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Night Three

It’s now night 3 of 6. Six straight days — er, nights — covering the ICU patients here at one of the local county hospitals. Night 1 was great. Occasional calls here and there from nurses for little things that did not require much brain power. I am also working with an intern. He is covering the non-ICU patients. Night 1 went well for him too. I think I saw him watching tv shows on his iPad during the down time.

Night 2 was definitely busier for the both of us. For me, there was one patient who pretty much required my attention the entire night. And when I finally failed at placing a functional arterial line, I had to go call Anesthesia to help me place it. And then while they were at bedside, I asked if they could also intubate my patient as well. Later, as the early morning hours rolled around, I was about to place a central line. I had collected the consent and all the necessary materials. I had the ultrasound machine ready. However, the patient was still moving around so I asked that the sedation be turned up and I would return shortly.

I never did return. Because while I was waiting for increased sedation, I got another call for a patient on the other side of the ICU. Apparently they were having non-convulsive seizures through much of the night and the EEG tech was notifying us. Six in the morning. The patient had already been well loaded with dilantin, a type of anti-seizure medication the night before. However, despite the dilantin, the seizures continued. I considered adding another medication at a constant infusion via IV. The caveat, though, is that a constant infusion of versed (the medication I was considering) requires a patient to be intubated because it can depress the respiratory function.

I did not want to make that decision alone, though. So I paged the on-call neurologist. Unable to get a response, I finally paged the neurologist who would come on call at 8 AM. She advised against the versed infusion and suggested a different regimen. By the time this was sorted out, the day teams had already began showing up and I signed out the events of the night to them.

Tonight I am writing this on night 3. The call team admitted at least one very sick, ICU patient. At this point we have come up with a plan and we will continue to see how the patient does over the course of the night.

While I generally dislike working nights, there are some things that are nice.

I just have to focus on those niceties for another 3 nights.

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County Life

This month is my first of two months rotating at one of the local county medical centers. It is very different than either of the other two hospitals in which we find ourselves.

Traditionally it has been called our “senior capstone” experience — acting as the senior resident at the county.

The patient population is diverse. Sick patients walking daily with strange diagnoses.

At night, we find ourselves mostly on our own covering the ICU patients.

During intern year, my first rotation was here at County.

It is very strange to find myself back, now in the senior resident position.

They say time flies. I am counting on it.

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Detroit

Just flew back from Detroit last week after a fellowship interview.

Surprisingly there were no direct flights from ONT (Ontario, CA) or LAX (Los Angeles, CA) to Detroit.

The weather was decent, aside from a half-hour thunderstorm that was accompanied with storm warnings on the local news.

The program was amazing. The faculty seemed welcoming and fellows had positive things to say about their program.

I’ll write more about the process and my thoughts as time goes by — most likely after the match.

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Time, Indeed, Does Fly

It amazes me how fast life marches on. I feel like I was just a medical student not too long ago. But here I am in my final year of residency. I have almost completed two months. Ten months remain after this. I have my first fellowship interview this coming Tuesday.

It is amazing how one changes over time. I remember when I started medical school. Like 90% of medical students, I briefly entertained the idea of pursuing a surgical specialty at some point. As it came time to apply for residencies I chose Internal Medicine with the intention of going into primary care. I wanted the long-term relationship with my patients. I wanted to get to know them. I wanted to work with them for the improvement of their overall health.

Interests change. Goals change. As I have gone through residency I feel very comfortable on the inpatient setting. Maybe that is a by-product of a heavily based inpatient Internal Medicine residency. My program produces some fine internists that make great hospitalists. Or maybe it is the result of working in a continuity clinic based at a county hospital mainly seeing underserved patients. Only a handful of my patients have any actual “continuity.” Sometimes it feels like every patient I see is a brand new patient to the system. And sometimes I wonder what ever happened to Mrs. X or Mr. Z. Some say that private practice is different. The patient population is different. Perhaps. But I may never actually find out.

