Brought to you by the Letter 'C'

Working at the VA means that the patient population is relatively homogenous. I've only ever seen one female patient during my past three weeks here, although that should change as the current generation of military personnel ages.

Coincidentally, for some weird reason, all the patients I've been given to follow have conditions that all begin with the letter 'c':

• Chronic Obstructive Pulmonary Disease (COPD): Probably one of the most common conditions we see in the VA, you often see this in smokers. This isn't merely a bad smoker's cough, between 10-15% of smokers will develop COPD which refers to a trio of pulmonary conditions: chronic bronchitis, emphysema, and mucus hypersecretion. Most COPDers probably have some combination of all three of these. The poor people really have trouble breathing - you and I have O₂ saturations of 99% breathing normal air, which is only 20% oxygen. These guys desaturate into the 80's breathing normal air, and some will never get higher than 92% breathing pure oxygen. I'm not sure what it feels like to be at chronically 92% O₂ saturation, but I'm going to find out - I'm gonna grab one of those fingertip O₂ saturation monitors and hold my breath and see how low my O₂ saturation can go before I pass out. Experimental results to follow shortly.
• C. difficile colitis: This one's pretty disturbing. It used to be that C. difficile was a relatively uncommon infection - a year ago, they'd only see 2 cases per month. There were 7 admissions for C. difficile colitis in the last week alone. To make matter worse, there seems to be a new strain of C. difficile going around, which produces another toxin which leads to worse symptoms - like double the amount of diarrhea people were producing before. And C. difficile is community-acquired. I'm not sure how we're passing the bug to each other, but all I can think of is the chapter from Eric Schlosser's Fast Food Nation that describes how our nation's beef is prepared. Just a thought.
• colonic bleeding: That about says it all.
• cutaneous candidiasis: Probably one of the more boring cases I followed, an overweight 90-year old veteran came in with macular lesions on his trunk, abdomen, and pubic area, mostly in areas where skin folds overlapped and created a nice little environment for this infection to occur. Boring because all it really involved was for me to take the patient history, then call for a dermatology consult. Um...what else...yeah, it was kinda gross.
• coronary artery disease: Well, I didn't actually see this. I had to work up a patient who came in with chest pain and send him for a stress test, but really we think he was having a bunch of panic attacks.
  

Well, that's one letter down, 25 to go.

The Agony and...More Agony

Monday, Columbus Day 2005, the day after Long Call. I get in about 7am and "pre-round" on my patients. The idea behind pre-rounding is to get a picture on any significant events during the night - the primary source is the patient, and other sources include any nursing notes or any vital signs or lab results that have just been reported. I get to JJ's room about 7:30 - the first thing I always ask is "How was your night? Did you sleep well?" Apparently he didn't - JJ is a light sleeper - would benefit from sleeping pills, but I sell him on the idea of trying ear plugs. Sounds like JJ is stable, though.

Mikey: Is there anything you'd like to ask me?
JJ: Yes. One of the nurses gave me some medicine - it was a powder mixed in water - and when I took it, I felt a burning in sensation all over my chest and then I felt it in my neck and shoulders and I had a headache for an hour.
Mikey: When did this happen?
JJ: About an hour ago.
Mikey: Are you having any pain now?
JJ: It ended about ten minutes before you came in.
Mikey: So the pain lasted about an hour?
JJ: Yes.
Mikey: Did you tell anyone?
JJ: Well, the nurse left before I actually took the medicine.
Mikey: Did you press the alarm button?
JJ: Well, I know the nurses are really busy...

Two things to note here:

1. JJ is an amazingly nice guy. Nicer than nice. Even knows how his hospital roommate is doing, he politely notifies a therapist the best way to wake his roommate up. Point being: there are patients who complain too much, and there are those that complain way too little.
   
2. The second that a patient reports the slightest bit of chest pain or pressure, you tell someone. Anyone - nurse, resident, attending physician. Anyone. Because as soon as you do, there's a set of events that occur to ensure that the patient isn't going into cardiac arrest.

Point #1 is obvious. Point #2 - and this is really hard for me right now - is obvious to me in hindsight, but I didn't tell my team until we were on rounds - about 90 minutes later. I'd made sure that JJ was stable, and didn't see him exhibiting any signs of myocardial infarction, so it never entered my mind. When I told my team, they alerted me to Point #2. Duh. I feel like such an asshole.

