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.



On Teaching

The following is something I wrote in 2009 while still a medical student:

Teaching is a hard thing. By teaching I don’t mean explaining or instructing. Take, for example, teaching basketball to someone. Telling someone the rules of the game is not, to me, teaching them how to play basketball. Explaining what the rules mean and how and when they apply is not teaching either. Teaching involves more. It is showing someone how to dribble the ball, demonstrating the correct form, and then helping the student develop these skills. Teaching is not merely conveying knowledge. It is imparting excellence — or, at the very least, competence in a particular area or field.

Teaching involves lifting a student up with compliments while simultaneously providing criticism that is at the same time constructive, painful, and humbling. Delivering these two — compliment and criticism — can be tricky. How does one find the right balance? It’s unfortunate that there is no formula. Each person is different. The combination of compliment and criticism that motivates and inspires one student could very well devastate and discourage another. Maybe the truly amazing teachers are able to read their students and expertly walk that fine line.

In the absence of truly amazing teachers, or truly amazing teachers with plenty of time to spend with us, a student must resort to other means of attaining competence. One alternative is learning from multiple teachers. Good teachers have different methods, techniques, and personalities. Each one can provide a different, yet helpful angle.

As this academic year inches closer and closer to an end, my mind seems to frequently wander to the future. One of the things I think about is my position as one of the chief residents next year. I hope that I will able to be a good teacher. I may even be willing to settle for an “ok” teacher too.

Maybe I am getting ahead of myself. Maybe I should just concentrate on learing as much as I can as a resident.

Teaching, I feel, is such a great responsibility. Especially when you are training people to take care of patients. The good thing is that I won’t bear this responsibility on my own. I will merely be a cog in a larger wheel; I will only be one part in a larger system. There will be plenty of seasoned attendings who will gladly teach the residents, and I am sure myself as well.

Teaching, I hope, is something that one can learn. And I hope that through the next year I will be able to develop my own teaching style. I’m sure I won’t be able to develop in a year — it’ll take time. But I do hope I am able to make a significant evolutionary leap in my development as an educator and teacher.


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.


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.


I’m Still Here

It’s been so long since I have posted. According to the site, the last post was back in November. I’m still here. And I’m still alive and surviving internship.

I plan to continue blogging. I will just need time to sit down and write. Often, I get home and just want to eat and sleep. But I will need to begin writing again.

There are so many stories and experiences to share.

I will also have to update the header image of this blog. I’m not quite in medical school anymore.

This week I have off. It is my 2nd (of 3) week of vacation. Unfortunately it cannot be a true vacation — I’m trying to use it to study for Step 3 which I am taking in a few weeks. And even when I am not actively studying, my mind is telling me that I SHOULD be studying.

I feel like a student again. But only because I have a Step 3 test to study for.

Well, until next time…

I will continue to write. I will continue to blog. Stay tuned.


Dr. W?

I was waiting in the lobby of the building. I had a 9:30 appointment with human resources. I knew they wanted to take a picture for my ID badge. I assumed I would be given some other info as well. I had already previously completed a bunch of new hire “paperwork” online.

As I sat and waited (im)patiently in the lobby I started playing with my phone. Then I heard a male voice call out, “Dr. W?” (And he did a decent job of pronouncing my last name, too!)

I almost laughed out loud. But I stood up and went to meet him, all the while trying so hard not to have a weird grin.

It’s still weird to hear someone seriously call me “doctor.” Better get used to it though. I start on service in about two weeks…


Medicine & Death

I just found this quote by Dr. Atul Gawande and I wanted to share it:

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.