Three Wishes (published on The Differential)

The following is a post I wrote during medical school.


Questions are powerful. They stimulate thought. They encourage discussion. And sometimes, they do so much more.

During my time on the Adolescent Psychiatry unit, one of my favorite questions to ask my patients was “if you had 3 wishes, what would you wish for?” or some variation thereof.

It’s not an exact science. But I felt like the question gave me a little bit of an insight into their minds. I had frequently heard the child psychiatrists ask this question of the tiny tots. I didn’t hear them ask this of the adolescents. I’m not sure why.

I remember one patient telling me that one of his 3 wishes included destroying the place we were in. As far as I could tell, I took this answer in stride. I asked him why and he admitted that he didn’t feel like the facility was very helpful. He just wanted to get out of there and go home. A couple days later, when I asked him again, I was glad to hear him say that he had changed his mind. He realized that value of the psychiatric unit and didn’t want it torn down and destroyed anymore.

Another patient told me of her wish to buy her mother a big house. It’s probably safe to assume how and why a wish like this would begin to take hold in the mind of a young person. Other teens also voiced their own desires for material items.

Regardless of the wish, big or small, I felt like it was a backdoor into understanding a little bit more about my patient. And in psychiatry, you take whatever you can get — at least that’s how I felt about it.

What happened to me, though, was that I began to look introspectively. I would like to think this sort of thing happens more often than not to students rotating through psychiatry. I began to think about what I would wish for if I were given 3 wishes. In fact, I was pretty much forced to think about it for myself when one of the patients turned the question back on me after he had answered the question himself.

If I remember correctly, I think I answered that I wished 1) to be done with my schooling and 2) for a lot of money. I told him I’d save the 3rd for later. He thought it was clever. But in looking at my first two wishes, I realize that I’m not that much different than the patients I was seeing. I seem to want physical and financial freedom just as much as they do. I just word it a little bit differently.

And that’s how one little question helped me feel closer to the patients I was seeing each day.


Stomach Pain: It Starts – Part I

The following post is a personal story. Often I find myself on the treating side of a physician-patient relationship. In this case I found msyelf on the patient side of things — as the family member of the patient. It’s a story about my wife and her two year ordeal with abdominal pain and the long road to a diagnosis and treatment.

It all started just over two years ago. At the time, my wife and I were still dating. It was Mother’s Day 2012 and we were both spending time with our respective mothers. I received word that Allison found herself in such agonizing abdominal pain that her family was all shocked. You see, she has a fairly high pain tolerance. But this pain paralyzed her and she found herself sobbing on the couch because of it. Her family took her to the local emergency department. There, they were able to control the pain with pain medications. Whatever scans they did (I never figured out if it was an ultrasound and/or CT scan), they were negative. The labs were normal. So they sent her home with a presumed diagnosis of gastric ulcer. She was instructed to follow up with a GI doctor to see whether an esophagogastroduodenoscopy (EGD) would be warranted.

When she followed up with the GI doctor as an outpatient they decided against an EGD at that time. The plan at that time was to carry on with life and only proceed with an EGD if the pain returned. Over the next few years she would have occasional abdominal pain. There was no pattern. Often it would be in the middle of the night. It would last anywhere from minutes to hours. However it would resolve on its own. The episodes were also very spread apart.

I suppose the episodes of pain, being so rare and spread out, were easy to ignore. Especially with the hustle and bustle of life. When the episodes first started, Allison was in her final year of nursing school. After graduation she found herself working on a busy cardiac unit in LA County while serving as a nurse manager for a non-profit women’s clinic. On top of that, we both would try our best to see each other on our free time. And so, life moved on. We both did. And eventually we got married in February of 2014.

After we got married, Allison moved in with me in Redlands. She continued with both her jobs in LA County making the early-morning, hour-plus, traffic-laden commute from the Inland Empire into LA County three times a week. Two times a week she commuted 45 minutes to women’s clinic. To say the least, it was a very tiring time.

Three months after our wedding she had a major attack. She had woken up before 5 AM to get ready for work. Half-asleep, I remember her leaving the bedroom. The next thing I remember she was back at my bedside, on the floor in tears because of intense abdominal pain. I had never seen her like this before. She was barely able to move. I quickly got out of bed and got dressed. And off we went to the Emergency Department.

As we checked in and she had her vitals taken, she mentioned that the pain had some radiation to her chest. They quickly took her back to get bloodwork and an had an EKG done. As expected the EKG was normal. Her bloodwork also came back normal. The sent her for an ultrasound of her abdomen. That came back normal as well.