The team enters JJ's room to see how he's doing - he looks a little more sick than yesterday - he's sweating and becomes short of breath when he sits up. When we listen to his lungs, we can hear fine crackles whenever he inhales and exhales. His urine is a really dark coca-cola color. We quickly bring in instruments to measure his blood pressure, O₂ saturation, and get an ECG. His blood pressure is up, his O₂ saturation is down, and we see ST depression in a couple leads on his ECG. This probably isn't due only to his pneumonia. One of the first things we can do is decrease the workload on his heart, so we order 20 milligrams of furosemide to be administered immediately. Furosemide is a potent diuretic and will prevent water resorption in the kidney, leading to a profound increase in urine output. Simply, this will decrease the amount of resistance that the heart has to work against with each contraction. Within several minutes, JJ has put out a couple hundred milliliters of 'Furosemide urine'. Stacey calls it that because of the color - before furosemide, JJ's urine was the color of Guinness - after furosemide, it's more the color of Bud Light. This is good - it means the drug is doing its job.

Stacey, Sally, Reva, and I huddle to discuss the case. I'm already feeling guilty about not alerting anyone about JJ's chest pain, previously. It gets worse. If you recall, the previous day we thought that JJ was dehydrated, so he was given one liter of normal saline. The evidence points strongly to the idea that we overloaded him with fluid. The increased blood volume could explain the increased blood pressure. The increased blood volume could cause leakage of fluid into his lungs, explaining the crackles we heard on exam, his shortness of breath, and his decreased O₂ saturation. We wondered why we hadn't noticed it earlier. I get flustered. I had visited JJ later in the evening to ask some more questions, and the nurse had mentioned that his O₂ requirement had increased to 6 liters of O₂ per minute, up from 3 liters earlier. I'd mentioned it to Rahul, who said not to worry about it.

When I report this in the huddle, it comes out in the following manner:
Stacey: This was sudden. He was only on 3 liters of O₂ yesterday.
Mikey: I noticed that his O₂ requirement was increased last night.
Sally: Did you tell anyone?
Mikey: I did - it didn't seem like anyone (and I was desperately searching for the correct words here) was concerned.

Already my day has turned upside-down, but I quickly realize that I've violated a cardinal rule in Medicine: don't correct your resident in front of your attending physician. To be honest, I was putting out information because I'd neglected to put it in my presentation beforehand, and now it looked like I was humiliating Stacey. I've never wanted so much for a hole to open up and swallow me whole. We have to finish rounding on the rest of our patients, which takes about an hour. I have a hard time paying attention - all I can think of is how much I've screwed up, how much of an asshole I am, and how I'm going to apologize to the team. This is the Longest. Hour. EVAR.

I take Stacey aside and privately apologize to her. I don't know what embarrasses me more - my failure to alert the team immediately concerning JJ's condition, or my correction of Stacey in front of our attending. She's baffled:

• First, JJ's condition is not my fault - she makes the point that numerous other people are involved in his care: nurses, interns, residents, and the attending - any one of these people should also have recognized the warning signs. Small comfort, really - I'm on the front line now, and because I wasn't more forthcoming with the information, JJ has now been transferred to the Telemetry Unit (where they can keep a constant eye on his vital signs) and perhaps faces a prolonged stay in the hospital.
  
• Second, being corrected in front of our attending doesn't matter to her. "We've all been where you are, so don't worry about it any further." I'm lucky. A lesser person could've have made sure that I paid for such an insult dearly. I expect better of myself. Medical knowledge will come with experience. Professional behavior is something that I should be able to handle right now, and I blew it.

I finish my work and head home. Tomorrow's another day. Perhaps I can rebound. There will be better days, but there will also be days just like this one. I wonder if I can handle the responsibility of being a physician. I wonder if today is an accurate measure of what kind of doctor I'm going to be. I fear that I'm going to be a bad doctor.

I spend the rest of the day alone with my thoughts, wishing this pain would end.

Wrecked All Eggs Sam

My team was on Long Call on Sunday, and I picked up two patients to follow. 'JJ' is a 74-year old man who was admitted to the hospital for a foraminotomy (a procedure that is performed to enlarge the passageway where a spinal nerve root exits the spinal canal). The surgery went well, but during the post-op recovery, JJ's blood pressure and O₂ saturation dropped, and he became delirious. He was transferred to an intensive care unit, where he received supportive care until his vital signs stabilized. At the time, it was suspected that JJ had developed a bilateral pneumonia secondary to aspiration, which is a risk in surgery requiring general anesthesia. He was subsequently transferred to our team for care.

Rahul and I visit JJ in the MICU (Medical Intensive Care Unit) to perform a history and physical exam. JJ is an incredibly nice man, and is patient with our questions and the physical. We say farewell, and go downstairs to our den to write our notes while JJ is transferred from the MICU to one of the medical wards. This looks like a straightforward case - a patient who developed pneumonia, and we'll just provide support during his recovery. He looked dehydrated during the physical exam, so we order an infusion of normal saline.

