I am extremely fortunate to work with a nurse who has over 20 years of experience. She knows how to run an efficient clinic, she gives great insight into our patients, and I really feel like we're a good team. She's funny, she's helpful, and she's very honest.
I see Hepatitis C patients, and many of them have substance abuse problems - active or in the past. In order to treat their Hepatitis C, patients need to be sober from all substances for at least 6 months. Most people have gotten over their addictions, which is why they are coming to see me - they are on their way to cleaning up their lives.
Yesterday, I saw a patient with Hepatitis C who is an alcoholic. He is still drinking, despite knowing about his liver disease. His wife is also a drug addict. He can't drive because of a suspended license, so he relies on her to take him to his appointments. You can imagine that she is not the most reliable driver; she is often gone for days at a time on binges. He had to cancel 2 previous appointments with me because she wasn't home. He told me that there is a divot at the foot of his bed where he spends nights sitting up, waiting for her. Very sad.
I was telling my nurse about the patient and about how I wished there was something we could do for him - get him to AA meetings, help his wife get sober, etc. She shook her head and looked at me. "I know you're new at this and all, but you know there are some people you just can't help. You can only do so much." She's right, I just have a hard time holding patients responsible for their actions; I tend to treat them as children who don't know any better. However, patients make bad decisions all the time - and they make bad decisions knowing that they are bad decisions! Whether it's substance abuse or not following their diabetic diet or not taking their blood pressure medications, my patients are adults and I might serve them better if I held them to higher standards. I'm certainly not helping them by dismissing their weight gain, their drinking, their noncompliance as reasonable choices. I'll need to learn how to be a little firmer on some of these things.
Friday, November 12, 2010
Sunday, October 31, 2010
Perspective
I had a patient last week who came on a gurney. This is odd, since I work in a clinic and people are usually ambulatory. But, after my nurse told the ambulance drivers to wait in the waiting room, I went in to see the patient.
He was mid-60s with a history of high blood pressure. I had read in his chart that he had both legs amputated due to some sort of chronic wounds. I skimmed over an operating room report that mentioned a hip disarticulation - where the leg was removed completely from the hip socket. That's a pretty disfiguring operation, but one I've seen before. What I didn't read, but noticed immediately when I walked into the room, was that both hips had been disarticulated. The man was lying on his stomach, propped up on his elbows. He had long hair and a beard, like the pictures of Jesus always show. He was just a torso and pelvis. I blinked and went to the computer, smiled and introduced myself.
We had a wonderful visit, he is quite funny and talked a lot about his various art projects. He has a piece in a museum - as a part of the permanent exhibit! Quite exceptional.
He said he would probably be depressed if he just sat and looked out the same window all day. Instead, he taught himself wood whittling, knitting, and other arts and crafts. He has friends that peddle them at various festivals and fairs around town. He gets asked to show his work in art exhibits around the country. I was amazed - he's very talented, and it's always inspiring to talk to someone about their work. But, more than that, he didn't let his limited mobility make him hopeless. He recognizes what he can't do. He said he wished he were able to get around more freely. But, he also said that he wasn't going to let that stop him from doing what he likes to do.
He showed me how life is all about perspective. You might not always be able to dictate your situation or circumstances, but how you respond to them is always within your control.
He was mid-60s with a history of high blood pressure. I had read in his chart that he had both legs amputated due to some sort of chronic wounds. I skimmed over an operating room report that mentioned a hip disarticulation - where the leg was removed completely from the hip socket. That's a pretty disfiguring operation, but one I've seen before. What I didn't read, but noticed immediately when I walked into the room, was that both hips had been disarticulated. The man was lying on his stomach, propped up on his elbows. He had long hair and a beard, like the pictures of Jesus always show. He was just a torso and pelvis. I blinked and went to the computer, smiled and introduced myself.
We had a wonderful visit, he is quite funny and talked a lot about his various art projects. He has a piece in a museum - as a part of the permanent exhibit! Quite exceptional.
He said he would probably be depressed if he just sat and looked out the same window all day. Instead, he taught himself wood whittling, knitting, and other arts and crafts. He has friends that peddle them at various festivals and fairs around town. He gets asked to show his work in art exhibits around the country. I was amazed - he's very talented, and it's always inspiring to talk to someone about their work. But, more than that, he didn't let his limited mobility make him hopeless. He recognizes what he can't do. He said he wished he were able to get around more freely. But, he also said that he wasn't going to let that stop him from doing what he likes to do.
He showed me how life is all about perspective. You might not always be able to dictate your situation or circumstances, but how you respond to them is always within your control.
Sunday, October 10, 2010
On My Own
I've finished two weeks of my first real job. So much has happened, yet so much is the same. My life is a cliche.
I took my Infectious Diseases boards, which nearly killed me. I am not sure if I passed. It was extremely difficult, and I left there feeling like I missed more than I got right. That's a normal feeling, I know, but it's still unsettling. It's not the end of the world if I don't pass. It would be embarrassing and a pain to have to study again, but I could take it again next year. Needless to say, it would be much better if I didn't have to. I should know in the next 2 months.
The job has been good. I've realized that out-patient infectious diseases is much more difficult than in-patient ID. In the hospital, people are super sick, and you do your best to help them get through their infection. But, in the clinic, these people are, for the most part, pretty well. They might have a non-healing wound or a weird rash, but they can walk and talk. They want a diagnosis. They aren't just going to be happy to survive, like the patients who are in the hospital. Those patients don't need a name for their infection, they just want to live; for the most part, they do. So, out-patient ID has been unexpectedly challenging.
Most of my patients, so far, are general medicine patients. They have diabetes and arthritis. They need pap smears and colonoscopies. Those patients are not as interesting to me medically, but they are quite interesting people. I enjoy talking to them and hearing about their lives. I do wish I had more HIV patients. I have one set to come in next week, and I'm supposed to meet with the ladies at the health department about referring any new HIV patients to me. I have gotten a fair number of Hepatitis C patients, which has been good. I hope to get everything set up to do liver biopsies in the next few months. So, all in all, the last 2 weeks have gone pretty smoothly.
I have had some interesting patients. I hope to get diagnoses and then post about them soon. It's always more interesting when I can figure out what's going on.
I took my Infectious Diseases boards, which nearly killed me. I am not sure if I passed. It was extremely difficult, and I left there feeling like I missed more than I got right. That's a normal feeling, I know, but it's still unsettling. It's not the end of the world if I don't pass. It would be embarrassing and a pain to have to study again, but I could take it again next year. Needless to say, it would be much better if I didn't have to. I should know in the next 2 months.
The job has been good. I've realized that out-patient infectious diseases is much more difficult than in-patient ID. In the hospital, people are super sick, and you do your best to help them get through their infection. But, in the clinic, these people are, for the most part, pretty well. They might have a non-healing wound or a weird rash, but they can walk and talk. They want a diagnosis. They aren't just going to be happy to survive, like the patients who are in the hospital. Those patients don't need a name for their infection, they just want to live; for the most part, they do. So, out-patient ID has been unexpectedly challenging.
Most of my patients, so far, are general medicine patients. They have diabetes and arthritis. They need pap smears and colonoscopies. Those patients are not as interesting to me medically, but they are quite interesting people. I enjoy talking to them and hearing about their lives. I do wish I had more HIV patients. I have one set to come in next week, and I'm supposed to meet with the ladies at the health department about referring any new HIV patients to me. I have gotten a fair number of Hepatitis C patients, which has been good. I hope to get everything set up to do liver biopsies in the next few months. So, all in all, the last 2 weeks have gone pretty smoothly.
I have had some interesting patients. I hope to get diagnoses and then post about them soon. It's always more interesting when I can figure out what's going on.
Sunday, September 19, 2010
And it Begins
Tomorrow I finally go back to work.
I've been unemployed now since July 1. I use that word loosely, because I took a job with a start date of September 20, so while I wasn't getting a paycheck I did know that there was a job waiting for me.
Well, September 20 is nearly here. I'm a little nervous to learn a new system, meet the new nurses and staff, and start seeing my own patient panel. There will be a steep learning curve, I know, but I hope the other parts of the transition are easy. Like, remembering people's names and knowing where the bathroom is. The little things that can make or break a day.
Next week is all orientation, which is a nice way to ease into things. Then, on September 27, I start seeing my own patients. Weird. I am sure I'll miss the nice shelter of fellowship - having people to run ideas by and talk difficult cases through. But, it'll also be nice to make the decision I want to make, rather than the decision the attending thinks is best. There will be good and bad about it, I'm sure. Hopefully things aren't so busy that I can't reflect on some of those instances here.
So, tomorrow I take my floaties off and jump in the deep end all by myself. I hope the lessons I've had for the last 6 years pay off.
I've been unemployed now since July 1. I use that word loosely, because I took a job with a start date of September 20, so while I wasn't getting a paycheck I did know that there was a job waiting for me.
Well, September 20 is nearly here. I'm a little nervous to learn a new system, meet the new nurses and staff, and start seeing my own patient panel. There will be a steep learning curve, I know, but I hope the other parts of the transition are easy. Like, remembering people's names and knowing where the bathroom is. The little things that can make or break a day.
Next week is all orientation, which is a nice way to ease into things. Then, on September 27, I start seeing my own patients. Weird. I am sure I'll miss the nice shelter of fellowship - having people to run ideas by and talk difficult cases through. But, it'll also be nice to make the decision I want to make, rather than the decision the attending thinks is best. There will be good and bad about it, I'm sure. Hopefully things aren't so busy that I can't reflect on some of those instances here.
So, tomorrow I take my floaties off and jump in the deep end all by myself. I hope the lessons I've had for the last 6 years pay off.
Wednesday, August 18, 2010
In the Trenches
I don't do a very good job of reading over my past blogs. Good thing I post infrequently, because then all of my stories seem new! So, forgive me if I've told this one before.
I know that I've mentioned my amazing friends. I am blessed to have a whole host of wonderful friends, all over the country. Today's focus is on my residency friends. Each year in residency is marked by "R" and the year. Intern year is R1. Second year, R2, etc. You normally stop counting after you graduate, so for me at the R3 level. An alternate way to mark time is PGY (post graduate year). PGY is better if you're doing a fellowship, because you're not an "R" anymore, you're a Fellow (so an "F"??), so PGY is more accurate. Anyway, I bring this up because my class is crazy tight and are still counting by "R"s. We're R7s this year.
I don't know it always amazes me, but our class continues to be close. We're technically 4 years out of graduation now. Last weekend, one of our classmates got married in Hawaii. There are 12 of us (of a class of about 25) who hang out on a pretty regular basis. Of those 12, 10 of us were in Hawaii to celebrate (one of the 2 who didn't come just had a baby, the other is getting married himself in less than a month).
I was telling a non-medical friend about how going through residency creates a bond that is hard to describe. "It's kind of like going to war with these people by your side..." My friend's reply: "Is that because y'all killed a lot of people?" I admit I laughed at the morbid joke. But, I think the simile really is true. You are at your worst - and you see the worst - with these people. You laugh and cry together, you share a bunk bed together, you eat together, you support each other on a daily basis. And there are definitely those days when you look across the patient's bed at your fellow resident and think, "Truly, I couldn't have made it through the night without you."
I know that I've mentioned my amazing friends. I am blessed to have a whole host of wonderful friends, all over the country. Today's focus is on my residency friends. Each year in residency is marked by "R" and the year. Intern year is R1. Second year, R2, etc. You normally stop counting after you graduate, so for me at the R3 level. An alternate way to mark time is PGY (post graduate year). PGY is better if you're doing a fellowship, because you're not an "R" anymore, you're a Fellow (so an "F"??), so PGY is more accurate. Anyway, I bring this up because my class is crazy tight and are still counting by "R"s. We're R7s this year.
I don't know it always amazes me, but our class continues to be close. We're technically 4 years out of graduation now. Last weekend, one of our classmates got married in Hawaii. There are 12 of us (of a class of about 25) who hang out on a pretty regular basis. Of those 12, 10 of us were in Hawaii to celebrate (one of the 2 who didn't come just had a baby, the other is getting married himself in less than a month).
