out.

“And don’t even start about my smoking,” she snarled.

“Ma’am. You’re 85. I’m not your father. I’m not going to lecture you but if you want to quit I’m ready to help you.”

Surprisingly, on my last appointment Mrs. Ribitz sobbed uncontrollably and told me I was her only Doctor who wasn’t a pain in the ass and that she would miss me. I guess I kind of grew to like her myself, once I realized that her visits were primarily social calls. She had the usual cadre of specialists addressing her medical problems. All I ever did for her was write for the occasional narcotic and listen to her complaints.

Not every patient was so complicated.

“I’ve got a drip,” said Mr. Ryan nervously after the nurse closed the door.

“I guess we’re not taking post-nasal, right?” I had seen Mr. Ryan several times before.

“Naw, it’s down there.” He gestured down there. “And it hurts when I whiz.”

“Sexually active?”

“Yeah. Do you think it’s the clap?”

“Could be,” I said, “Let’s take a look…yup…certainly looks like it. Tell you what, I’ll send these swabs for cultures and we’ll treat you in the meantime.”

“Hey Doc, don’t tell my wife, Okay?”

“Maybe you need to tell her. I think she needs to know.” This is one of those moral dilemmas they’re always talking about. His wife is also one of my patients.

I had seen his wife just a week before for unusual vaginal bleeding. Of course we ended up referring her to OB/Gyn, just to be safe.

The latest fad in family medicine is identifying “barriers to care.” Naturally, some of these barriers were intuitively easy to identify. Being poor and unable to afford a doctor visit comes to mind, as does being unable because of a disability to travel to the clinic. But some of the barriers are a stretch. Being angry and deciding to express this anger by not taking one’s free prescription medications seemed kind of weak to me but this was exactly the kind of barrier I was supposed to take seriously.

One of our initial clinical assignments was to visit a patient at their home and identify their “barriers to care. My patient was an obese, pleasant, single mother of two with the usual comorbidities, all complicated by medical non-compliance. We weren’t actually supposed to say “non-compliant,” instead substituting the more optimistic and non-judgmental phrase “pre-compliant.’

Having lost her Section 8 housing because of some fraudulent activity which involved subletting her subsidized apartment while she lived with her mother, she lived in a small but adequate house, the rent for which ate up most of her meager income from the public treasury. The first thing she complained about was the poor upkeep of the house and asked me what she was expected to do about it. The social worker who accompanied me nodded empathetically as if to say, “Here, you newly minted doctor and representative of ‘The Man,’ here is a barrier to care. How will you help her over it?”

In my written report I suggested that this was a matter far beyond our scope of practice, something best worked out between the tenant and landlord either amicably or in the City small claims court. Besides, this in no way effected her access to our clinic as her visits cost her exactly nothing and a broken window and leaky faucet are not exactly homeowner’s emergencies.

My wife and I managed a housing project years ago (before my wife quit after discovering a dead tenant which is another story) and we used to get calls at 3AM demanding that we drive across town to unclog a toilet. The helplessness of the dependency class does not admit to any effort, no matter how small, to take responsibility for anything in life. The typical response to the natural question, “Do you have a plunger?” was, “I’m not sticking my hand in the toilet.”

I once got a frantic call from a tenant’s whose apartment was on fire.

“Did you call 911?” I asked.

“No. Do I need to?”

“Not unless you think I’m going to get in my private fire engine and drive over there.”

But I digress.

I also pointed out in my report that despite her claims of poverty, the patient must have had other income. She had furniture, the babies were fed, there was a large (but not extravagant) entertainment center in the living room, and I saw no signs of deprivation of any kind. The children also looked clean and well-cared for. She even had a working automobile.

Apparently her mother helped out.

Lack of daycare was another barrier to care, as it prevented her from coming to clinic even though my wife sometimes has to drag all four of my kids to her doctor’s appointments. I discovered however that while the baby-daddy’s mother, the baby-granny, wanted to take an active role in caring for the children, my patient had refused her access to her grand-children until she bought them expensive clothes as a propitiatory gift. My patient bragged about this. Apparently greed and arrogance were also legitimate barriers to care.

It turned out that she was angry. Yes angry. Angry that when she came to clinic no one listened to her concerns and nobody explained her treatment regimen in a manner which she could understand. Nor did we respect her sensibilities as an independent, intelligent African-American woman.

“I just don’t feel like you take me seriously,” was her explanation as to why she didn’t take her insulin as directed. The social worker soothed her ruffled feathers and I held my tongue. I was not kind to her in my written report. She was a stupid, lazy, selfish woman all of which characteristics are personal problems, not medical issues or barriers to care.

