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Back To Work

I go back to work this week. It’s the first time I have been on a shift since mid August. My wife and I recently celebrated the birth of our first child, a baby girl. I was fortunate to be able to arrange my schedule in order to accomodate this time off.

It’s odd going back to work after a long time. Part of me welcomes going back. Part of me wants to hang out with this brand new, little human being.

They say that having children changes your priorities and perspectives.

Personally, I think its’ too early for me to say what, if anything, has changed.

Sure, I wish I could spend a ton of time with the little one. But I also have gotten antsy and wanted to get out of the house.

If it were an option or possiblity, I wonder how I would do being a stay-at-home dad/husband. I would probably have to be intentional about being active and doing things out in the community with the baby. Needless to say, I’ve got tons of respect for men and women who are full-time caregivers with their children at home.

We’ll see how it goes.

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About 3 Months Left

There’s about 3 months to go in this academic year.

That means I will be a Chief Resident for only another 3 months. My contract is coming to an end. The incoming Chief Residents have already been chosen and announced.

It some ways I feel like I know what a lame duck president must feel like.

The year has gone by faster than I could have anticipated. It’s been a period of satisfaction, personal & professional growth, and frustration. There have been ups and downs. Joys and disappointments.

My fellow residents who graduated from residency last year — well those who went on to work “real” jobs — have pulled in so much more money than I have this year. I’m sure they are enjoying the dough. Sure it is not has high as those surgical specialties. But it sure is a lot more than what I’ve been paid this year.

Still, I don’t regret it. Knowing what I do now, I would do it again.

There is a fraternity of sorts with former chief residents. And I’m proud to have joined those ranks.

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Attending Status

What’s in a title?

My ID badge now says “Attending Physician.”

I guess that’s my title now.

Last month I worked two hospitalist shifts. A week later I followed it up with 7 MOD shifts.

As a hospitalist I was responsible for my entire set of patients. I did get to work with one resident who was spending the month doing a hospitalist elective.

During the MOD shifts, I was the attending on one of our Internal Medicine teaching teams. I had a senior resident and two interns.

It is definitely a new feeling to have “the last say.” All my previous experiences on inpatient medicine had been as a resident. There were always things that I deferred to the attending. Like discharges home, for example.

As the attending, I had the final say. And it was a very different experience.

Serving as the attending on the teaching service was interesting as well. I remember frequently paging my senior residents to check in and make sure they did certain things. And as I did that, a light in my head turned on. I realized why I used to get several pages from attendings as they wanted to make sure I followed through on certain things.

When you have other people taking care of patients under your license and supervision, you start to pay attention.

Part of my job as a Chief Resident is doing a cetain number of MOD shifts. Seven shifts down. Looking forward this upcoming year. I have a lot to learn about medicine still. I have a lot to learn about teaching residents and students. I also have a lot of fun in store.

Stick around, dear reader. This should be a fun year.

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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.

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Helpless

I can remember a string of particularly busy nights. I was on the ICU service — sort of.

During our training, we have one month where we are assigned to “MICU NF.” The month has been described to me by previous residents as the worst month of your entire residency. There are two 3rd-year Internal Medicine residents assigned each month. They alternate weeks as the senior resident admitting patients to the medical intensive care unit (MICU). On the week you are not admitting at night, you spend your days in clinic. On the week when you are admitting at night, you spend 5 straight nights working. The last two days of the week are covered by other senior residents on their elective months so that you have a couple days off.

To be honest, the nights are “hit or miss.” After all, you cannot predict what comes through the door of the emergency department or when patients will decompensate on the wards. In addition to fielding calls from the ED for admission, you are responsible for carrying the Rapid Response pager. A rapid response can be called for any patient already admitted to the hospital. A staff member, usually the patient’s nurse, can call a rapid response on the ward when they feel their patient is decompensating and requires rapid intervention and/or transfer to the ICU for higher level of care.

On this particular night I was coming in to my 3rd night in a row. As I arrived I went to speak to the on-call MICU attending to find out our bed and team capacity for the night. She told me I had room for four patients. I nodded and went to the call-room.

Later that night, after I had already admitted one transfer patient I was sitting at my computer when the admission pager went off. It was the ED and they asked if I had a bed available. I answered “yes,” and proceeded to take down the information.