I was telling a non-medical friend about how going through residency creates a bond that is hard to describe. "It's kind of like going to war with these people by your side..." My friend's reply: "Is that because y'all killed a lot of people?" I admit I laughed at the morbid joke. But, I think the simile really is true. You are at your worst - and you see the worst - with these people. You laugh and cry together, you share a bunk bed together, you eat together, you support each other on a daily basis. And there are definitely those days when you look across the patient's bed at your fellow resident and think, "Truly, I couldn't have made it through the night without you."
Thursday, August 5, 2010
Hola!
I'll try to not turn this into a travel blog.
I am in Argentina visiting a friend who has chosen to live here for her 3 months of unemployment. She's waiting for her credentials to clear at her new hospital in Florida. Being a true adventurer, she and her boyfriend decided to live in Argentina for in the interim. Because, heck, why not. I love her spirit.
I first met W in Kenya. She was a pediatric resident, and I was a medicine resident. We landed in Kenya the same day, on different flights, and met up to travel from Nairobi to Eldoret to work at the Moi Teaching and Referral Hospital. It was through Indiana University's consortium that exchanges US residents with Kenyan residents. It was a fantastic experience, and it lead met to create the first Handle With Care charity event, that raised over $30,000 for the IU-Kenya Partnership.
So, W and I met and immediately realized we were separated at birth. Have you ever met someone you just clicked with? Just immediately felt like you could spend hours with them and not get sick of them? That was us. And thank GOD, since we were in freakin' Kenya and didn't know a single soul. At least it felt like our souls were old friends.
We were inseparable for that month, besides working in different wards (she in peds, me on the women's ward). In fact, everyone there assumed we were with the same residency program, since we just got along like gang busters.
Since leaving Kenya in 2006, I visited her in Providence, she visited me in California, and I visited her in Michigan. And now, here we are in Argentina together. We made a pact to travel to every continent together (except Antarctica, no desire to freeze to death). I think that's a good goal to have - every few years, head out to a new place, learn a new culture, and have a lot of fun together.
I'm grateful for so many wonderful people in my life, and W is one of those people that I can't imagine not having around. I picture us as old grandmas, walking in Instanbul together, and it makes me really happy.
I am in Argentina visiting a friend who has chosen to live here for her 3 months of unemployment. She's waiting for her credentials to clear at her new hospital in Florida. Being a true adventurer, she and her boyfriend decided to live in Argentina for in the interim. Because, heck, why not. I love her spirit.
I first met W in Kenya. She was a pediatric resident, and I was a medicine resident. We landed in Kenya the same day, on different flights, and met up to travel from Nairobi to Eldoret to work at the Moi Teaching and Referral Hospital. It was through Indiana University's consortium that exchanges US residents with Kenyan residents. It was a fantastic experience, and it lead met to create the first Handle With Care charity event, that raised over $30,000 for the IU-Kenya Partnership.
So, W and I met and immediately realized we were separated at birth. Have you ever met someone you just clicked with? Just immediately felt like you could spend hours with them and not get sick of them? That was us. And thank GOD, since we were in freakin' Kenya and didn't know a single soul. At least it felt like our souls were old friends.
We were inseparable for that month, besides working in different wards (she in peds, me on the women's ward). In fact, everyone there assumed we were with the same residency program, since we just got along like gang busters.
Since leaving Kenya in 2006, I visited her in Providence, she visited me in California, and I visited her in Michigan. And now, here we are in Argentina together. We made a pact to travel to every continent together (except Antarctica, no desire to freeze to death). I think that's a good goal to have - every few years, head out to a new place, learn a new culture, and have a lot of fun together.
I'm grateful for so many wonderful people in my life, and W is one of those people that I can't imagine not having around. I picture us as old grandmas, walking in Instanbul together, and it makes me really happy.
Wednesday, July 28, 2010
Just a Job
I met up with a good friend of mine from medical school. He was in town with his wife and one-year-old son. So, after we all ate lunch (ok, the little guy did more running than eating), the wife and son went to hang out at the mall while my friend and I caught up.
V is a general surgeon in the Army. He's going to Afghanistan for 6 months, then Alaska for 6 months, then off to Texas for his surgical-oncology fellowship. His wife will stay with her folks nearby while he's doing surgeries in a tent that is only accessible by helicopter.
We spent a lot of time talking about life in medicine. How much sacrifice it takes, how much how give up, what you expect out of it, etc. It was nice to hear someone else also feel like, "Hey I'm 30-something and my life is just now starting...awesome."
We also talked about how other people look at doctors. When people ask me what I do, I cringe. I love my job - LOVE it. But, the scene always plays out the same way. THEM: So what do you do? ME: I'm a doctor. THEM: (silence)
V said, "You know, at the end of the day, it's just a job." And he's right. It's just a job. It's a way for me to make money so I can live, like anyone else with a job. I think it's hard in medicine to not let it take over your life, so that's probably different than most professions. But, V's point was just that - don't let it consume you, it's just a job. It's something I am struggling to put into practice. This profession will suck you dry, it will take and take and take. People will ask and beg and pull more of your time. I probably need to be a little more removed and treat it more like a job, before I get so burned out I have to walk away.
V is a general surgeon in the Army. He's going to Afghanistan for 6 months, then Alaska for 6 months, then off to Texas for his surgical-oncology fellowship. His wife will stay with her folks nearby while he's doing surgeries in a tent that is only accessible by helicopter.
We spent a lot of time talking about life in medicine. How much sacrifice it takes, how much how give up, what you expect out of it, etc. It was nice to hear someone else also feel like, "Hey I'm 30-something and my life is just now starting...awesome."
We also talked about how other people look at doctors. When people ask me what I do, I cringe. I love my job - LOVE it. But, the scene always plays out the same way. THEM: So what do you do? ME: I'm a doctor. THEM: (silence)
V said, "You know, at the end of the day, it's just a job." And he's right. It's just a job. It's a way for me to make money so I can live, like anyone else with a job. I think it's hard in medicine to not let it take over your life, so that's probably different than most professions. But, V's point was just that - don't let it consume you, it's just a job. It's something I am struggling to put into practice. This profession will suck you dry, it will take and take and take. People will ask and beg and pull more of your time. I probably need to be a little more removed and treat it more like a job, before I get so burned out I have to walk away.
Sunday, July 11, 2010
D#11
Today is day #11 of unemployment. I finished fellowship on June 30, and my freedom began. I've gone in to work a few times to do some liver biopsies. I've been studying 2-4 hours a day - my boards are in October. I've been sleeping in a bit, playing around, shopping. It's been fun.
I did some moonlighting last weekend. It was nice to be back in the hospital, rounding on the patients.
On patient was 19-20 years old, I forget exactly. He was diagnosed in his mid-teens with a genetic liver disease and got a liver transplant. Now, he's in the hospital after having gotten a round of chemo for a newly discovered leukemia. His immune system is literally at zero. Geez, I think, how much bad can one person get? I walk into his room, and he's not there. I walk back out, and this big guy attached to an IV pole is walking around with a surgical mask on. He asks if I'm looking for him, and I say that I am. He goes into his room, and he sits on his bed, taking his protective mask off now that he's in the confines of his own room with his own germs and no one else's.
He says he's doing fine. He was out doing laps for exercise. I listened to his heart and lungs, which all sounded fine. He hadn't had a fever in a few days, so I figured he was on the mend as far as his infection was concerned. His recent bone marrow biopsy looked clean, so one more was going to be done in 2 weeks. If that was clean, he was good to go - in remission, and able to get on with his life...albeit with frequent doctors visits.
We chatted for a bit, and he walked out with me, putting his mask back on. He said he was on lap 17 of 30, so he wanted to get back out there to finish. I said good bye, and told him I'd see him the following day. He thanked me and began back on his trek around the nursing stations.
I just smiled in disbelief. This was a kid who should be out playing basketball with his friends, sitting on the beach with his girlfriend, or just fooling around on his computer in his own room. He should be angry and frustrated about his situation. He has a liver from someone who died. He's getting toxic medications to wipe out his own bone marrow. He's at risk for infections every time he leaves his room or someone comes in. His life span, in all probability, isn't going to be what his best friend's is.
But, he was smiling and gracious, positive and determined. I don't know why I thought he'd be depressed. It's the only life he has, why would he spend it being miserable? You just keep going, right? Whether you miss your flight, crash your car or get diagnosed with cancer. We all come up against obstacles, and how we deal with them defines who we are. Sit down and pout or get up and keep going.
As I go through this transition period of the security of fellowship to the unknown world of being on my own, I hope I can have the tenacity that this young man has - the strength to keep getting up no matter how many times I get knocked down.
I did some moonlighting last weekend. It was nice to be back in the hospital, rounding on the patients.
On patient was 19-20 years old, I forget exactly. He was diagnosed in his mid-teens with a genetic liver disease and got a liver transplant. Now, he's in the hospital after having gotten a round of chemo for a newly discovered leukemia. His immune system is literally at zero. Geez, I think, how much bad can one person get? I walk into his room, and he's not there. I walk back out, and this big guy attached to an IV pole is walking around with a surgical mask on. He asks if I'm looking for him, and I say that I am. He goes into his room, and he sits on his bed, taking his protective mask off now that he's in the confines of his own room with his own germs and no one else's.
He says he's doing fine. He was out doing laps for exercise. I listened to his heart and lungs, which all sounded fine. He hadn't had a fever in a few days, so I figured he was on the mend as far as his infection was concerned. His recent bone marrow biopsy looked clean, so one more was going to be done in 2 weeks. If that was clean, he was good to go - in remission, and able to get on with his life...albeit with frequent doctors visits.
We chatted for a bit, and he walked out with me, putting his mask back on. He said he was on lap 17 of 30, so he wanted to get back out there to finish. I said good bye, and told him I'd see him the following day. He thanked me and began back on his trek around the nursing stations.
I just smiled in disbelief. This was a kid who should be out playing basketball with his friends, sitting on the beach with his girlfriend, or just fooling around on his computer in his own room. He should be angry and frustrated about his situation. He has a liver from someone who died. He's getting toxic medications to wipe out his own bone marrow. He's at risk for infections every time he leaves his room or someone comes in. His life span, in all probability, isn't going to be what his best friend's is.
But, he was smiling and gracious, positive and determined. I don't know why I thought he'd be depressed. It's the only life he has, why would he spend it being miserable? You just keep going, right? Whether you miss your flight, crash your car or get diagnosed with cancer. We all come up against obstacles, and how we deal with them defines who we are. Sit down and pout or get up and keep going.
As I go through this transition period of the security of fellowship to the unknown world of being on my own, I hope I can have the tenacity that this young man has - the strength to keep getting up no matter how many times I get knocked down.
Wednesday, June 30, 2010
Pagerless
Today was my last day of fellowship. I'm pagerless for the first time in 8 years.
This has been a long, long journey. I'm not sure I've ever told the "how I knew I wanted to be a doctor" story. Unlike some of my friends, it wasn't something I ever thought about doing. I didn't know any doctors. No one's dad or mom was in medicine. It wasn't something people did where I grew up. I'll save that story for another day.
Today wasn't a bad day. Busy, but not terrible. I turned in trusty pager 3446, thankful to never hear the screech of that thing again. I updated my sign-out, the list of patients we are actively following, for the next fellow coming on. I took a few last phone calls, talked to some residents about the plans for their patients.
Soon it was 5p. I unceremoniously got up, put my white coat on, grabbed my purse, and left. I saw another of the fellows, and said I'd see her tomorrow for the "We're Unemployed!" Party I'm hosting.
I walked out of the VA. It won't be the last time. I have a few more days of liver biopsies to do. But, it was my last day leaving as a fellow. I felt like there should've been music, fireworks, something. Instead, I just felt a great sense of accomplishment and freedom. True, those feelings were mixed with the nausea of wondering how I'm going to fool people into believing I know what I'm talking about.