His lab values are generally unremarkable, although we note that his hematocrit is rather low. There are a number of things that could cause a drop in red blood cells, but primarily we worry about an internal bleed or anemia. X-rays of his chest and abdomen don't show any evidence of hematomas, so we worry about a gastrointestinal bleed. Well, there's a relatively quick way of testing for blood in one's stool: the fecal occult blood test.

Rahul asks whether I went to learn how to perform a rectal exam. I figure I have to learn it at some point, right?

Rahul: Okay, here's the rectal exam in four steps:

1. Put a glove on.
2. Insert your index finger into the rectum, swipe, palpate the prostate and take note of any nodules.
3. Swipe the stool from your index finger onto the fecal smear card.
4. Take off your glove.

Mikey: Take off my glove?
Rahul: Yeah. Why - don't you want to?
Mikey: No, I just thought it was funny that you had to mention that as one of the four steps.
Rahul: I have to - last week I saw John running down the hall looking for a smear card with the glove still on his hand, stool and all.
Mikey: Ah.

We go into JJ's room and inform him about the possible bleeding, and tell him that we have to perform the rectal exam. JJ takes it in stride - shouldn't be a surprise: JJ was a rifleman in both the Korean and Vietnam Wars, so he shouldn't be afraid of my index finger. Rahul throws me some gloves, and we set up for the procedure. Rahul notes that we're missing one thing - lubricant.

From Rahul's Words of Wisdom:

Performing a rectal exam without lube is really really cruel to the patient.

Okay, I'm gloved up and ready to go. I'm pretty sure I'm more nervous than JJ, but I also think that it'd be more cruel for me to hesitate. It's done in about 10 to 15 seconds - I got a pretty good swipe and felt the prostate, palpating no nodules. I quickly smear some stool on the test card and we send it off to the lab. We make sure that JJ is comfortable and tell him that we'll check in on him tomorrow.

And I remember to take off the glove. As if.

Tomorrow (maybe): The Agony and ...More Agony

A Question for You:

Physicians aren't the only people in hospitals that round on patients. Most hospitals have clergy that visit the patients, too. They even write notes in the patient charts. So, here's the question:

Which is the scarier image:
A group of people in white coats standing around your bed going 'Hmmmmmmm....'

or

A priest walking into your room saying 'Hey, whassup? Uhhhh, hey - do you believe in God?'

Spoiled

Two weeks into my Medicine Clerkship: I'm feeling like I get the system more. My confidence yo-yos quite a bit. I've got good days where I'm on top of most everything, and then there are those other days where I feel like I should be sitting in the corner wearing a dunce cap.

My team is awesome:

• Reva: fellow medical student. Reva has been great, helping me transition into this rotation. Always helpful with stuff I've forgotten since the pre-clinical years. We make a pretty good team.
• John: an intern from Ireland, and Reva's supervisor. Always teaching, and even takes an hour or so from his schedule every week to teach us an aspect of the physical exam. Doctors trained outside of the United States tend to get better training regarding the physical exam than their American counterparts, so I definitely take the opportunity to learn from them whenever possible.
• Rahul: my intern, also very helpful in helping me along.
  
• Stacy: The team resident (PGY-3). Great person, keeps the team laid-back.
• Sally: The team's attending physician. Sally is AWESOME. She's always smiling, always keeps in mind to make teaching points when appropriate, fantastic bedside manner. During attending rounds, when she gives a lecture to the team, she brings in chocolate.

The Medicine Department is always feeding us. We're pretty much responsible only for dinner if we're in the hospital late. Weekends we're on our own, but still - this is more than most other places would do. In short, it probably goes downhill from here.

I love my patients. I'm at a Veterans Administration Hospital, so all of my patients have been in the military. Vietnam Vets are hitting their mid- to late-50s about now; World War II vets are in their 80s and 90s. I'm not sure what I expected - you know that they're people just like everyone else, but there's that tendency to put them on that pedestal because of the sacrifices they've made. Of course, when I meet them, they're (usually) the sweetest people - really nice, and modest to a fault when asked about their military service. They're just really grateful if we do our best to make them feel better. Actually, they do pretty well even if you just talk to them. This is something we noticed quite a bit in our psychiatry patients, that depressed patients would look a little happier when you stopped by and engaged them for a while. In the patient charts, that's noted as: "Brightens with attention." It sounds kind of lame, I suppose, but it's so much better than "Kicks the medical student out of the room." Which hasn't happened to me.

Yet.