Sunday, December 16, 2007
Tower Apartments
We just bought a new camera and I thought I'd try to get a picture of the tower behind the building, which is lit up for the holidays.
Friday, December 14, 2007
Sicko
After months of intending to see the movie, Diana and I finally rented it at the movie store. Like other Michael Moore films, it is entirely anectodal, too emotional to allow the viewer to actually consider the issues (without extreme amounts of guilt, anyway), and utterly aggravating. Still, you should see it.
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
Sunday, November 25, 2007
Code Blue
Last week I participated in my first code. First a word on codes in the hospital.
Each night my team is on call, we carry code pagers, which as the name suggests, only go off when someone is coding. A code is called when a patient stops breathing, or either doesn't have a pulse or has a life-threatening arryhthmia. When the code pager goes off, there are a series of distinctive beeps, and then the operator says what kind of code it is, and where in the hospital it is happening. When we are on call overnight, our team is responsible for any code on the wards or in the ICU, which means my senior resident (who is a second year resident) is responsible for running the code. Every one on the team is supposed to have a designated role which ideally has been discussed before the pager goes off. Obviously, code pages are urgent, and when the pagers sounds, everyone goes running.
It was about 4:45 when I was awoken from sleep by the code pager. I took one second to make sure I wasn't hallucinating, and then put on my shoes as fast as I could, grabbed my scrub top, and took off out of the call rooms running toward the ICU. Unfortunately, the medical student call rooms are across the hospital from there, and after a rapid trip up the stairs, I found the ICU (running up stairs in Queen Anne definitely paid off).
It wasn't hard to find the code. The patient's room was overflowing with nurses, respiratory therapists, and numerous other people. I caught the eye of my senior resident right away, and he told me to put gloves on and break the nurse who was doing chest compressions. He told me to do them like her, but faster.
Before this, I had only done chest compressions on mannequins in CPR class. You hear that it is hard, but it doesn't really sink in until you have to do it. As I did compressions, I had no idea what was going on with the patient, nor had I ever seen him before. I focused on what I was doing and kept my ears open for further instructions. It was chaos around me. Hovering over everyone was my senior resident and a cardiology resident, managing the chaos, trying to determine why the patient is coding, and what algorithm they should be following to correct it.
Fortunately, the residents did figure it out, the patient was given some medications (this is another story), and he soon had a pulse again. I no longer had to do compressions, which was good because I was exhausted. From start to finish, the code took about 25 minutes (I did compressions for only a couple minutes) and as far as I know, the patient stabilized and recovered.
It was my first code, and though it ended well, it is a traumatic, even brutal, experience for the patient. It's hard to convey the chaos of the code, with the alarming sounds of the monitors, the resident giving orders, the nurses giving meds, the anesthesiologist having a hard time intubating the patient, the surgery resident seemingly stabbing blindly into the patient's groin with a giant needle, and the patient's unconscious body absorbing chest compressions and these other insults. Fortunately for everyone, this code ended well. It's frightening to think that in a couple years, I'll be a resident in the hospital overnight, responsible for running a code like that one. It's exciting but intimidating to realize how much we're expected to learn in a short time.
Each night my team is on call, we carry code pagers, which as the name suggests, only go off when someone is coding. A code is called when a patient stops breathing, or either doesn't have a pulse or has a life-threatening arryhthmia. When the code pager goes off, there are a series of distinctive beeps, and then the operator says what kind of code it is, and where in the hospital it is happening. When we are on call overnight, our team is responsible for any code on the wards or in the ICU, which means my senior resident (who is a second year resident) is responsible for running the code. Every one on the team is supposed to have a designated role which ideally has been discussed before the pager goes off. Obviously, code pages are urgent, and when the pagers sounds, everyone goes running.
It was about 4:45 when I was awoken from sleep by the code pager. I took one second to make sure I wasn't hallucinating, and then put on my shoes as fast as I could, grabbed my scrub top, and took off out of the call rooms running toward the ICU. Unfortunately, the medical student call rooms are across the hospital from there, and after a rapid trip up the stairs, I found the ICU (running up stairs in Queen Anne definitely paid off).
It wasn't hard to find the code. The patient's room was overflowing with nurses, respiratory therapists, and numerous other people. I caught the eye of my senior resident right away, and he told me to put gloves on and break the nurse who was doing chest compressions. He told me to do them like her, but faster.
Before this, I had only done chest compressions on mannequins in CPR class. You hear that it is hard, but it doesn't really sink in until you have to do it. As I did compressions, I had no idea what was going on with the patient, nor had I ever seen him before. I focused on what I was doing and kept my ears open for further instructions. It was chaos around me. Hovering over everyone was my senior resident and a cardiology resident, managing the chaos, trying to determine why the patient is coding, and what algorithm they should be following to correct it.
Fortunately, the residents did figure it out, the patient was given some medications (this is another story), and he soon had a pulse again. I no longer had to do compressions, which was good because I was exhausted. From start to finish, the code took about 25 minutes (I did compressions for only a couple minutes) and as far as I know, the patient stabilized and recovered.