Every one's journey to being a doctor is different. Mine was pretty straight forward. College for 4 years, then med school for 4 years. Residency was 3 years, plus an extra year for the Chief Resident year. Now, 2 years of fellowship have ended. That's 10 solid years of medical training. Ten freaking years. On the one hand it's a ton of time. On the other hand, there are a whole host of diseases I've never seen. Heck, there are a ton that I've barely read about, let alone seen with my own eyes. So, although I'm as prepared as I'll ever be, there's always that feeling of wanting to train just a little bit longer.
Eventually, we need to step out of the nest and see if we can fly. Let's hope the next years are as great an experience as the last 14.
This has been a long, long journey. I'm not sure I've ever told the "how I knew I wanted to be a doctor" story. Unlike some of my friends, it wasn't something I ever thought about doing. I didn't know any doctors. No one's dad or mom was in medicine. It wasn't something people did where I grew up. I'll save that story for another day.
Today wasn't a bad day. Busy, but not terrible. I turned in trusty pager 3446, thankful to never hear the screech of that thing again. I updated my sign-out, the list of patients we are actively following, for the next fellow coming on. I took a few last phone calls, talked to some residents about the plans for their patients.
Soon it was 5p. I unceremoniously got up, put my white coat on, grabbed my purse, and left. I saw another of the fellows, and said I'd see her tomorrow for the "We're Unemployed!" Party I'm hosting.
I walked out of the VA. It won't be the last time. I have a few more days of liver biopsies to do. But, it was my last day leaving as a fellow. I felt like there should've been music, fireworks, something. Instead, I just felt a great sense of accomplishment and freedom. True, those feelings were mixed with the nausea of wondering how I'm going to fool people into believing I know what I'm talking about.
Every one's journey to being a doctor is different. Mine was pretty straight forward. College for 4 years, then med school for 4 years. Residency was 3 years, plus an extra year for the Chief Resident year. Now, 2 years of fellowship have ended. That's 10 solid years of medical training. Ten freaking years. On the one hand it's a ton of time. On the other hand, there are a whole host of diseases I've never seen. Heck, there are a ton that I've barely read about, let alone seen with my own eyes. So, although I'm as prepared as I'll ever be, there's always that feeling of wanting to train just a little bit longer.
Eventually, we need to step out of the nest and see if we can fly. Let's hope the next years are as great an experience as the last 14.
Monday, June 21, 2010
Robbed
The past few weeks, I've had a difficult patient. His personality isn't difficult; he's a complete sweetheart. His case is difficult. He has lung cancer that is nonoperable. So, he's dying, but not any time soon. About a month ago, he came down with a case of Clostridium difficile diarrhea. It's a terrible infectious diarrhea that is most often caused by giving someone antibiotics.
(Allow me to step on my soapbox...)
Do. Not. Ask. Your. Doctor. For. Antibiotics. Ever. There, I've said it. We can't cure everything that ails you with amoxicillin. Not every sniffle needs Augmentin. Not every time your kid pulls at his ear is it infected. Your body's natural immunity does a darn good job most of the time. If you doctor says it's a virus, go home, drink your 7-Up, take a hot bath, and go to bed. Atibiotics always carry a risk with them, and people forget that. They aren't Tic-Tacs. They are drugs with side effects, some of them dangerous.
(Stepping off my soapbox...)
So, Mr. W got a bad case of C.diff. He got treated for 2-3 weeks, which is standard. His diarrhea slowed down, so they stopped it. However, a week later, the diarrhea returned with a vengeance. We started him on our most potent antibiotic for C.diff. Three days later, no improvement. His tests for the bacteria were negative, but no one believed them. His case was classic for relapsing C.diff.
I doubled his antibiotic dosage. No improvement.
His white blood cell count climbed every day. 16,000. 25,000. 33,000. 45,000. [normal is 6,000-10,000). He was getting weaker and weaker. He lost his appetite. I kept assuring him that it would work. That we would figure it out. That before long he'd be back in the nursing home where he could talk to his friends and watch movies.
The team called me on Saturday morning and said his chest X-ray looked like it had a small pneumonia. I wasn't too impressed by it, and I asked them not to treat it. He had no fever, no respiratory symptoms. More antibiotics would make the C.diff worse. They agreed. Twelve hours later, he had some shortness of breath, so they started some antibiotics. It was a reasonable thing to do.
Sunday, his chest X-ray LLS. That's my shorthand for "looked like sh^t." I think I learned it from my surgical chief resident. More important, Mr. W himself LLS. He was on a face mask delivering high flow oxygen, and he was breathing fast. But, he said he was comfortable. He told me how he was doing. I told him, as I had every day for the past 13 days, "Don't worry, we'll figure this out."
Today, I walked into his room, and he looked like death. He was always cachectic - so skinny you could see his ribs, and his temples were sucken in. But, there's a look that death has. Once you see it, you know it. Mr. W was there.
My eyes welled up. The respiratory therapist (RT) was in the room, giving him a breathing treatment that was clearly futile. I asked how Mr. W was doing, and he told me the obvious. I leaned over Mr. W, and listened to his chest, even though I knew there was nothing I could do. A few tears fell on Mr. W's sheet. The RT said, "Did you know him?" I told him I had taken care of him for the past 2 weeks. He asked me if I was ok. I thanked him for his concern, and I told him I'd be fine.
I just felt like I didn't do a darn thing for Mr. W. I told him it was going to be ok. I told him we'd figure it out. I told him he'd be better soon. None of those things happened. I don't know what killed him. I don't know if he had relapsed C.diff. I don't know why he got septic.
I just know I felt robbed.
I felt like Mr. W was pulled out from under my grasp. I thought I had a hold on him, and I didn't. I thought I could pull him out, but I couldn't. I was robbed. What hurts more is that I feel that Mr. W was robbed, too. Of a few more months. A few more movies. A few more laughs with his old buddies. Yeah. He was robbed.
(Allow me to step on my soapbox...)
Do. Not. Ask. Your. Doctor. For. Antibiotics. Ever. There, I've said it. We can't cure everything that ails you with amoxicillin. Not every sniffle needs Augmentin. Not every time your kid pulls at his ear is it infected. Your body's natural immunity does a darn good job most of the time. If you doctor says it's a virus, go home, drink your 7-Up, take a hot bath, and go to bed. Atibiotics always carry a risk with them, and people forget that. They aren't Tic-Tacs. They are drugs with side effects, some of them dangerous.
(Stepping off my soapbox...)
So, Mr. W got a bad case of C.diff. He got treated for 2-3 weeks, which is standard. His diarrhea slowed down, so they stopped it. However, a week later, the diarrhea returned with a vengeance. We started him on our most potent antibiotic for C.diff. Three days later, no improvement. His tests for the bacteria were negative, but no one believed them. His case was classic for relapsing C.diff.
I doubled his antibiotic dosage. No improvement.
His white blood cell count climbed every day. 16,000. 25,000. 33,000. 45,000. [normal is 6,000-10,000). He was getting weaker and weaker. He lost his appetite. I kept assuring him that it would work. That we would figure it out. That before long he'd be back in the nursing home where he could talk to his friends and watch movies.
The team called me on Saturday morning and said his chest X-ray looked like it had a small pneumonia. I wasn't too impressed by it, and I asked them not to treat it. He had no fever, no respiratory symptoms. More antibiotics would make the C.diff worse. They agreed. Twelve hours later, he had some shortness of breath, so they started some antibiotics. It was a reasonable thing to do.
Sunday, his chest X-ray LLS. That's my shorthand for "looked like sh^t." I think I learned it from my surgical chief resident. More important, Mr. W himself LLS. He was on a face mask delivering high flow oxygen, and he was breathing fast. But, he said he was comfortable. He told me how he was doing. I told him, as I had every day for the past 13 days, "Don't worry, we'll figure this out."
Today, I walked into his room, and he looked like death. He was always cachectic - so skinny you could see his ribs, and his temples were sucken in. But, there's a look that death has. Once you see it, you know it. Mr. W was there.
My eyes welled up. The respiratory therapist (RT) was in the room, giving him a breathing treatment that was clearly futile. I asked how Mr. W was doing, and he told me the obvious. I leaned over Mr. W, and listened to his chest, even though I knew there was nothing I could do. A few tears fell on Mr. W's sheet. The RT said, "Did you know him?" I told him I had taken care of him for the past 2 weeks. He asked me if I was ok. I thanked him for his concern, and I told him I'd be fine.
I just felt like I didn't do a darn thing for Mr. W. I told him it was going to be ok. I told him we'd figure it out. I told him he'd be better soon. None of those things happened. I don't know what killed him. I don't know if he had relapsed C.diff. I don't know why he got septic.
I just know I felt robbed.
I felt like Mr. W was pulled out from under my grasp. I thought I had a hold on him, and I didn't. I thought I could pull him out, but I couldn't. I was robbed. What hurts more is that I feel that Mr. W was robbed, too. Of a few more months. A few more movies. A few more laughs with his old buddies. Yeah. He was robbed.
Saturday, June 19, 2010
I'm Crazy??
I was doing a liver biopsy on a patient yesterday. He's about 58 or so, very nice guy. His arms were covered in tattoos, from shoulder to wrist. His abdomen and chest were also covered. I told him I was going to be getting my first tattoo, and I asked him what he thought. He said, "I think you're crazy!"
I laughed and said, "I'm crazy? After you've got all these??..." He countered with the most logical answer: "Well, I got mine in prison."
And....End scene.
I did not see how that answered my question at all. Regardless, I pushed him on it, and he said he spent about 10 years in jail in Indiana. I told him I went to college near his jail. I figured this made us something akin to blood brothers. He didn't seem so moved.
He said that in jail, they would sharpen down the E string on a guitar to a sharp point. Then they'd rig that up to a tape cassette player and turn it on. The mechanism that would spin the heads somehow fashioned an amateur tattoo gun. I said, "Wait, you got most of these in jail - even the colored ones?" He said yep. He said, "I don't know how they do it now a-days, I haven't been in for awhile, but that's how we did it."
I guess if you've got 10 years to kill, painfully marking your body is one way to pass the time. I was mostly impressed at the resourcefulness of these convicts. I was also mostly convinced that was how he got Hep C. Regardless, he has some beautiful pictures that I'm sure represent the many people and many situations he's lived through.
I laughed and said, "I'm crazy? After you've got all these??..." He countered with the most logical answer: "Well, I got mine in prison."
And....End scene.
I did not see how that answered my question at all. Regardless, I pushed him on it, and he said he spent about 10 years in jail in Indiana. I told him I went to college near his jail. I figured this made us something akin to blood brothers. He didn't seem so moved.
He said that in jail, they would sharpen down the E string on a guitar to a sharp point. Then they'd rig that up to a tape cassette player and turn it on. The mechanism that would spin the heads somehow fashioned an amateur tattoo gun. I said, "Wait, you got most of these in jail - even the colored ones?" He said yep. He said, "I don't know how they do it now a-days, I haven't been in for awhile, but that's how we did it."
I guess if you've got 10 years to kill, painfully marking your body is one way to pass the time. I was mostly impressed at the resourcefulness of these convicts. I was also mostly convinced that was how he got Hep C. Regardless, he has some beautiful pictures that I'm sure represent the many people and many situations he's lived through.
Monday, June 14, 2010
Proud Asian Mom
This past weekend was the West Hollywood Gay Pride Parade. It was fantastic. There were lots of fancy costumes, lots of floats about safe sex and HIV awareness, and a lot of half-naked men. Not bad for a Sunday afternoon if you ask me.
It was the 40th anniversary of the gay pride parade. There's a great history of the parade at this link if you go the side link that says "history." Quite amazing.
There was one parade participant who nearly brought me to tears. The elderly lady above was walking with 2 young men. Her sign says, "Proud Asian Mom of a Gay Kid." This woman registered as a parade participant. She may have had to pay an entrance fee. She had to make her sign. She went through all that trouble to show support for her son.
How amazing. My mom doesn't have to march in a parade to show her support for me. I'd like to think she would if it came down to that. As it stands, my vote for Mother of the Year goes to this proud Asian mom. And I'm sure there's a proud Asian kid out there who thinks the same thing.
Friday, May 28, 2010
Stuck
Literally.