Her anger, I wrote, was a form of transference. Impotent and ineffectual in every other aspect of life, she gave herself the illusion of control by making her social worker and the physicians at the clinic jerk like puppets to her whimsy. The clinic, after all, was probably the only place in the world where she was taken seriously. In every other venue she was just a fat, dumb, single mother without the sense to take advantage of the help she has been given by the State.

Tragic, perhaps. A crying shame and a waste of her potential, no doubt. But not a medical problem.

This report was not received well by the program chairwoman. As if I was a third-grader, I was asked to rewrite my homework, not once but twice, in order to please the sensitivities of the program. And the second rewrite wasn’t good enough either. I was asked to write it again but decided to blow it of and never heard about it again.

Sound and Fury

Mr. Smith Has an Epiphany

I’ve got Your Back

It’s my wife. The pager displays our super-secret marital code for “Everything is all right. I just want to see how you are doing. Call me at home.”

“Hey baby,” I say when my lovely wife picks up, “How’s everything going?”

“I’ll be home in another hour. Sorry. Things are kind of busy tonight and I have a couple of patients I can’t sign out just yet…OK, I’ll see you when I get home…I love you too…bye.”

Mr. Smith sits in his hall bed and gapes.

“Don’t gape, Mr. Smith. Even doctors have families. Hard to believe, huh? You probably think that we live here which is understandable because we’re never closed and there’s always someone here when you come in with one bullshit complaint or another. It’s not like you’ve ever been turned away when you come looking for narcotics. You might not get them every time but somebody always takes you back, treats you with more respect than you probably deserve, and listens intently to your latest drug-seeking gambit.”

“In fact, I even like to go home at a regular hour if you can believe that. Sometimes I can’t because in this department we try to get a disposition on everybody before we leave, something I had almost accomplished until I made the mistake of picking up your chart. But why should I mind? My children will get to bed tonight just fine without me and I certainly spend too much time watching TV with my wife anyways. The importance of your chest pain, on the other hand, does not diminish just because you’ve been here six times in the last two months with a similar complaint. I’m pretty confident that you’re going to be just fine but I’d feel bad chasing you out if this time, and I’m just talking here, it was a real heart attack. I don’t see how the world could get along without your vibrant soul.”

“Oh no. Don’t get up. Sit. Stay a while. I’m on a hunt for cardiac enzymes and this time your blood is going to score! The normal EKG was disappointing, I’ll admit, but your constant “ten-out-of-ten” chest pain radiating up your neck encourages me. This could be the big one. You’ve just got to believe, Mr. Smith.”

“Are you falling asleep? Brave soul! Your pain is so intense that it is no wonder you seek the oblivion of slumber. It was even untouched by the morphine I reluctantly gave you before I realized who you were. I’d give you something stronger but I’m at a loss for what to give except that we both agree it probably starts with a “D”. How can you expect me to remember its name if you can’t?”

“I understand what you mean when you say that you have no power and the man is sticking it to you. On the other hand, here we are. I have a college degree, two years of graduate school, a medical degree and two years of residency training. My attending has all that plus a few years of a fellowship. You may have not graduated from high school and be the most hard-luck guy in town but you have the power to make us dance like trained monkeys just by uttering three little words:”

“My chest hurts.”

“Now that’s power. Not to mention our highly skilled nurses cleaning up your urine and the fine technicians in our lab feverishly analyzing you blood as if you were the great Tsar of Russia himself.”

“So no, I don’t mind seeing you. The paper work is not too bad. I feel kind of silly writing out your discharge instructions seeing as we’ve done it exactly the same many times before. I know you get a good laugh out of “Return to Emergency Department if pain returns and is not relieved by nitroglycerine.” I think it’s funny too. Especially that part about following up with your primary care physician. That guy is always out of town. How on earth can you follow up with him?”

“Don’t worry, Mr. Smith. I got your back. You’re covered. Sleep, gentle spirit. When you awake I hope to give you the good news that your heart is fine and Motrin, not narcotics, will ease the pain.”

Mr. Smith Has an Epiphany

Spectator Medicine

Emergency

Mrs. Jones looks like a cadaver. Her bony yellow legs stick out of the bottom of the gown. A pack of relatives clutch at each of her claw-like hands and stare confidently at the monitor over the bed.

“She’s doing better, right?” Her blood pressure had been coming up steadily. A great-grandson reads the numbers to the relatives standing in the hall who nod in relief.