Along the way I have decided to pursue sub-specialization. That means that after I complete this Internal Medicine Residency, I will hopefully complete my time as a resident and begin my time as a fellow in an Internal Medicine subspecialty. Of course, there is the chance I won’t match. So for the time being, allow me some privacy. Once (or if) I become a fellow, I will talk about it then.

If I don’t become a fellow I will be able to begin practicing medicine as an attending. That is a weird thought. It’s comfortable NOT having the final say. It’s easier when the decisions and responsibilities don’t fall on your shoulders alone.

The rest of the year promises to be challenging. But I should probably enjoy the ride. Because before I know it, this year will be done.

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MICU to Heme/Onc — What a Change

After a month of intensity on the MICU, I have switched to the Hematology and Oncology service.

I won’t lie. The first few days after Switch Day I realized that I missed the intensity and the severity we had on an hourly basis with critically ill patients. It was like coming off of an adrenaline rush.

There are few Heme/Onc emergencies that require a response from the team immediately. I have explained to teams requesting a consult that their request was placed quite late in the day after we have completed rounds, and since it is not an urgent matter, we will see the patient in the morning.

I have been consulted on masses found incidentally or not-so-incidentally on imaging. Masses that are highly suspicious for malignancy. After seeing the patients, I write my recommendations: Please obtain a tissue biopsy. If stable for discharge, patient can follow up in Heme/Onc clinic as an outpatient. (Of course, there are frequently other specific tests I might ask for.)

Sayonara. See you later. Thanks for your question.

I don’t mean to sound or appear callous about patient’s with cancer. I appreciate the gravity of the subject matter. I know it often sounds like a death sentence when the diagnosis falls upon a patient’s ears for the first time. And the second. And sometimes, even the third. I know how it affects the family of the patient. I know they are scrambling for news, grasping for hope. I know how it feels because I was one of those family members when my mom was diagnosed with cancer while I was in college. So don’t misunderstand me. I don’t downplay the significance or the weight of what I deal with now that I am on the Hematology and Oncology service.

I just mean that the energy required of me is a lot less.

The intensity of the critical care unit takes it’s toll emotionally, psychologcially and physically.

I sleep a bit more now. I have time to read more now. And yesterday, I even had time to go discuss a research project with an attending.

It’s a good thing that residency affords these highs and lows. I don’t think I would survive 100% of either level.

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Again, MICU

This year I was one of the “lucky” residents who were assigned two MICU months and two CCU months.

I am finishing my 2nd year of residency in the MICU. It has been a long and exhausting month. My last call was probably my most emotionally draining one.

The call day had ended and I soon found the MICU empty of other residents. I was the senior left on duty. Around 10 pm, one of the nurses came up to me and told me that an arterial line was no longer functioning properly. The line was needed as the patient was on a couple medications to support her low blood pressure and the arterial line provided an accurate measure of her blood pressure. This patient also needed frequent blood draws to check her pH, CO2, O2, and HCO3 levels in her blood.

I asked the nurse to get things ready and I would attempt to try and place another line. After notifying the attending, I started scouring the MICU for our ultrasound machine. Knowing that the patient was on pressors (medication to maintain blood pressure), I figured her artery might be small and I would use any help I could get.

To make a long story short, I made 3 attempts with the help of the ultrasound. First attempt I got a red flash of blood in my catheter that indicated I had hit the vessel. However I could not successfully advance the guide wire. As I re-checked the location of the vessel on the ultrasound, I realized that her vessels were clamping down even tighter. I had to try further up her arm for attempts #2 and #3.

After three attempts I threw in the towel. I paged my attending and asked for help. He came back and suggested we try a femoral arterial line instead of one in her wrist. Having never placed one I was eager to at least try. In the end, though, the attending ended up placing one.