I was doing a liver biopsy today on a man with Hepatitis C. He needs it before he can get his kidney transplant. Fortunately, he's HIV negative and already immune to Hepatitis B.
I was numbing him up with 20cc of xylcaine. I finished and went to recap my needle. I don't always recap. I often leave it laying out, attached to the syringe. But, I'm always afraid that I (or someone else) will get stuck reaching in to the tray for a gauze pad or something. So, I found the cap and pushed the needle in, without using my hand to hold the cap - just like we're taught. But, the cap kept sliding around, so I used my knuckle to brace the cap. Well, I pushed the needle too hard, and it popped through the cap and poked my knuckle. Hard.
I immediately knew what happened, and I could see the blood pool under my glove. Dang it. I tried to biopsy the patient, but somehow missed. In my defense, he had tough anatomy. Oh, and I just stuck myself with a needle. Right. So, Dr. P stepped in and did it; he got a great sample, so it was all good. I degloved, washed my hands with soap and water and put a bandaid on. I finished up with that patient and started on the next one. I had a presentation to give at noon, so I had to bail on the next biopsy and head up to the conference room.
I didn't tell Dr. P right away. I was embarrassed - I should've known better. I could have just left the stupid needle uncapped. Plus, I didn't want him to lose faith in my ability to do more biopsies. I'm still committed to this patient population, and I want to learn this skill.
So, as our afternoon clinic winds down, I finally tell him that I stuck myself and ask if I can leave clinic to get to employee health to get my labs done. He was shocked, and said of course. While I'm in employee health, my cell phone rings: Dr. P. He says he was shocked to hear of the needle stick, and he wants me to know that he's there for me and with me during this whole thing. It was awesome of him to call and say that. He said to make sure the physician assistant (PA) in employee health orders an HIV RNA PCR now, at 2 weeks, at 4 weeks and at 8 weeks. He said he can get the PA a dozen articles saying that is the best way to handle acute Hepatitis C. I thank Dr. P and hang up.
The PA said he can't order it, because it's not in the protocol. He says he will order a Hep C Antibody. I ask him if he really thinks I've started making Antibodies in the last 3 hours. I'm not mad at him, but I'm trying to show that the Antibody is a waste of a test. So, I call Dr. P who has left clinic. He says he'll go and meet me back in clinic so he can order the proper tests himself.
Normally, if you're going to get infected, the PCR is positive by week 3. In acute Hep C, if you have a positive PCR and it doesn't decrease on it's own by 8 weeks, you need to start treatment to cure it. He admitted that I'm a low risk in the sense of the way I was stuck, but it's fairly high risk given the patient is known to be Hep C positive with a high viral load.
So, I've become Dr. P's personal patient. He's quite the world expert in hepatology, so I'm very fortunate that he's overseeing my care. He has taken quite a liking to me, and he has really pulled me under his wing to learn about Hep C and all liver diseases, really. It's nice to know he's in my corner, even though I'm pretty confident that I'll come through this with just a bruised knuckle.
I was doing a liver biopsy today on a man with Hepatitis C. He needs it before he can get his kidney transplant. Fortunately, he's HIV negative and already immune to Hepatitis B.
I was numbing him up with 20cc of xylcaine. I finished and went to recap my needle. I don't always recap. I often leave it laying out, attached to the syringe. But, I'm always afraid that I (or someone else) will get stuck reaching in to the tray for a gauze pad or something. So, I found the cap and pushed the needle in, without using my hand to hold the cap - just like we're taught. But, the cap kept sliding around, so I used my knuckle to brace the cap. Well, I pushed the needle too hard, and it popped through the cap and poked my knuckle. Hard.
I immediately knew what happened, and I could see the blood pool under my glove. Dang it. I tried to biopsy the patient, but somehow missed. In my defense, he had tough anatomy. Oh, and I just stuck myself with a needle. Right. So, Dr. P stepped in and did it; he got a great sample, so it was all good. I degloved, washed my hands with soap and water and put a bandaid on. I finished up with that patient and started on the next one. I had a presentation to give at noon, so I had to bail on the next biopsy and head up to the conference room.
I didn't tell Dr. P right away. I was embarrassed - I should've known better. I could have just left the stupid needle uncapped. Plus, I didn't want him to lose faith in my ability to do more biopsies. I'm still committed to this patient population, and I want to learn this skill.
So, as our afternoon clinic winds down, I finally tell him that I stuck myself and ask if I can leave clinic to get to employee health to get my labs done. He was shocked, and said of course. While I'm in employee health, my cell phone rings: Dr. P. He says he was shocked to hear of the needle stick, and he wants me to know that he's there for me and with me during this whole thing. It was awesome of him to call and say that. He said to make sure the physician assistant (PA) in employee health orders an HIV RNA PCR now, at 2 weeks, at 4 weeks and at 8 weeks. He said he can get the PA a dozen articles saying that is the best way to handle acute Hepatitis C. I thank Dr. P and hang up.
The PA said he can't order it, because it's not in the protocol. He says he will order a Hep C Antibody. I ask him if he really thinks I've started making Antibodies in the last 3 hours. I'm not mad at him, but I'm trying to show that the Antibody is a waste of a test. So, I call Dr. P who has left clinic. He says he'll go and meet me back in clinic so he can order the proper tests himself.
Normally, if you're going to get infected, the PCR is positive by week 3. In acute Hep C, if you have a positive PCR and it doesn't decrease on it's own by 8 weeks, you need to start treatment to cure it. He admitted that I'm a low risk in the sense of the way I was stuck, but it's fairly high risk given the patient is known to be Hep C positive with a high viral load.
So, I've become Dr. P's personal patient. He's quite the world expert in hepatology, so I'm very fortunate that he's overseeing my care. He has taken quite a liking to me, and he has really pulled me under his wing to learn about Hep C and all liver diseases, really. It's nice to know he's in my corner, even though I'm pretty confident that I'll come through this with just a bruised knuckle.
Sunday, May 9, 2010
To Whom It May Concern
I did some moonlighting this weekend, which was much needed since I just signed up for my ID Boards - $2060. For a stupid test I don't even want to take. {serenity now...}
I had an interesting juxtaposition of patients this weekend, two in particular.
Patient 1 was a new admission. He's in his mid-20s, a student of some kind. I couldn't ask him because he came in unresponsive with a Glascow Coma Score of 6 (1+4+1). Why did he have no purposeful movements? He had been partying the night before with crystal meth and GHB. Oh, and his tox screen later revealed cocaine. GHB is often used as a date rape drug because it renders its users unconscious. However, before this end result, it can give a euphoric rush. So, his friend brought him in barely breathing, heart rate down to 50, body temperature a cool 94 degrees Fahrenheit. It's hard not to get angry at your patients in situations like this - a young kid, his whole life ahead of him, just spinning the Roulette wheel with his life.
Patient 2 is just over 60. Her lymphoma came back and isn't curable. She's actively dying. Her sister flew in from the Midwest and asked how long I thought she had. I guessed about 3-5 days. She asked if I could write a letter so she could go get herself instated as the patient's durable power of attorney. I know this is what the patient wanted, so I said sure. I wrote a simple letter, something like this...
To Whom It May Concern;
This woman is my patient, and she is unable to make her own decisions due to losing a long battle with a fatal disease. According to her wishes, her sister is to act on her behalf.
It made me want to write a letter to Patient 1.
To You, For Whom I'm Concerned;
Don't blow this life. Don't make the mistake of thinking you are invincible and immovable. You, like the rest of us, are made of frail skin and bones, and your heart is but a muscle that can only be stretched so far. Take this opportunity to get your life in order. You've been spared Death, just barely, this time. But, Death is fickle, and he may not be so forgiving next time.
I had an interesting juxtaposition of patients this weekend, two in particular.
Patient 1 was a new admission. He's in his mid-20s, a student of some kind. I couldn't ask him because he came in unresponsive with a Glascow Coma Score of 6 (1+4+1). Why did he have no purposeful movements? He had been partying the night before with crystal meth and GHB. Oh, and his tox screen later revealed cocaine. GHB is often used as a date rape drug because it renders its users unconscious. However, before this end result, it can give a euphoric rush. So, his friend brought him in barely breathing, heart rate down to 50, body temperature a cool 94 degrees Fahrenheit. It's hard not to get angry at your patients in situations like this - a young kid, his whole life ahead of him, just spinning the Roulette wheel with his life.
Patient 2 is just over 60. Her lymphoma came back and isn't curable. She's actively dying. Her sister flew in from the Midwest and asked how long I thought she had. I guessed about 3-5 days. She asked if I could write a letter so she could go get herself instated as the patient's durable power of attorney. I know this is what the patient wanted, so I said sure. I wrote a simple letter, something like this...
To Whom It May Concern;
This woman is my patient, and she is unable to make her own decisions due to losing a long battle with a fatal disease. According to her wishes, her sister is to act on her behalf.
It made me want to write a letter to Patient 1.
To You, For Whom I'm Concerned;
Don't blow this life. Don't make the mistake of thinking you are invincible and immovable. You, like the rest of us, are made of frail skin and bones, and your heart is but a muscle that can only be stretched so far. Take this opportunity to get your life in order. You've been spared Death, just barely, this time. But, Death is fickle, and he may not be so forgiving next time.
Tuesday, May 4, 2010
"You'd be amazed."
This is a completely non-medical post, so if you normally read this for the medicine, you can skip this one. Just to make it worth your while, here are two snippets: 1) we may have a man with measles up at the Zoo and b) we have a super resistant bacteria in a patient with no good options to treat him. So grab your Purell and come back in a few days, I should have a medical post by then.
I have been having a few days of feeling unappreciated. Underappreciated? Whatever. You know those days where you think, "Why doesn't anyone say thank you? Am I completely invisible?" I started thinking that I could disappear for a few days and relatively few people would notice and probably even fewer would really care or worry. I just starting feeling insignificant.
Now, to be honest, I haven't gone to church much lately. Ok, at all. In like weeks. OK!, OK! months. Geez, cut me some slack, I work most every Sunday. I remembered that song from Veggie Tales - "God is bigger than the boogie man..." And I realized that God cares, God appreciates me, God smiles when I do something nice for someone.
I read this blog that reminded me that not only is God an encouraging supportive force in my life, but God is also a strong protector. Check out this blog if you have time; grab a box of tissues before you go. This woman has the strength of an ox, and she reminded me that with God we can do anything. I love love love how she finished a recent blog, so I'm going to leave you with her thoughts:
"If this past year has taught me anything, it is that I can lean hard on my God. He can handle it all. Every priest and pastor who has counseled me along the way has said just that. The error comes in thinking that He cannot, in thinking that we have to shoulder the fear, anger, frustration, and hate ourselves. We don’t. It is not our job. God can even handle the F-bomb. You’d be amazed."
Amen, sister. God can handle the F-bomb.
I have been having a few days of feeling unappreciated. Underappreciated? Whatever. You know those days where you think, "Why doesn't anyone say thank you? Am I completely invisible?" I started thinking that I could disappear for a few days and relatively few people would notice and probably even fewer would really care or worry. I just starting feeling insignificant.
Now, to be honest, I haven't gone to church much lately. Ok, at all. In like weeks. OK!, OK! months. Geez, cut me some slack, I work most every Sunday. I remembered that song from Veggie Tales - "God is bigger than the boogie man..." And I realized that God cares, God appreciates me, God smiles when I do something nice for someone.
I read this blog that reminded me that not only is God an encouraging supportive force in my life, but God is also a strong protector. Check out this blog if you have time; grab a box of tissues before you go. This woman has the strength of an ox, and she reminded me that with God we can do anything. I love love love how she finished a recent blog, so I'm going to leave you with her thoughts:
"If this past year has taught me anything, it is that I can lean hard on my God. He can handle it all. Every priest and pastor who has counseled me along the way has said just that. The error comes in thinking that He cannot, in thinking that we have to shoulder the fear, anger, frustration, and hate ourselves. We don’t. It is not our job. God can even handle the F-bomb. You’d be amazed."
Amen, sister. God can handle the F-bomb.