“We’re giving her fluid. She was pretty dry when she came in.” I am not nearly as optimistic.

Mrs. Jones came to the Emergency Department from her nursing home. According to EMS a nurse had noticed that she was looking more cadaver-ish than usual and became alarmed when she couldn’t get a blood pressure.

“Her doctor said not to give her fluids.” The daughter is the spokesman for the relatives. “He said it would flood her lungs.”

Mrs. Jones’ medical history reads like a pathology textbook. Her congestive heart failure is the least of her problems at this point as it’s competing with severe hypovolemia, probably from diarrhea over the past several days.

“Her lungs sound pretty clear. We’re waiting for the chest x-ray but I’m pretty sure she can tolerate a lot more fluid than we’ve given her. We can always take some of the fluid off later but her organs need fluid now.”

The daughter holds up her hand.

“We want to speak to a real doctor. Our doctor told us to keep residents away from her.”

“I am a real doctor,” I say pointing to my ID badge. The family looks suspicious.

“The other doctor who was in here said she didn’t need that,” says the daughter pointing to the small bag of levophed dripping into her central line. “He said it will make her lungs fill with fluid.”

That must have been my medical student. Or maybe one of the janitors. They clearly don’t buy my explanation of the role of pressors in shock. The daughter throws me a dark look. I promise to get a real doctor to answer their questions.

Several hours later and Mrs. Jones still looks like a cadaver. According to the monitor Mrs. Jones is doing fine though she clearly has one foot in the next world. Her daughter who has become adept at reading the numbers is annoyed that we have not stopped the pressors and have not removed the endotracheal tube, something she insists we do immediately. I don’t think she’s going to be very receptive to the discussion of code status once her mother gets up to the ICU but the prognosis for her mother is grim, cheerfully normal vitals notwithstanding. Mrs. Jones is fighting myelodyplastic syndrome which has converted to leukemia, something I only discovered when I browsed through her old records.

“Why does she need to go to the ICU?” asks the daughter.

“Because she’s dying. The only things keeping her alive are the fluids and the ventilator. I hate to be blunt but surely you are familiar with her medical history.”

“Her doctor said she still had at least six months. You’re not even a real doctor. What do you know?” Some of the relatives look embarrassed. The alpha-relatives, however, are clearly not impressed with me and mutter darkly about a second opinion.

“Let’s get her up to the ICU and you can talk to her oncologist in the morning.”

Mrs. Smith has fibromyalgia. I have hardly introduced myself before her husband mentions this twice. My attending laughed when I picked up the chart. Mrs. Smith is well known to the department. A quick check of the computer shows fifteen visits in the last year for similar pain. She writhes in agony on the bed.

“How long have you had the pain,” I ask, grimly determined to think the best of her.

“Since last night…I’m paining real bad…All Over.” By this time she has learned not to point to a specific spot as we have a distressing tendency to take people at their word and order all kinds of inconclusive and painful tests and studies.

“She gets like this a lot,” says her husband, clearly distressed, “You guys never do nothing for her.”

Normal physical exam. Mrs. Smith has still not caught on that when I am listening for bowel sounds I am actually palpating her abdomen with my stethoscope. Sometimes you have to distract the patient. Neither is there anything unusual in the review of systems or the history except for pain.

“What do you take for your pain?” Her old charts record a bewildering array of pain medications. “Let me try you on some Motrin.”

“I want to speak to a real Doctor,” she says.

The nurse mentions to me that “pain lady” was sleeping soundly just minutes before I opened the curtain.

Mr. Simon’s mother hold the basin as he heaves and vomits a large quantity of red-colored fluid, spits to clear his mouth, then lays back in the bed and continues to curse at the nurses. I’d ordinarily be alarmed but the paramedics told us that his neighbor thought he was hypoglycemic and force-fed him a bottle of fruit punch. His vitals are stable and he’s not tachycardic. On the other hand alcoholics are susceptible to upper GI bleeds from ulcers, varices, and esophageal tears. We send a sample of his vomit to be tested for blood and I make sure to order a type and screen but I don’t think he is bleeding. His blood counts come back normal a few minutes later and his vomit is negative for blood.

“If you stick me again I’m going to kick your fucking ass,” yells Mr. Simon to the respiratory therapist by way of introduction. Aside from being drunk, diabetic, and high on heroin, Mr. Simon’s immediate medical problem is the inability to maintain his oxygen saturation without supplemental oxygen. When he takes off his mask, his oxygen saturation falls to the high seventies. Mr. Simon is only 29 and a heavy smoker but this is definitely not normal. I want to get an arterial blood gas on him. If he thinks the respiratory therapist is hurting him he’s going to enjoy it even less if I have to stick him.