When I arrived in the Emergency Department I found “my” patient. I shall call her Dinah. She was intubated and off sedation. I glanced up at the monitor above her bed; her heart was racing. Her blood pressure was acceptable. I glanced over at the IV pumps, though, and noted that she was on levophed1.

I spoke with her RN to get a bit more detail about what had transpired since Dinah had arrived in the ED. I also spoke with Dinah’s husband (whom I shall refer to as Husband from here on out).

Dinah was young. She was in her late 30s. She and Husband had a couple teenaged children at home. For the last week she had been under the weather. But it was not totally unexpected. Others at home were also sick. They probably all had the same bug going around. But a few days prior she developed a productive cough and shortness of breath. These two symptoms did not improve and finally she agreed to come seek care.

When she arrived, she was hypoxic indicating that she wasn’t getting enough oxygen. She was started on supplemental oxygen and then subsequently was tried on BiPAP. Unable to tolerate that, the physicians in the ED decided to intubate her in order to mechanically ventilate2 her.

By the time I was called and arrived in the ED to evaluate Dinah, she had already coded once. That complicated matters even further. She had not woken up after the cardiac arrest. But it was difficult to tell at that point if this was due to the arrest itself or the medications that had been running to keep her sedated while she was on the mechanical ventilator.

Soon after arrival to the ICU, Dinah would code again. The team worked efficiently performing chest compressions, recording the events, and pushing medications as I called them out. After ten or so minutes we got a pulse back.

I updated the family who was still present at the hospital. The number of people had grown. Watery eyes looked at me for something — anything. They wanted hope. I wished that I could have confidently given that to them. But I couldn’t. By this time there were signs of multiple organ systems failing. She wasn’t producing any urine. She was in shock requiring vasopressors. She was in respiratory failure with a machine breathing for her. She had yet to show any signs of waking up after the cardiac arrest earlier despite being taken off medications that would sedate her.

I knew the prognosis was grim. I tried to explain that to them. I then asked if there had ever been any discussion of end-of-life care. Would she want to be on all of these machines? But it is very rare for a person in their 30s to have serious discussions of this nature. People don’t talk about dying — at least not their own deaths — at this age. They talk about growing old together with someone they love. They talk about watching their children grow up, go off to college, get married, and have children of their own.

Husband confirmed my suspicion. They had never discussed these issues before. For now, he insisted, we would continue doing everything we could — including keeping her a Full Code3. I didn’t argue with the decision. Had Dinah been 95, I may have. But Dinah was in her 30s. She was supposedly healthy just a week ago.

Thinking back to that night I am not sure when I started to sense my own helplessness. I think it hit me after Dinah arrived on the unit from the ED and I started counting up the organ systems that had failed. It definitely hit me after she coded again.

For the rest of the night she continued to decompensate. She was dying in front of me. And all I could do was throw temporizing measures at the situation. Her oxygen saturation kept dropping. The respiratory therapist kept increasing the support provided by the ventilator. Her blood pressure kept sliding down, slowly but surely. I kept ordering additional vasopressors until she was maxed out on 4 different ones. I think the helplessness hit me with each vasopressor I ordered.

Of course, the helplessness hit me every time I turned to the family to offer an update. Every update was negative. I don’t think I delivered an ounce of “good” news that night. I watched as family streamed into the room two-by-two (per ICU policy) with tears streaking down their faces.

Before my shift ended Dinah passed away. She did so with her family present, surrounding her hospital bed.

And I stood by, helpless.

  1. Levophed, or norepinephrine, is an IV medication classed as a “vasopressor.” It helps by raising the blood pressure in a patient with hypotension or low blood pressure. This class of drugs is often referred to as “pressors” for short. []
  2. Mechanical ventilation involves an advanced airway, typically a tube that goes in through the mouth and passed the vocal cords. This tube is attached to a machine — a ventilator — that is able to breathe for a patient by pumping oxygenated air into her lungs. It can also sense when a patient is trying to take a breath and assist. []
  3. When a patient’s code status is “Full Code,” in the event of cardiopulmonary arrest, a Code Blue is called. Chest compressions, shocks (if appropriate for the cardiac rhythm), and medications are administered in the hopes of “bringing the patient back.” []
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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?

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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.