Thursday, April 29, 2010
Why, Grandma...
I thought of Red Riding Hood today, because I saw an older lady up in the clinic up at The Zoo. She was in her 60s. She was referred because of a confusing test result. Remember, in the fairy tale, how Red Riding Hood saw the Wolf who was pretending to be her Grandma. And she said, "Why, Grandma...what big eyes you have!" And the Wolf slyly replied, "The better to see you with, my dear..." And on and on.
Anyway, this lady was like a Grandma. In fact, she could've been a Grandma (I didn't ask her; I know she has 2 kids). I had to tell her that we had gotten her confirmatory test results.
Why, Grandma, yes it is an HIV virus you have.
Wow. What a life-changing day at the doctor's office. She knew that the original test was positive but the confirmatory test was negative. So, the other doctor sent a blood test to see if the lab could see any actual virus in her blood. They saw over 200,000 copies.
At first, she seemed ok with it. Then, I asked her how much she knew about HIV, and whether I should start from the beginning. She lost it. The translator turned to me, looking as helpless as I felt. I put my hand on her leg and said I would do a basic overview today, and I asked her to write down questions over the next 3-4 weeks and ask them at the next visit. She was really strong and pulled herself together. So we went through everything, and I think she'll do great. She's smart, she's organized, and I think she'll take control of her disease rather than the HIV taking control of her.
Hopefully, I'll be the one to see her in a month. It's an immediate bond you build with someone, when you share that diagnosis with them and do the initial education. I'd like to be the one to start her on her meds and encourage her progress. I have a good feeling about her, I think she'll do quite well.
Anyway, this lady was like a Grandma. In fact, she could've been a Grandma (I didn't ask her; I know she has 2 kids). I had to tell her that we had gotten her confirmatory test results.
Why, Grandma, yes it is an HIV virus you have.
Wow. What a life-changing day at the doctor's office. She knew that the original test was positive but the confirmatory test was negative. So, the other doctor sent a blood test to see if the lab could see any actual virus in her blood. They saw over 200,000 copies.
At first, she seemed ok with it. Then, I asked her how much she knew about HIV, and whether I should start from the beginning. She lost it. The translator turned to me, looking as helpless as I felt. I put my hand on her leg and said I would do a basic overview today, and I asked her to write down questions over the next 3-4 weeks and ask them at the next visit. She was really strong and pulled herself together. So we went through everything, and I think she'll do great. She's smart, she's organized, and I think she'll take control of her disease rather than the HIV taking control of her.
Hopefully, I'll be the one to see her in a month. It's an immediate bond you build with someone, when you share that diagnosis with them and do the initial education. I'd like to be the one to start her on her meds and encourage her progress. I have a good feeling about her, I think she'll do quite well.
Friday, April 16, 2010
Stage 4
Friday afternoons is Hepatitis Clinic at the VA. I love Hepatitis Clinic. I love the attendings there - both the ID attendings and the liver attendings. I love the patients - let's face it, if you have Hep C, you've probably lived an interesting life. I love the virus - so sneaky, so hard to treat. I may be the only fellow who loves that clinic, but I love it.
Today, I had a patient. He's got Hep C (obviously), but he also has been having nightly fevers, sweats and has had a 20lb weight loss over this time. The ID fellow who saw him 2 weeks ago ordered a bunch of lab tests to try and figure this out. TB was negative, endemic fungal infections were negative. His white blood cells were high, signalling some sort of inflammation/infection. Two random tests came back minimally elevated: Murine Typhus and Q fever.
Now, Murine Typhus holds a special place in my heart. As a resident, I once put a man through a million dollar work up (literally, I saw the financials) before I talked to the ID fellow who recommended I check for Murine Typhus. It was positive. Ever since I've never had a problem humbling myself to ask for help. I also decided that ID doctors were the coolest, smartest people around.
Q fever is a tricky diagnosis. If you don't think of it, you'll never diagnose it. My patient lives in the sticks, so he could've picked it up from whatever farm or wild animals go roaming through his backyard.
I elected to treat him - both diseases are treated the same way - and have him follow up in 3 weeks to see how he's doing. Of course, the treatment of his Hep C is on hold until we get this other diagnosis made.
His liver disease is pretty far gone. His liver feels like my kitchen table, rather than a water balloon. He has tendon contractures in his hands, which is a sign of late liver disease. I would suspect that if I biopsied him, he'd be Stage 4 - cirrhosis. This means we need to treat him now and hope he responds. He's got about a 30% predicted success rate based on his age/virus type/etc, which is admittedly not great. But, I don't think I have time to wait 1-2 years for the newer drugs to come out, because I don't know that his liver will hold up that long. It's going to be hard enough to cure him if he has frank cirrhosis, and the more cirrhotic he gets the worse it'll be.
I didn't tell him all this yet. Better to find out what is causing his acute symptoms, then deal with the chronic liver disease. I'm hoping he'll do well with the Hep C meds, but I'm not terribly optimistic. It will be hard for me to sell him on the treatment when I have such low expectations. Then again, I don't have anything else to offer him at this time.
Today, I had a patient. He's got Hep C (obviously), but he also has been having nightly fevers, sweats and has had a 20lb weight loss over this time. The ID fellow who saw him 2 weeks ago ordered a bunch of lab tests to try and figure this out. TB was negative, endemic fungal infections were negative. His white blood cells were high, signalling some sort of inflammation/infection. Two random tests came back minimally elevated: Murine Typhus and Q fever.
Now, Murine Typhus holds a special place in my heart. As a resident, I once put a man through a million dollar work up (literally, I saw the financials) before I talked to the ID fellow who recommended I check for Murine Typhus. It was positive. Ever since I've never had a problem humbling myself to ask for help. I also decided that ID doctors were the coolest, smartest people around.
Q fever is a tricky diagnosis. If you don't think of it, you'll never diagnose it. My patient lives in the sticks, so he could've picked it up from whatever farm or wild animals go roaming through his backyard.
I elected to treat him - both diseases are treated the same way - and have him follow up in 3 weeks to see how he's doing. Of course, the treatment of his Hep C is on hold until we get this other diagnosis made.
His liver disease is pretty far gone. His liver feels like my kitchen table, rather than a water balloon. He has tendon contractures in his hands, which is a sign of late liver disease. I would suspect that if I biopsied him, he'd be Stage 4 - cirrhosis. This means we need to treat him now and hope he responds. He's got about a 30% predicted success rate based on his age/virus type/etc, which is admittedly not great. But, I don't think I have time to wait 1-2 years for the newer drugs to come out, because I don't know that his liver will hold up that long. It's going to be hard enough to cure him if he has frank cirrhosis, and the more cirrhotic he gets the worse it'll be.
I didn't tell him all this yet. Better to find out what is causing his acute symptoms, then deal with the chronic liver disease. I'm hoping he'll do well with the Hep C meds, but I'm not terribly optimistic. It will be hard for me to sell him on the treatment when I have such low expectations. Then again, I don't have anything else to offer him at this time.
Wednesday, March 24, 2010
The Hope Trap
So, I did some moonlighting the other day. Shocking, I know. This was for an Infectious Diseases group, and they usually have some pretty interesting cases.
This, however, turned out to be a day of super sad cases.
The one that sticks out in my head most is a 22-year-old girl with the rarest of rare cancers diagnosed about 8 months ago. She has metastatic disease to her abdomen and lungs, causing fluid build-up in each of these cavities. We have to put a needle in her abdomen and one in each lung space every so often to drain the fluid. It keeps reaccumulating because of the tumors.
We have an expert at our hospital, so she came in for a second opinion. There is one case report of another woman who had the same cancer (different point of origin, less metastatic disease) who was alive 7 years after getting this certain chemo regimen. So the oncologist said, "What have we got to lose?"
Obviously, her parents are hoping for a miracle. The patient had gotten one round of chemo, 5 days before I saw her. I was seeing her for a possible pneumonia, which was not really a pneumonia but actually just cancer in her lungs that looked like pneumonia. But, rather than risk being wrong, we were treating her for the slim possibility of an overlying infection. It wasn't helping.
Her next round of chemo is in 6 weeks. I don't think she'll live that long. I also don't think that her cancer is going to magically melt away after one round of chemo...it's just so extensive.
Should we have even given her the chemo? Are we just feeding a false hope? It's hard not to be optimistic (even stupidly optimistic) when you look a 22-year-old girl and her parents in the eyes. You really want to believe that this might work, even when you know the odds are overwhelmingly against it.
I call it the Hope Trap.
We desperately want to give good news. We want to believe that our patient will be the exception to the rule. And I think that's ok, to an extent. However, we also, simultaneously, need to be preparing the patient and her family for the likely result of death. We need to assist in that transition - just in case. We need to make death an acceptable ending and not a failure. If - no when - she dies, it's not because she didn't fight hard enough or because the doctors did give enough medications or because the parents didn't pray enough. It's just because the cancer was too deep and her body got too weak. No one failed.
Death is the natural result of living, and I think we forget that.
This, however, turned out to be a day of super sad cases.
The one that sticks out in my head most is a 22-year-old girl with the rarest of rare cancers diagnosed about 8 months ago. She has metastatic disease to her abdomen and lungs, causing fluid build-up in each of these cavities. We have to put a needle in her abdomen and one in each lung space every so often to drain the fluid. It keeps reaccumulating because of the tumors.
We have an expert at our hospital, so she came in for a second opinion. There is one case report of another woman who had the same cancer (different point of origin, less metastatic disease) who was alive 7 years after getting this certain chemo regimen. So the oncologist said, "What have we got to lose?"
Obviously, her parents are hoping for a miracle. The patient had gotten one round of chemo, 5 days before I saw her. I was seeing her for a possible pneumonia, which was not really a pneumonia but actually just cancer in her lungs that looked like pneumonia. But, rather than risk being wrong, we were treating her for the slim possibility of an overlying infection. It wasn't helping.
Her next round of chemo is in 6 weeks. I don't think she'll live that long. I also don't think that her cancer is going to magically melt away after one round of chemo...it's just so extensive.
Should we have even given her the chemo? Are we just feeding a false hope? It's hard not to be optimistic (even stupidly optimistic) when you look a 22-year-old girl and her parents in the eyes. You really want to believe that this might work, even when you know the odds are overwhelmingly against it.
I call it the Hope Trap.
We desperately want to give good news. We want to believe that our patient will be the exception to the rule. And I think that's ok, to an extent. However, we also, simultaneously, need to be preparing the patient and her family for the likely result of death. We need to assist in that transition - just in case. We need to make death an acceptable ending and not a failure. If - no when - she dies, it's not because she didn't fight hard enough or because the doctors did give enough medications or because the parents didn't pray enough. It's just because the cancer was too deep and her body got too weak. No one failed.
Death is the natural result of living, and I think we forget that.
Thursday, March 18, 2010
Timing is Everything
So, I just got home from the Zoo. Clinic was disastrous as usual. But, since it wasn't any more disastrous than usual, it seemed ok. I had to act as the attending on a few patients because we were short attendings. The clinic is definitely much better from that view, let me tell you. No paperwork, no phone calls, no making the sure the lab got the sample. Just give advice, sign your name, and next patient please. Not bad at all.
I saw my own patient this afternoon who is still an enigma. She's from the Middle East and presented with a monstrous liver cyst that we found on ultrasound and confirmed on CT. It's probably a parasitic infection that is often seen in that part of the world. However, we don't know how active it is, if that's really what it is, etc. She came in a month after we diagnosed her and announced that she's pregnant. Now, we're trying to figure out a) how do we diagnose what this thing is, b) do we need to biopsy it and how can we convince the surgeons to do that, c) do we empirically treat her with a drug that will likely harm the baby, d) do we take the chance of this thing rupturing as her uterus gets bigger - which would send her into anaphylactic shock and a chance of death for her and the baby. Oh, and did that CT scan she got 2 months ago...did that happen before or after she got pregnant? The timing is pretty close. That's a hefty dose of radiation, and I'm not sure a fetus would survive and if it did survive what kind of long term damage it would cause. I mean, the fetus would've been a few cells big at that time, so I can't imagine it would survive that blast of radiation. However, I got her to see the OBs tomorrow, so we'll let them track back for the timing of everything and see what their recommendations are.