All the while, they tried to treat her pain. They first tried a GI cocktail1. That did nothing. They tried an IV medication called toradol2. That had little effect. Finally they pulled out the “big gun” and gave her dilaudid. This finally provided her some relief to the pain but it caused nausea which required an anti-emetic medication.

The ED doctors didn’t have much in the form of answers. They noted all the tests were normal. We had discussed my wife’s history of abdominal pain and they felt further evaluation by a GI specialist was in order. I was ahead of them, though. While we were waiting for results I had already called over to the GI Clinic and set up an appointment with one of the GI attendings.

Unfortunately that appointment would not be for another 3-4 weeks.

As the acute pain had passed, broken by administration of some high-powered narcotic, we were discharged home. After all, with all the tests coming back “normal,” there was no signs of an acute issue that needed emergent care or intervention. On the way out we received prescriptions for an anti-acid medication, an oral pain medication, and some stool softeners (as oral pain medications often cause constipation).

Tired, frustrated without a clear diagnosis but relieved that the pain had passed, we finally went home. We were also eager to get to the GI appointment.

  1. A GI cocktail is a mixture of medications frequently used to alleviate abdominal pain due to indigestion. []
  2. Toradol is a type of anti-inflammatory given via IV or as an injection. It is in the family of drugs called NSAIDS, like ibuprofen. []

Code Status

Every single patient that gets admitted to the hospital needs to be asked about their “code status.”

I usually ask about this in this way:

Now I have to ask this question to everyone I admit, regardless of what they are being admitted for.

In the event of an emergency, if your heart were to stop or beat ineffectively, if you are unable to breath on your own, what would you like us to do?

Do you want us to do everything to bring you back? This includes doing chest compressions, shocking your heart (if it is appropriate) and putting a tube down your throat to help you breathe with a machine.

Some patients who have been admitted frequently will be familiar with this question. They will immediately answer and ask that we either “do everything” or do nothing and just “let them go.”

Others stare blankly at you because they have never been forced to answer this question. They may look at their spouse. For those that hesitate I explain that there are risks to these attempts at resuscitation and that the older a patient is and the more medical problems they have, the less likely a full recovery should be expected.

I also allow them time to think about it and discuss it. I tell them that they don’t have to decide now. I also tell them that the decision they make is not final and “set in stone.” They can change their minds later. However, if they are unable to make a decision at this time, they will default to a “Full Code” status until they tell us otherwise.

Asking the question(s), regarding code status, is easy. Hearing the answer, on the other hand, can sometimes be difficult.

What about the senior citizen with medical comorbidities — who is unable to answer questions on their own due to the severity of their medical problems — whose family insists we do everything to keep them alive? It is not rare.

As physicians, we look at the patient from an admittedly detached point of view. Sometimes it is out of habit. Sometimes it is out of necessity.

It is difficult when we see our patient, who has poor functional status by any standard of measure and who would likely incur more harm than good by performing resuscitation measure in the event of cardiopulmonary arrest, carry a “full code” status in their chart because family is unable to come to terms with their state of health.

I do realize that there are many reasons a family will have for not rescinding a full code status. That is probably a topic for a whole different post.

This post, to me, seems more like a stream of consciousness post than a post that was well thought out and that had a point to prove or make. I apologize for that. It is just an issue/topic that has been on my mind recently.

For those of you who have had to carry this type of conversation regarding code status, how do you approach patients? How do you approach families? How do you discuss this issue regarding patients who are unlikely to have any benefit from resuscitation but whose families are adamant that all measure be taken?


What’s a Chief Resident?

As I mentioned in the last post, I will be staying here at LLU for at least a year after residency officially ends. I will be staying on as one of the Internal Medicine Chief Residents.

So what does that mean?

I have found that it means different things to different people. In other residencies, the chief resident position or title is given to residents in their final year of training. And during that year as “chief resident” they are given additional tasks. From what I have seen, this is the case with other residencies like Emergency Medicine and ?many surgical specialties.

In Internal Medicine, the chief resident is someone who has already completed their residency. A quick search on google for “chief resident” brought me to the Duke Internal Medicine website. This is their description of what a chief resident is:

The Chief Resident position is the single largest investment in leadership made by the Department of Medicine, and the chiefs serve as key leaders for the program. Chiefs are selected for their exceptional clinical and leadership skills. The chiefs work as a team to provide leadership and support of the key missions of the residency program and function as key mentors and advocates for the residents. While each chief has separate responsibilities at their primary site (Duke, Durham VA Medical Center, Duke Regional Hospital, and VA Quality/Safety), the camaraderie among the chiefs sets a positive tone for the program and allows us to accomplish the many goals we set for the year. Notably, many former chief residents remain on faculty at Duke, serving in leadership positions throughout the health system. In recent years, the chief residents have been responsible for organizing the Stead Societies, reorganizing the noon conference series, instituting leadership training for JARs at the VA and evaluating patient flow on the general medicine services. In addition, the chiefs galvanize the competition for our annual Turkey Bowl, lead recruitment of new interns and have a tradition of providing entertainment at the annual DOM Holiday Party.