“Stop cursing at the nurses, Mr. Simon,” I suggest gently, “They’re trying to help you.”

“I’m paying your fucking salary,” screams Mr. Simon. “I don’t need this shit from you.” Mr. Simon is what is optimistically known as “self pay” meaning he wouldn’t pay his medical bills even if he had the money.

According to his mother he went on his current binge after being dropped by his girlfriend. He had stopped taking his insulin a day before and his presenting blood sugar was too high to be read by the glucometer. The complete metabolic panel pegged it at 769 which is pretty high but everything else wasn’t too far out of whack. He also had a normal anion gap which was unexpected as the assumption was that he had diabetic ketoacidosis. His potassium was normal so we started him on a modest insulin drip.

Mr. Simon is a mystery. A rancid, abusive, tattooed enigma. His chest films are normal, his respiratory rate is normal, and his GCS is a solid 15. His ABG confirms both a mixed metabolic and respiratory acidosis and a low oxygen saturation. Pulmonary embolism? His D-dimer is low so he’s not making it easy for us. Aspiration? My senior resident starts him on clindamycin as a precaution but would he really be so hypoxic so quickly? Physical exam pretty normal too except that he feels clammy.

Maybe it’s cardiac but unfortunately is EKG is normal. Maybe the cardiac enzymes will give us a clue. I ask him about chest pain but as Mr. Simon answers some variation of “fuck you” to every question, the review of systems is probably going to be a little sketchy.

“Yeah my chest fucking hurts,” He says.

Surprise, surprise. “What does the pain feel like, Mr. Simon?”

“Have you ever had your heart chewed up and then spit back into your chest? That’s what that bitch did to me.” (He points to a scruffy looking young lady who has crept into the room and now shirks against the wall.)

“Not recently. Listen, is it some kind of metaphorical pain or does your chest really hurt?”

“Fuck you. I need to take a crap.”

He’s stable for now although it’s a struggle to keep his oxygen mask on. He keeps pulling it off and threatening to leave. While this isn’t a prison, he is drunk and high so I could restrain him if necessary. He definitely needs to be admitted and I ask the unit coordinator to break the good news to the medicine intern

Mr. Simon was admitted but bolted a few hours later before the source of his hypoxia could be identified. I imagine he is in some hole shooting up with his insulin money.

Mrs. Jones died in the ICU that day.

Mrs. Smith got six vicodin and left gravely disappointed.

Spectator Medicine

Pulmonary Consult

Breathe

“I’m a difficult patient,” declaims Mrs. Olafsen proudly around a mouthful of Whopper with cheese. “Nobody knows what’s wrong with me.”

“Really? It certainly looks like that from your chart.” Mrs. Olafsen is gigantic. It took four nurses to get her from the stretcher to her bed. Her legs, like two scaly tree-trunks, encircle a greasy fast food sack which was supplied by one of her skinny daughters.

“I’m Dr. Bear, one of the Emergency Medicine residents working with the pulmonary service. Your doctor asked us to come take a look at you.”

There is a lot of Mrs. Olafsen to look at.

“They tell me you had some trouble breathing.”

“Oh yeah.” She carefully shifts her enormous body and gestures for her daughter to hand her the vat of soda resting on the night stand. “I couldn’t hardly breath when I came in. Isn’t that right?”

Her daughters nods furiously.

The chart does not do Mrs. Olafsen justice. Asthma, COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), NIDDM (Non-Inuslin Dependent Diabetes mellitus), PVD (Peripheral Vascular Disease)…all the usual abbreviations. Everything about her is larger than life. She actually looks and sounds pretty good, all things considered.

“I’ve had the flu or something for the last two weeks. I just couldn’t breath at all this morning and my daughter called the ambulance.” She roots in the bag for the greasy debris and finishes her drink with an exuberant slurp.

No kidding. She presented a few hours earlier in Status Asthmaticus, a sometimes fatal exacerbation of asthma which is refractory to the usual treatments. Imagine every small airway in your lungs clamping down tight. I read with interest on her chart that the use of heliox (a low-density mixture of oxygen and helium that results in less airway resistance) was contemplated but not used because she got better.

The oxygen going to her small tracheostomy hisses and bubbles in the humidifier. I see that she is at her baseline oxygen requirement and is “satting” in the upper nineties. Vitals suprisingly good. Her blood pressure is better than mine and she is the most alert and engaged patient I have seen all day.