So, now we're in this dilemma - diagnosis with a biopsy might harm the baby (not that I could convince any surgeon to get in the same room with her, let alone put a needle in her), treating without a diagnosis will probably harm the baby, taking a wait-and-see approach may lead to anaphylaxis...do you recommend termination of the pregnancy? We don't even know what this is, for all we know it's a benign cyst with no risk to the patient at all, save the abdominal pain that will occur as the uterus grows.
I don't envy this woman and her husband, they have a big decision to make without a lot of information. Hopefully, in the next month or so we can fill in the holes so they can decide what's best for them.
I saw my own patient this afternoon who is still an enigma. She's from the Middle East and presented with a monstrous liver cyst that we found on ultrasound and confirmed on CT. It's probably a parasitic infection that is often seen in that part of the world. However, we don't know how active it is, if that's really what it is, etc. She came in a month after we diagnosed her and announced that she's pregnant. Now, we're trying to figure out a) how do we diagnose what this thing is, b) do we need to biopsy it and how can we convince the surgeons to do that, c) do we empirically treat her with a drug that will likely harm the baby, d) do we take the chance of this thing rupturing as her uterus gets bigger - which would send her into anaphylactic shock and a chance of death for her and the baby. Oh, and did that CT scan she got 2 months ago...did that happen before or after she got pregnant? The timing is pretty close. That's a hefty dose of radiation, and I'm not sure a fetus would survive and if it did survive what kind of long term damage it would cause. I mean, the fetus would've been a few cells big at that time, so I can't imagine it would survive that blast of radiation. However, I got her to see the OBs tomorrow, so we'll let them track back for the timing of everything and see what their recommendations are.
So, now we're in this dilemma - diagnosis with a biopsy might harm the baby (not that I could convince any surgeon to get in the same room with her, let alone put a needle in her), treating without a diagnosis will probably harm the baby, taking a wait-and-see approach may lead to anaphylaxis...do you recommend termination of the pregnancy? We don't even know what this is, for all we know it's a benign cyst with no risk to the patient at all, save the abdominal pain that will occur as the uterus grows.
I don't envy this woman and her husband, they have a big decision to make without a lot of information. Hopefully, in the next month or so we can fill in the holes so they can decide what's best for them.
Monday, March 8, 2010
Unlimited Energy
I'm back home, visiting my parents, sister and her husband, and my niece and nephew. My niece is nearly 3 and my nephew just turned 1. They are adorable. I love them to pieces.
They wear me out.
My sister has a long body pillow, like 4-5 feet long, and we found it yesterday. My niece loves it. We discovered a game today, which she calls "Hannah's Game." Hannah's Game is going to be the death of me.
We put the pillow on the arm of the couch. She then sits on the pillow, balancing, while I sit on the floor. We pretend she is getting off balance, and I pull her and the pillow off into my lap. That's fun, but that's not the end of it.
Next, I hold the pillow with her laying in it. One hand on her lower back, one hand under her legs. Then we count to three and I launch her and the pillow up on to the couch. She weighs about 30lbs, I'd guess. So, it's like military pressing 30lb. Over and over and over again. She shrieks with delight, and says, "I haffa do it again!" After about 20 rounds of Hannah's Game, I need a break! Fortunately, I can usually distract her with a less intense game while I recover.
I'm sure the afternoon will have many more rounds of Hannah's Game for us to enjoy. I'm hoping I can come up with an easier game for tomorrow, or I'm going to be one sore puppy.
They wear me out.
My sister has a long body pillow, like 4-5 feet long, and we found it yesterday. My niece loves it. We discovered a game today, which she calls "Hannah's Game." Hannah's Game is going to be the death of me.
We put the pillow on the arm of the couch. She then sits on the pillow, balancing, while I sit on the floor. We pretend she is getting off balance, and I pull her and the pillow off into my lap. That's fun, but that's not the end of it.
Next, I hold the pillow with her laying in it. One hand on her lower back, one hand under her legs. Then we count to three and I launch her and the pillow up on to the couch. She weighs about 30lbs, I'd guess. So, it's like military pressing 30lb. Over and over and over again. She shrieks with delight, and says, "I haffa do it again!" After about 20 rounds of Hannah's Game, I need a break! Fortunately, I can usually distract her with a less intense game while I recover.
I'm sure the afternoon will have many more rounds of Hannah's Game for us to enjoy. I'm hoping I can come up with an easier game for tomorrow, or I'm going to be one sore puppy.
Monday, March 1, 2010
Interesting Observation
I take a class on clinical controversies, which examines clinical trials and looks at what went wrong, what could be done better, etc. Last week we had a hematology-oncology attending come talk about 2 cancer studies. He made a comment in passing that really hit me.
We were talking about lung cancer, which is his specialty. It's the #1 cancer killer of both women and men. He said that most people, even doctors, are shocked when they hear that. He said breast, prostate, even colon cancer get a lot more publicity and research money despite causing so many fewer deaths per year.
He then said, "I think the numbers shock peope because whenever you read an obituary and someone dies of lung cancer it just says 'So-and-so died of cancer.' But, if they die of breast cancer, for example, it says, 'breast cancer.' Read the obituaries some time - if it doesn't specify the cancer, it's probably lung cancer. And if it does say lung cancer, they will go out of their way to say that the person was a non-smoker."
I never thought of that, but it really rings true. I think there's a stigma attached to lung cancer - like you did it to yourself (hence the quickness to point out if someone was a non-smoker). I also think people don't want to organize marathons or raise money around lung cancer because it's so preventable. There's a lot of blame attached to lung cancer, inherently. I never thought about it, but I know that when I hear of a smoker with lung cancer, I think, "Well, what did they expect." This doesn't mean that I give them worse care or that I treat them badly. It just means I have a little less sympathy for them. Same with alcoholic patients with cirrhosis. Maybe it's because we see these patients in such volume that you get jaded to the individual patient. You see them as another smoker with another lung cancer. It's just sad.
I think people probably do this with HIV as well. It's super easy to rally around kids with HIV - they are innocent in their disease. But people with multiple sexual partners, people who use IV drugs...those people are gambling and losing. I don't know why I have so much more sympathy with HIV patients. Maybe because people diagnosed with HIV in the beginning were "innocent" - no one knew how it was being passed around, no one knew who was going to get it. And these people were shunned, attacked, and left for dead. Literally. When I see a person recently diagnosed with HIV, like any other preventable condition, it makes me sad. I can't understand why they don't protect themselves.
I guess it's time for my pitch: Stop smoking, no excessive alcohol, no intravenous drugs, practice safe sex, wear seat belts and use sunscreen. Life ain't half bad if you can surround yourself with lovely people and act lovely in return. Might as well make it last.
We were talking about lung cancer, which is his specialty. It's the #1 cancer killer of both women and men. He said that most people, even doctors, are shocked when they hear that. He said breast, prostate, even colon cancer get a lot more publicity and research money despite causing so many fewer deaths per year.
He then said, "I think the numbers shock peope because whenever you read an obituary and someone dies of lung cancer it just says 'So-and-so died of cancer.' But, if they die of breast cancer, for example, it says, 'breast cancer.' Read the obituaries some time - if it doesn't specify the cancer, it's probably lung cancer. And if it does say lung cancer, they will go out of their way to say that the person was a non-smoker."
I never thought of that, but it really rings true. I think there's a stigma attached to lung cancer - like you did it to yourself (hence the quickness to point out if someone was a non-smoker). I also think people don't want to organize marathons or raise money around lung cancer because it's so preventable. There's a lot of blame attached to lung cancer, inherently. I never thought about it, but I know that when I hear of a smoker with lung cancer, I think, "Well, what did they expect." This doesn't mean that I give them worse care or that I treat them badly. It just means I have a little less sympathy for them. Same with alcoholic patients with cirrhosis. Maybe it's because we see these patients in such volume that you get jaded to the individual patient. You see them as another smoker with another lung cancer. It's just sad.
I think people probably do this with HIV as well. It's super easy to rally around kids with HIV - they are innocent in their disease. But people with multiple sexual partners, people who use IV drugs...those people are gambling and losing. I don't know why I have so much more sympathy with HIV patients. Maybe because people diagnosed with HIV in the beginning were "innocent" - no one knew how it was being passed around, no one knew who was going to get it. And these people were shunned, attacked, and left for dead. Literally. When I see a person recently diagnosed with HIV, like any other preventable condition, it makes me sad. I can't understand why they don't protect themselves.
I guess it's time for my pitch: Stop smoking, no excessive alcohol, no intravenous drugs, practice safe sex, wear seat belts and use sunscreen. Life ain't half bad if you can surround yourself with lovely people and act lovely in return. Might as well make it last.
Thursday, February 25, 2010
Last Night??!!?
I saw a patient today in clinic at the Zoo. He was diagnosed with HIV in December. Actually, he meets criteria for AIDS, because his immune system is so shot. He also had a terrible brain infection with Toxoplasma gondii. He came in, at that time, very confused and unable to care for himself. His wife brought him in. She, fortunately, says she tested negative...at least so far.
I see him today, 2 months after being discharged from the hospital. He left with 3 medications to treat his meningitis. He told me that he stopped taking his medications a week or so ago, because he felt that they were causing burning when he urinated. I think my jaw hit the floor. He has an active parasitic infection in his brain, and he stopped his medications on his own because of some pain when he pees. He claims the burning has stopped now that he's off the medications. I'm not challenging that he got the symptoms - people get weird side effects from medications. I'm questioning his judgement and understanding of his illness in stopping his medications without consulting a doctor.
I looked at my translator and asked about 3 different ways if he was really not taking his medications. His wife agreed that he had stopped taking his meds. She didn't seem to think this was unusual at all. Their 3 year old boy was playing with the paper on the examination table, and all I could think was, "This kid isn't going to know his father." The man has a limited lifespan even in the best case scenario, and not taking his medications does not exactly put him in the "best case" category.
I presented him to Dr. D, the attending, who is very hands-on when it comes to couples with HIV. She wanted to come talk to them herself.
She asked if the wife had been tested - she claimed yes, and it was negative. The wife then claimed that the nurse hadn't set her up for a repeat test. Repeat testing is standard procedure - in discordant couples the negative partner should be tested every 6 months. So, we began to question if she really got tested in the first place. Dr. D asked them when was the last time they had sex. The wife looks at the husband, who says "Ayer." I think he's speaking English, and I ask, "A year?" The translator looks at me and says, "Last night" (literally, "Yesterday"). Dr. D looks at them and say, "Last night?!!?!" She then went on a rampage about how he has a sky high viral load, is amazingly infectious, and does she want her child to be an orphan. She said, "I don't want you having any relations until he is on HIV medications." They agreed, but I am not convinced they are going to follow this advice.
We explained backwards and forwards how HIV works, how serious his brain infection was, etc. They kept saying they understood, but they didn't look scared enough to have understood. Even the translator was worried for the wife.
They are supposed to come back next week, hopefully after him returning to taking his meds, hopefully with her getting an HIV test again, and hopefully with them in the right mind to take care of themselves. We don't need another child watching his parents die of AIDS.
I see him today, 2 months after being discharged from the hospital. He left with 3 medications to treat his meningitis. He told me that he stopped taking his medications a week or so ago, because he felt that they were causing burning when he urinated. I think my jaw hit the floor. He has an active parasitic infection in his brain, and he stopped his medications on his own because of some pain when he pees. He claims the burning has stopped now that he's off the medications. I'm not challenging that he got the symptoms - people get weird side effects from medications. I'm questioning his judgement and understanding of his illness in stopping his medications without consulting a doctor.
I looked at my translator and asked about 3 different ways if he was really not taking his medications. His wife agreed that he had stopped taking his meds. She didn't seem to think this was unusual at all. Their 3 year old boy was playing with the paper on the examination table, and all I could think was, "This kid isn't going to know his father." The man has a limited lifespan even in the best case scenario, and not taking his medications does not exactly put him in the "best case" category.