Minutes later, the patient would code. She went pulseless and chest compressions were immediately started. We brought her back. But she would do it again later that night. The second code was not successful. And in the early morning hours I phoned sleepy relatives to deliver the fatal news.

The following morning as rounds began, one of my interns notified me that Mrs. X had approached him. She wanted to withdraw life support on her husband. She would later do so and request that the intern and attending be present as they disconnected him from the medications and ventilator that kept his body alive for the past week.

I watched as she wailed and cried over her husband’s body. And slowly and quietly we walked away; because we had to move on to other sick patients.

We moved on to a room where a young body lay motionless. A mother was hysterical saying that it was “too soon.” There wasn’t a dry pair of eyes in that room as our team walked in. And I watched as my attending deliver blow after verbal blow. The patient was past any intervention. There was no surgery or medication left to try. Expected reflexes were absent. There were no signs of spontaneous breathing; the patient was fully dependent on the ventilator. Our medical advice to the family? Withdraw life support. Despite initial vehement protestation by a grieving mother, the family finally made the decision to withdraw life support late that day.

One of the family members looked right at us and said, “I don’t know how you can do this every day.”

Sometimes, I wonder that too.

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Very Sick and Nearly Dead

When caring for patients on an inpatient basis — that is, patients who are admitted to the hospital as opposed to seeing patients in clinic — there are many moments when you must have crucial conversations. For the most part, medical students are shielded from needing to carry out these conversations. As a medical student, I may have asked patients on admission about their code status. However, I never wrote orders based on my conversations. And if a patient stated that they did not want to be resuscitated in the event that their heart stopped or they could not breathe on their own, I always told the intern or resident so that they could confirm and document the conversation. I think it’s appropriate to allow students to begin asking these types of questions; I also think it’s appropriate (and legal) to have residents/interns confirm and do their own asking when a medical student initiates discussion of these topics.

There are other conversations that, unfortunately, become more familiar as one gets accustomed to inpatient medicine. The conversation with patients and families regarding goals of care is probably as heavy as it gets. At times, this conversation spans days. When taking care of patients who are all-of-a-sudden critically ill, it is often extremely difficult for this conversation to take place and families often need to be walked through the reality of the situation and the grim prognosis. Even with patients who are chronically ill, these conversations may take time.

One of the key pieces of information during these conversations is the severity of the condition and the prognosis. In my short experience I have found that patients and families react differently. Some will cling to your every word, writing down the way you say things and even making sure to write down your name. Others listen with a blank stare; they make you wonder if the are even listening. It is both the honor and the burden of the physician to accurately and effectively convey this information.

Unforunately, it isn’t always a burden we carry well. Too often, I hear doctors (myself included) described the state of a patient as “very sick.” I don’t know if there is a good answer to why we, as a profession, do this. Perhaps it is easier to say someone is “very sick” rather than that they “are dying.” Perhaps some of us view death as the doctor’s ultimate defeat — something that we sometimes refuse to admit. Perhaps we have our own personal issues with death and dying (consciously or sub-consciously) and treating a dying patient forces us to confront, or at least acknowledge these issues (consciously or sub-consciously). Regardless of the “why,” I think we ought to do a better job of communicating to families and patients.

I remember calling a patient’s daughter. I remember telling her that her father was “very sick.” As she tried to grapple with the words I were telling her, she asked me, “Is he dying?” As I sat holding the telphone handset to my ear I finally answered, “Yes, he is dying. I cannot say when. I cannot tell you if it is days or weeks right now. But he is dying. He is getting weaker everyday.” Five days later, after I had left the service, I learned that my patient had passed. And in finding out about his death, I found solace in the fact that I had done what I could to prepare the family.

As difficult as it is to hear that your loved one is dying, I think we owe it to our patients and their families to be prepared for whatever comes next — at least what we think is most likely according to our education and experience. Some patients and their families understand what “very sick” means. Others don’t. The words we use, though, are not important. What is important — what is crucial — is that we communicate effectively with our patients and their families.

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