Mrs. Olafson. Viking fertility godess surrounded by her pretty, reverential daughters. Nothing much to do, really, except write the usual admission orders and the standard prose on the admission HPI. (“46-year-old woman with a history of asthma presented to the Emergency Department in staus asthmaticus…etc. etc.”) However, If there’s one thing I’ve learned this month it’s that everybody can have a pulmonary embolus and Mrs. Olafson is a set-up for one. The D-dimer was equivocal so I order a doppler ultrasound of her massive lower extremities.

The ultrasound lab pages me an hour later.

“You’ve got to be kidding.”, says the tech, “It’ll take three of us just to lift her pannus out of the way.”

“Just do the best you can. I don’t think she’ll fit in the CT scanner.” I know it’s asthma but we’ve had a bad experience recently with a pulmonary embolus (PE) so the service is a little spooked. I examine my logic for ordering the ultrasound. A negative scan, by itself, does not rule out a pulmonary embolus which can only be confirmed or excluded by a CT 0f the pulmonary artery and it’s branches. A low D-dimer would have done it but it is high…but not that high. Why not just skip the ultrasound? We’re going to start DVT prophylaxis anyways.

“When will I get a bed,” asks Mrs. Olafson clearly tired of repeating her story to another guy in a white coat.”

“I don’t know. But we’ll get you upstairs eventually.” The moon will not set before I see Mrs. Olafson safely transferred and slumbering in semi-upright splendor. She seems melted in the flickering light of the television.

The Fresh Prince of Bel Air. I swear, it’s the only thing on at 3 AM.

Mr. Bomagard has died. An hour ago, the ICU informs me.

“Who?” I’ve never heard of him. I’m cross-covering.

“You know, the guy we coded for half an hour yesterday.”

Oh. That guy. I was at the code but it was very well-attended so I didn’t do much. An elderly and demented gentleman who checked out several months ago but whose body had been preserved as a museum to our arrogance and folly.

Mr. Bomagard actually died yesterday. He was in asystole for close to ten minutes before his heart was coaxed back into sputtering life. That was the best CPR I have ever seen. His arterial line measured optimistically normal blood pressure during compressions but trickled away to nothing when they were stopped. And he had the oxygen saturation of a teenager. He came back in stages. From asystole to ventricular-fibrillation at which point he was shocked, the response becoming more dramatic as the current was dialed up. He was finally stabilized in a tenuous sinus rythm on a continuous infusion of amiodarone. And three different pressors to keep his blood pressure up.

What were we doing to you, Mr. Bomagard? You have been in a nursing home for the last three years and haven’t spoken or moved in nine months. This was your fourth ICU visit in the last year. Maybe when you’re being fed through a tube, breathe through a tube, defecate and urinate through a tube…maybe it’s time to let you go. It’s not even a question of your dignity because we’ve taken that away from you. Your shrivelled naked body bounced to the rythms of chest compressions under the bright flourescent lights for ten minutes while your children looked on from just outside the door. Another minute and we would have called it off.

We should have let him go a year ago but families lie. The patient always perks up for them. He knows they’re in the room. It’s not much of a quality of life but we’ll take it. Please don’t let him die. We still see the man we knew in the contracted husk with the tubes and wires sticking out of him. You didn’t see him when he held his first grandchild or on our honeymoon before he shipped out for the Pacific. He’s still in there, somewhere.

He has to be.

“It’s not like they held a gun to my head and made me smoke,” says Mrs. Needlebacker between coughs. “I knew it was bad but I still did it.”

“Don’t beat yourself up, Mary,” I say, “We all have bad habits.”

“Do you, young man?”

“Well, I used to drink but my wife made me quit.”

Mrs. Needlbacker laughs then coughs. I didn’t really drink that much but what can I say? She is 65-years-old and lung cancer has got her in its death grip. When, in her 150 pack-year history of smoking did she realize it was kiling her? When she became short of breath working at her job as a cashier? When her need for supplemental oxygen finally overlapped into her entire day?

She has been coughing up blood. I write “hemoptysis” on my daily note.

“Can I do anything for you, Mary?”

“Yeah, let me out to smoke.” She laughs but she’s serious.

“You’re on oxygen. Your hair might explode.” If it was in my power I’d wheel her downstairs myself and let her smoke as much as she could stand. “Besides, those things will kill you.”

More laughter, more coughing. “No, you’re killing me.” We make the same jokes every day.

I will be off the service on Monday. We are transferring her to hospice in the morning.

Pulmonary Consult