I presented him to Dr. D, the attending, who is very hands-on when it comes to couples with HIV. She wanted to come talk to them herself.
She asked if the wife had been tested - she claimed yes, and it was negative. The wife then claimed that the nurse hadn't set her up for a repeat test. Repeat testing is standard procedure - in discordant couples the negative partner should be tested every 6 months. So, we began to question if she really got tested in the first place. Dr. D asked them when was the last time they had sex. The wife looks at the husband, who says "Ayer." I think he's speaking English, and I ask, "A year?" The translator looks at me and says, "Last night" (literally, "Yesterday"). Dr. D looks at them and say, "Last night?!!?!" She then went on a rampage about how he has a sky high viral load, is amazingly infectious, and does she want her child to be an orphan. She said, "I don't want you having any relations until he is on HIV medications." They agreed, but I am not convinced they are going to follow this advice.
We explained backwards and forwards how HIV works, how serious his brain infection was, etc. They kept saying they understood, but they didn't look scared enough to have understood. Even the translator was worried for the wife.
They are supposed to come back next week, hopefully after him returning to taking his meds, hopefully with her getting an HIV test again, and hopefully with them in the right mind to take care of themselves. We don't need another child watching his parents die of AIDS.
Saturday, February 20, 2010
Nonsense
I am moonlighting this weekend. It's for an Infectious Diseases group, so I like it. I get to see some interesting cases, learn from those great MDs how they are managing the cases, and I get to make some extra cash. The only downside is I have no day off for weeks and weeks. Oh, well, there are pluses and minuses to everything.
I had a patient today who was really interesting. I think I've said this before, but a patient's wife once told me, "You never want to be an 'interesting case' - it doesn't usually bode well for the patient!" She's right. "Interesting" to doctors usually means rare, bizarre, and usually portends a bad outcome.
This super cute, elderly patient had a bone infection in his ankle and foot, because he's bed bound after a massive stroke. He got a pressure ulcer on his ankle with an infection that eventually settled in to the bone. That, in and of itself, is not interesting at all. That's run-of-the-mill infectious diseases. Dime a dozen stuff. His stroke, however, produced a fascinating symptom. I'm pretty sure "fascinating" can be added to "interesting" in the list of things you never want to be called by a doctor.
The patient is aphasic. Wikipedia has a great chart that describes a bunch of different language disorders often resulting from stroke or brain injury. This patient has Wernicke's aphasia. He probably doesn't understand me much, but I can't tell because I can't understand him at all. He has no trouble enunciating. His words are just a bunch of garbage for the most part. Some are real words. Some are made up. Most just don't go together at all.
I asked him how he was doing. He said, "Well, the angels all go in a row, and then baddle and baddle, and then it's done." He then looked at me and asked, "How diddy come splot and biggin to know?" I had no answer, so I just said, "I'm not sure..." It was terrible, because I didn't know if he comprehended that he made no sense and that I had no idea what he said. He seemed happy enough, "pleasantly demented" as we usually say. But, in this case, he's not demented, he just has a problem with the language center of his brain.
I'm assuming he didn't realize that he was not making any sense, or he would've gotten frustrated with my lack of a response. So, I guess that's a silver lining in his case. I told him his antibiotics were working, and that he'd be out of the hospital soon.
He said, "There you go."
I had a patient today who was really interesting. I think I've said this before, but a patient's wife once told me, "You never want to be an 'interesting case' - it doesn't usually bode well for the patient!" She's right. "Interesting" to doctors usually means rare, bizarre, and usually portends a bad outcome.
This super cute, elderly patient had a bone infection in his ankle and foot, because he's bed bound after a massive stroke. He got a pressure ulcer on his ankle with an infection that eventually settled in to the bone. That, in and of itself, is not interesting at all. That's run-of-the-mill infectious diseases. Dime a dozen stuff. His stroke, however, produced a fascinating symptom. I'm pretty sure "fascinating" can be added to "interesting" in the list of things you never want to be called by a doctor.
The patient is aphasic. Wikipedia has a great chart that describes a bunch of different language disorders often resulting from stroke or brain injury. This patient has Wernicke's aphasia. He probably doesn't understand me much, but I can't tell because I can't understand him at all. He has no trouble enunciating. His words are just a bunch of garbage for the most part. Some are real words. Some are made up. Most just don't go together at all.
I asked him how he was doing. He said, "Well, the angels all go in a row, and then baddle and baddle, and then it's done." He then looked at me and asked, "How diddy come splot and biggin to know?" I had no answer, so I just said, "I'm not sure..." It was terrible, because I didn't know if he comprehended that he made no sense and that I had no idea what he said. He seemed happy enough, "pleasantly demented" as we usually say. But, in this case, he's not demented, he just has a problem with the language center of his brain.
I'm assuming he didn't realize that he was not making any sense, or he would've gotten frustrated with my lack of a response. So, I guess that's a silver lining in his case. I told him his antibiotics were working, and that he'd be out of the hospital soon.
He said, "There you go."
Wednesday, February 10, 2010
Guru in the Clinic
Last week, I returned to Clinic at the Zoo. [If you've forgotten, I've termed the county hospital the "Zoo" - a) because it rhymes with the real name and b) because it really is a free for all up there.] It was, as usual, extremely busy. I never feel like I can give great care in that environment. There are way too many patients smashed into a 4-hour morning. Even when the 4-hour morning turns into a 5-hour morning (as it does 99% of the time), it's still not enough time. I don't get to look through labs as closely, I don't get to ask enough questions and I don't get to really know the patients.
Last week, I had an older man who had moved here from India about 10ish years ago. He was quite funny and nice. He had a nonhealing foot ulcer, but it was gradually getting better. He was refusing amputation, which would've cured the infection and probably (eventually) given him greater mobility. But, he was rather attached the foot, so I didn't push it.
He started giving me little words of advice, like a talking fortune cookie. I spent quite a bit of time with him (relatively speaking), partly because I liked his sound-bites of wisdom and partly because he seemed like he enjoyed an audience. He said, "If you're driving a train, you cannot stop and remove all of the little pebbles on the track. You will never get where you're going. Those pebbles are like life's problems - you just have to keep going and push them out of the way." He said a few other snappy things which were very inspirational. I wish I could remember them all. I told him that his family and friends are very lucky to have him around.
He looked a little sad, and he said, "You know how a lamp gives off light - lots of light! - everywhere except underneath the lamp. That is like me with my family. They do not see my light, they only see me as a old man." I wished I could've spent more time with him. I told him I'd see him in 6 weeks, and I thanked him for being a light to our clinic.
Last week, I had an older man who had moved here from India about 10ish years ago. He was quite funny and nice. He had a nonhealing foot ulcer, but it was gradually getting better. He was refusing amputation, which would've cured the infection and probably (eventually) given him greater mobility. But, he was rather attached the foot, so I didn't push it.
He started giving me little words of advice, like a talking fortune cookie. I spent quite a bit of time with him (relatively speaking), partly because I liked his sound-bites of wisdom and partly because he seemed like he enjoyed an audience. He said, "If you're driving a train, you cannot stop and remove all of the little pebbles on the track. You will never get where you're going. Those pebbles are like life's problems - you just have to keep going and push them out of the way." He said a few other snappy things which were very inspirational. I wish I could remember them all. I told him that his family and friends are very lucky to have him around.
He looked a little sad, and he said, "You know how a lamp gives off light - lots of light! - everywhere except underneath the lamp. That is like me with my family. They do not see my light, they only see me as a old man." I wished I could've spent more time with him. I told him I'd see him in 6 weeks, and I thanked him for being a light to our clinic.
Wednesday, February 3, 2010
Just Takes One
I had a patient today with diabetes and a nonhealing foot ulcer. He has already has a below the knee amputation on the left. He's probably going to need another one on the right, due to the ulcer.
My attending starting to talk to him on the importance of good diabetic control to avoid even further complications. The patient cut him off and said, "Doc, I mean no disrespect, but I don't want to hear it." He said that no one ever listens to him, people just sit and lecture him about his illness, and he doesn't want any more of it. The attending is a very, very caring man and really tried to talk to the patient on a more personal level. The patient just shut down.
Once the attending left, the patient told the med student and me his reason for being so angry. It seems he had a bad experience once with a nurse. She told him that he needed X units of insulin. He said that X units had cause him to have an episode of hypoglycemia - he got shaky and passed out. Hypoglycemic episodes can be scary as well as life threatening.
He told her what had happened the last time he took X units. He asked, "So, how many units do you think I should take now?" She looked at him and said, "X." No difference, no acknowledgement of his past symptoms, no regard for his fear of another bad event.
All it took was one bad encounter, and this patient has closed himself off from having an honest conversation about his diabetes. It's sad, but it happens all the time. I think we healthcare providers forget that just one encounter with us can make a lifelong impression -- for bad and for good. We need to listen to our patients, let them know that we really hear what they are saying, and approach things as a team. The only way to be effective providers in patients with chronic diseases is if we're both on the same side.
My attending starting to talk to him on the importance of good diabetic control to avoid even further complications. The patient cut him off and said, "Doc, I mean no disrespect, but I don't want to hear it." He said that no one ever listens to him, people just sit and lecture him about his illness, and he doesn't want any more of it. The attending is a very, very caring man and really tried to talk to the patient on a more personal level. The patient just shut down.
Once the attending left, the patient told the med student and me his reason for being so angry. It seems he had a bad experience once with a nurse. She told him that he needed X units of insulin. He said that X units had cause him to have an episode of hypoglycemia - he got shaky and passed out. Hypoglycemic episodes can be scary as well as life threatening.
He told her what had happened the last time he took X units. He asked, "So, how many units do you think I should take now?" She looked at him and said, "X." No difference, no acknowledgement of his past symptoms, no regard for his fear of another bad event.
All it took was one bad encounter, and this patient has closed himself off from having an honest conversation about his diabetes. It's sad, but it happens all the time. I think we healthcare providers forget that just one encounter with us can make a lifelong impression -- for bad and for good. We need to listen to our patients, let them know that we really hear what they are saying, and approach things as a team. The only way to be effective providers in patients with chronic diseases is if we're both on the same side.
Monday, February 1, 2010
"I don't think you have cancer..."
So, this past month has been pretty light. I had vacation for 2 weeks, then I had clinic only 1 day a week for the rest of January. Those last 2 weeks were supposed to be for research. I took "research" to mean sleeping in, working on an art project, and reading the occasional medical article. I'm pretty sure that's what it means. [Some people may be dismayed by this idea that their doctor is off somewhere wasting time rather than reading every new article that comes out. I prefer to think of it as making myself well-rounded.]
I covered this last weekend at the hospital. Thirteen patients to see each day, so not bad. One I saw on Sunday is a middle aged man with an intestinal disorder that requires he takes steroids. This makes him a little immunocompromised and at risk for weird infections. He came in with abdominal pain, which isn't unusual for him given his condition. What was unusual is that the abdominal CT scan picked up a weird finding in his lower lungs. A scan dedicated to the lungs confirmed a weird nodular pattern with a focal problem in one of the upper lobes. Now he's got to get a procedure done to figure out what the heck is going on in his lungs. Could be an infection (hence the reason I saw him) or cancer or some other inflammatory process.
He looked sad, so I asked if he was doing ok. After chatting for awhile, he said, "Do you think it's cancer?" To be honest, I have no idea. I suppose I could've said that: 'Well, sir, I'm not sure that's why we need the biopsy.' But, he knows that. So, instead I said (with as much confidence as I could muster), "Well, maybe I'm biased since I do infections for a career, but this pattern is more suspicious for an infectious process, I think." I'd like to say he breathed a sigh of relief, and I renewed his hope in the world. What really happened is he looked at me skeptically and didn't say a word. So, I said, "We should know for sure by the middle of the week, when we have all the results back. Either way, we're going to do our best to get you through this." Again, he didn't look all that convinced; I said good bye and put my note in the chart.
Sometimes you just can't make someone feel better. Sometimes they are too scared, too nervous, too cynical to think they might catch a break. He's been sick his whole life with an incurable intestinal disease. Why should things start looking up now? I encouraged him to have a positive outlook, and we'd see how things went.