Chief residents are chosen during the SAR (PGY-3) year, and serve as chief residents with a faculty appointment during their PGY-5 year. Typically Chief Residents complete a fellowship or hospital medicine faculty year during the PGY-4 year, and return to their fellowship or hospital medicine position after completion of the chief year.

[emphasis added]

They make it sound like quite the lofty position, don’t they? Apparently their chiefs serve in their PGY-5 year (5 years after graduation from medical school).

It would be important to note that there are differences with how my progarm does things. Internal Medicine (IM) Chief Residents here are selected during their PGY-3 year but proceed directly into the chief residency following the completion of residency. And I would hold off on claiming any “exceptional clinical and leadership skills” for myself. Also (not noted above), we will spend time rounding as the Attending Physician with the teaching service for a number of weeks throughout the year. But for the most part, the job responsibilities are similar across teh country for IM Chief Residents. In fact, the new group of LLU chief residents will be attending the APDIM Meeting in Houston, Tx in April. This meeting brings together leaders from IM residencies across the country (including program directors and chief reisdents) to sit down and learn about education and leadership.


The Twists & Turns of Life

As I look at my blog it seems that I have not written an update since November of 2014. I do apologize for not being better in keeping up with writing. I am not sure who I am apologizing to, though, as I have no clue about who is actually still reading this.

A few days ago I came by to browse through my archives. It was a trip down memory lane, so to speak. As a blog, this one has been around for quite a while. My first post, although it was moved over here from a previous iteration, was written while I was still an undergraduate student back in the 2005-2006 academic year. I definitely did not forsee where I would be today.

Last year I remember blogging about fellowship applications. Even that did not go as planned. I started out the fellowship application season intent on joining the NRMP Match hoping for a spot in Nephrology. My plan was to puruse nephrology and then follow that up with a year of critical care training. I even interviewed at Henry Ford’s combined Nephrology/Critical Care program.

But life happens. Life sometimes gets in the way of — well, life.

As the deadline approached I was faced with many questions. I wrestled with these questions and in the end decided that it would be best for me to withdraw from the fellowship match. It was not an easy decision. And on the weekend prior to the deadline to finalize rank lists, I officially withdrew.

I have not ruled out a fellowship. But I had decided that at this time, it would be best for me to wait.

There were many questions that I faced in making this decision. I won’t share all of them. But some included quality of life, lifestyle, job satisfaction, and family.

After making my decision I spoke with our Internal Medicine Program Director. He was one of the faculty members who wrote a letter of recommendation for me. I shared my decision with him — that I had decided not to participate in the match. He asked if I had ever considered doing a year as a chief resident. He had no idea that I had. In fact, as an intern I had actually thought I wanted to one day be a chief resident. And so I answered that it was something that I had been interested in doing in the past.

Now, about 5 months away from the end of residency, I find myself as one of the future Internal Medicine Chief Residents.

Life is full of twists and turns. Sometimes, half the fun is watching where it takes you.


The Event — It’s Time to Clean This House

Let’s ignore the details — for a moment — of what has happened in the city of Ferguson from the day Michael Brown was shot until the decision of the grand jury not to indict Darren Wilson was announced. Let’s compress it into a singular event.

Essentially, that event seems to have thrown open this nation’s closet door. It’s the closet into which we have thrown all our racially charged skeletons for the sake of appearing tidy, clean, and welcoming to guests who may come to visit — or the nosy neighbors who might peer through open windows. It’s a closet that has been stuffed full and whose contents burst out as soon as that door cracked open. But the Event didn’t crack the closet door open; it violently flung it open and exposed our darkest secrets to a watching international audience.

Whether or not you believe that the Event was motivated by racial undertones or not, it has pulled back the covers to reveal a deep pain, anger, and mistrust that was conveniently pushed aside or ignored for a very long time.

It’s time for this House to have an honest, deep, rip-the-carpet-out, fix-the-bannister, get-rid-of-all-the-termites type of spring cleaning. Or else watch as this House crumbles from the inside.


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.