Maybe some people are just hardwired to be "glass-half-empty" and nothing you can do is going to convince them that it's also half-full.
I covered this last weekend at the hospital. Thirteen patients to see each day, so not bad. One I saw on Sunday is a middle aged man with an intestinal disorder that requires he takes steroids. This makes him a little immunocompromised and at risk for weird infections. He came in with abdominal pain, which isn't unusual for him given his condition. What was unusual is that the abdominal CT scan picked up a weird finding in his lower lungs. A scan dedicated to the lungs confirmed a weird nodular pattern with a focal problem in one of the upper lobes. Now he's got to get a procedure done to figure out what the heck is going on in his lungs. Could be an infection (hence the reason I saw him) or cancer or some other inflammatory process.
He looked sad, so I asked if he was doing ok. After chatting for awhile, he said, "Do you think it's cancer?" To be honest, I have no idea. I suppose I could've said that: 'Well, sir, I'm not sure that's why we need the biopsy.' But, he knows that. So, instead I said (with as much confidence as I could muster), "Well, maybe I'm biased since I do infections for a career, but this pattern is more suspicious for an infectious process, I think." I'd like to say he breathed a sigh of relief, and I renewed his hope in the world. What really happened is he looked at me skeptically and didn't say a word. So, I said, "We should know for sure by the middle of the week, when we have all the results back. Either way, we're going to do our best to get you through this." Again, he didn't look all that convinced; I said good bye and put my note in the chart.
Sometimes you just can't make someone feel better. Sometimes they are too scared, too nervous, too cynical to think they might catch a break. He's been sick his whole life with an incurable intestinal disease. Why should things start looking up now? I encouraged him to have a positive outlook, and we'd see how things went.
Maybe some people are just hardwired to be "glass-half-empty" and nothing you can do is going to convince them that it's also half-full.
Sunday, January 24, 2010
Quick Trip
I was asked to attend a meeting in DC yesterday. I was flown from LA to DC on Friday night, then back to LA Saturday night. I was in DC for 18 hours. DC, other than Chicago, is the one place that when I get there, I truly feel like I'm home.
This meeting was put together by a pharmaceutical company. They brought in 12-14 hospitals - mostly academic medical centers. Each center was represented by a senior faculty person and a junior faculty or fellow. The focus was HIV. The goal was to anticipate what the future of HIV is going to be - who are the patients, what are their problems, what will doctors need to best treat them. We discussed what resources we, as physicians, are missing in dealing with HIV patients. We discussed our "wish list" of what we want. We discussed patient programs we'd like to see, social workers we'd like to have, and electronic medical records we'd like implemented. I met a lot of great people who are also passionate about fighting this disease.
I don't know that I am much of an expert, although I have a lot of opinions for sure. :) I was flattered to be asked to join this group. I hope my input, and the meeting in general, will help this company come up with ways to help physicians treat people with HIV. I came across a quotation by Seneca (a Roman philosopher in 1st century AD) in a magazine on the plane ride home: "Luck is what happens when preparation meets opportunity." I think this quotation is great because it reminds me that people who take advantage of situations and are able to turn them into success stories are people who worked and prepared so that when that one opportunity comes, they can make it a "lucky" one.
So, don't feel guilty that you got the promotion and someone else didn't. Alternatively, don't make yourself the victim in a situation that doesn't go your way. We all have to be working hard and preparing ourselves daily for that chance that happens to come - you never know when your "luck" will change.
This meeting was put together by a pharmaceutical company. They brought in 12-14 hospitals - mostly academic medical centers. Each center was represented by a senior faculty person and a junior faculty or fellow. The focus was HIV. The goal was to anticipate what the future of HIV is going to be - who are the patients, what are their problems, what will doctors need to best treat them. We discussed what resources we, as physicians, are missing in dealing with HIV patients. We discussed our "wish list" of what we want. We discussed patient programs we'd like to see, social workers we'd like to have, and electronic medical records we'd like implemented. I met a lot of great people who are also passionate about fighting this disease.
I don't know that I am much of an expert, although I have a lot of opinions for sure. :) I was flattered to be asked to join this group. I hope my input, and the meeting in general, will help this company come up with ways to help physicians treat people with HIV. I came across a quotation by Seneca (a Roman philosopher in 1st century AD) in a magazine on the plane ride home: "Luck is what happens when preparation meets opportunity." I think this quotation is great because it reminds me that people who take advantage of situations and are able to turn them into success stories are people who worked and prepared so that when that one opportunity comes, they can make it a "lucky" one.
So, don't feel guilty that you got the promotion and someone else didn't. Alternatively, don't make yourself the victim in a situation that doesn't go your way. We all have to be working hard and preparing ourselves daily for that chance that happens to come - you never know when your "luck" will change.
Saturday, January 16, 2010
Back at It...Soon
My vacation ends in a few days. This last week has been nice - a few errands to run each day, a little bit of work to catch up on, but all in all not much to do.
It's nice to wake up without the alarm going off. It's nice to go for a run and not rush through my post-run stretch. It's nice to make lunch at home and sit in my kitchen and eat it.
I thought I would get bored. Maybe there were a few stretches were I got restless. But, there are so many books to read, so many trails to run. I would always want to work in some capacity. But, it would be nice to take a week off every now and then. It would be nice to have my evenings not full of articles to prepare. I know that day is going to come soon...it was nice to get a glimpse of it now.
It's nice to wake up without the alarm going off. It's nice to go for a run and not rush through my post-run stretch. It's nice to make lunch at home and sit in my kitchen and eat it.
I thought I would get bored. Maybe there were a few stretches were I got restless. But, there are so many books to read, so many trails to run. I would always want to work in some capacity. But, it would be nice to take a week off every now and then. It would be nice to have my evenings not full of articles to prepare. I know that day is going to come soon...it was nice to get a glimpse of it now.
Saturday, January 9, 2010
Still Cold
The race is over. It's been over for 8 hours. I'm still cold.
We got up at 3a to catch the shuttle to the race at 3:30a. I layered on running tights, dry-fit long sleeve shirt, dry-fit short sleeve shirt, cotton long sleeve and a hooded sweatshirt. Not to mention gloves and ear warmers. The sweatshirt was my Brother's - thank goodness I wore it. It was 34 degrees. I saw a few snow flurries.
We stood out in the windy cold for two hours. Wow, I was chilled to the bone.
Then we got to our corral and waited some more. Soon the freezing rain started. Eventually the fireworks went off to let us know we could start! We ran 4 miles into the sleet. My plan was to shed the sweatshirt after a mile or so, but I kept it for the first 5 miles. I saw my Sister-in-Law's parents who were there to cheer us on. I gave them the cotton long sleeve and the hooded sweatshirt. The next mile or 2 was awesome. Through Main Street, into the Magic Kingdom Castle. We saw Cinderella and Prince Charming and the whole Royal Family outside the castle! It was still dark out, so the lights were all on. We also saw a lot of the Disney characters around the park. Peter Pan, Wendy, Captain Hook and Smee. The Bears. Captain Jack and the pirates. So many more. It was awesome! Those 2 miles were the best by far.
Then I immediately wished I had my sweatshirt back. The last 6 miles had the wind at our backs, which was better. My hip started to hurt with about 3 miles left. The rest of the run was fine - rain began so we got wet. At the end, we got Mylar wraps which usually toast you like a baked potatoe - unfortunately, you need the sun in order to really make them effective. In the end, they just worked to keep the rain off.
We got on the shuttle bus to go back to the hotel. For some reason, the bus was frigid. I don't know why the bus driver didn't have the heat on. We got back to the hotel and ran (literally) back to our room. I didn't think I had another 10 feet in me, let alone a few blocks. I couldn't get the water in that shower hot enough. My toes are still cold.
We got cool Donald Duck metals, and we finished the race in just over 2 hours. Not bad for below-freezing temperatures. If I do this again next year, I hope it's a tad bit warmer.
We got up at 3a to catch the shuttle to the race at 3:30a. I layered on running tights, dry-fit long sleeve shirt, dry-fit short sleeve shirt, cotton long sleeve and a hooded sweatshirt. Not to mention gloves and ear warmers. The sweatshirt was my Brother's - thank goodness I wore it. It was 34 degrees. I saw a few snow flurries.
We stood out in the windy cold for two hours. Wow, I was chilled to the bone.
Then we got to our corral and waited some more. Soon the freezing rain started. Eventually the fireworks went off to let us know we could start! We ran 4 miles into the sleet. My plan was to shed the sweatshirt after a mile or so, but I kept it for the first 5 miles. I saw my Sister-in-Law's parents who were there to cheer us on. I gave them the cotton long sleeve and the hooded sweatshirt. The next mile or 2 was awesome. Through Main Street, into the Magic Kingdom Castle. We saw Cinderella and Prince Charming and the whole Royal Family outside the castle! It was still dark out, so the lights were all on. We also saw a lot of the Disney characters around the park. Peter Pan, Wendy, Captain Hook and Smee. The Bears. Captain Jack and the pirates. So many more. It was awesome! Those 2 miles were the best by far.
Then I immediately wished I had my sweatshirt back. The last 6 miles had the wind at our backs, which was better. My hip started to hurt with about 3 miles left. The rest of the run was fine - rain began so we got wet. At the end, we got Mylar wraps which usually toast you like a baked potatoe - unfortunately, you need the sun in order to really make them effective. In the end, they just worked to keep the rain off.
We got on the shuttle bus to go back to the hotel. For some reason, the bus was frigid. I don't know why the bus driver didn't have the heat on. We got back to the hotel and ran (literally) back to our room. I didn't think I had another 10 feet in me, let alone a few blocks. I couldn't get the water in that shower hot enough. My toes are still cold.
We got cool Donald Duck metals, and we finished the race in just over 2 hours. Not bad for below-freezing temperatures. If I do this again next year, I hope it's a tad bit warmer.
Friday, January 8, 2010
I thought Florida was the Sunshine State
So, it's race time. Tomorrow is the Disney Half-Marathon that my Brother and Sister-in-law and I are running. When my Brother asked me about doing it, I thought, "How fun! Running around Disney World in the Florida sunshine with my family...what could be better?" I've never been to Disney World, but it seems to be like Disney Land - warm, Mickey Mouse, sunny, happiness on a stick.
Not today. Not tomorrow.
Weather.com tells me the high tomorrow is 38 degrees ("feels like 29") with rain likely the whole morning. Not exactly what I signed up for. Good thing I packed running tights and long-sleeve shirts. I have no rain slicker, so we'll just see how it goes. It has the potential to be the most miserable 13.1 miles I've ever experienced. At least my Brother and SIL will be there to whine with.
Stay tuned for the post-race recap!
Not today. Not tomorrow.
Weather.com tells me the high tomorrow is 38 degrees ("feels like 29") with rain likely the whole morning. Not exactly what I signed up for. Good thing I packed running tights and long-sleeve shirts. I have no rain slicker, so we'll just see how it goes. It has the potential to be the most miserable 13.1 miles I've ever experienced. At least my Brother and SIL will be there to whine with.
Stay tuned for the post-race recap!
Monday, January 4, 2010
Family Time in The Region
I got to spend a few days with all my siblings. This is not an easy thing to do, because we're spread all over the place. While I live in LA, my brothers live in Orlando and my sister is Northwest Indiana - affectionately known as The Region. People from The Region are (affectionately?) known as Region Rats. Do with that piece of information what you will.It was great to see them all. I won't pretend that we grew up sing Kumbaya together every night, but for the most part we got along. We've grown closer as we've gotten older, and I think we appreciate each other more now. We definitely cherish our time together. And we love spending time with the kiddies - my sister has a little girl and boy. As you can see in the picture, some one made sure Uncle Dude was cozy with more than enough stuffed animals during his nap.
This time off has reminded me to stop and smell the roses - metaphorically, of course, since it's 3 degrees here right now. I hope to remember this lesson when I get back to the bustle of LA. In the mean time, though, the Disney Half-Marathon is in a few days...there I'm just hoping to make it across the finish line.
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