It was my first code, and though it ended well, it is a traumatic, even brutal, experience for the patient. It's hard to convey the chaos of the code, with the alarming sounds of the monitors, the resident giving orders, the nurses giving meds, the anesthesiologist having a hard time intubating the patient, the surgery resident seemingly stabbing blindly into the patient's groin with a giant needle, and the patient's unconscious body absorbing chest compressions and these other insults. Fortunately for everyone, this code ended well. It's frightening to think that in a couple years, I'll be a resident in the hospital overnight, responsible for running a code like that one. It's exciting but intimidating to realize how much we're expected to learn in a short time.
Ski season!
There's been some snow in the mountains and some of the highest mountain passes haven't closed yet for the winter, so my friend David and I thought we'd check out the early season conditions. Shin deep powder and a blue bird day. Tough to beat for November.
I've figure out how to add a slide show of pictures, so you can view them here or click on them to be taken to another website.
I've figure out how to add a slide show of pictures, so you can view them here or click on them to be taken to another website.
Monday, November 12, 2007
Life at the VA
These days I'm at the VA hospital in Seattle, having moved on from Harborview (I'm still on my Internal Medicine rotation). It's a totally different patient population, but the vets are friendly, tend to see you as their doctor even though you're a student, and they usually have chronic diseases like emphysema or heart failure. So far I have only had male patients at the VA and they are generally over 65. My team has not had any patients who are returning from Iraq or Afghanistan, and I think this is because there is a large military hospital south of Seattle by Fort Lewis.
In my experience so far, the patients at the VA tend to be a little sicker than at Harborview, but this is probably because they are usually older and because unlike at Harborview, our team at the VA has patients in the ICU.
This week two of the patients on our team died. I was with one of the interns to pronounce the patient dead. This requires making sure that the person's pupils are not reactive to light, and then listening for heart and lungs sounds. Both of the patient's on our service had severe liver disease, and they and their families had agreed that they receive only "comfort care". In addition to being DNR (meaning that if they stop breathing or their heart stops, we will not perform CPR or go to extreme measures to prolong their life), they are taken off all monitoring and are made comfortable assuming by treating any pain that they may be in. These people are usually extremely sick, with nothing that can be done to cure them or restore some quality of life. Making them "comfort care" allows them to die naturally, without the trauma of a code (emergent resusitation), which usually breaks ribs, can puncture lungs, can be tragic for the family to see. Moreover, codes usually either don't revive the patient, or lead to a proctracted period of respiratory support in the ICU, with the family having to decide what to do.
When I was on call almost two weeks ago, I admitted a patient who had renal failure which was caused by urinary retention due to benign prostatic hypertrophy (BPH - watch the evening news and you'll see ten commercials for BPH drugs). He also had blood in his urine and was severely anemic. He was stable when he was admitted, and basically all we had to do for him was drain the 3L (that is a massive amount, by the way) of urine out of his bladder with a catheter to relieve the pressure on his kidneys and then watch his renal function hoping that the damage hadn't been permanent. One of the great advantages of being a medical student is that I have lots of time to talk to the patients, and I had gotten to know this gentleman very well. Once I got over the fact that he was originally from Canada, I learned that he had been quite an athlete and outdoorsman, and had done extensive mountaineering and hunting in Alaska. He told me he decided at a young age that he would live for love and adventure and had been successful on both accounts. He had recently been working as a gardener (he is 74), but had experienced gradually worsening fatigue in the past six months or so. As you might infer, I took quite a liking to this gentleman.
That night while I was reading up on renal failure and hematuria, his urine became more and bloody until the bag which his collected it looked like it was filled with blood. He continued to feel fine, but when his labs came back in the morning, he had become dangerously anemic (for you medical types, his Hct dropped from 25 to 15) and needed to be transferred to the ICU. It was a little harrying to discuss the new plan with my senior resident, which now focused on immediate planning should he go into shock. This entailed placing two large-bore IVs, one in each arm, calling the blood bank and writing his orders for ICU transfer. This was my first patient whose condition I watched rapidly deteriorate and it affected me more than I would have anticipated. Meanwhile, the patient himself was nonplussed and without new symptoms. I think he realized that I was more alarmed than he, and was even a little amused by this.
We transfused several units of blood into him, and several days later his urine cleared. His kidney function has improved, but not to normal and now he is waiting to be seen by the urologists to determine the cause of his bleeding.
Experiences like this are one reason I would not want to be an ER physician. It's a special experience to take care of patients throughout their time in the hospital, to see them every morning, ask them how their doing, check their labs every day and modify the plan. Sometimes when you meet them, you can't make a diagnosis, but over the course of hours or days, the pieces start to fall into place. Sometimes the patient gets better, sometimes you can only stabilize them, and sometimes they are found to have a chronic disease (like renal failure) or worse, a terminal diagnosis. No matter what, it's a unique and privileged experience to be with a patient as they go through what is often a life-changing experience.
In my experience so far, the patients at the VA tend to be a little sicker than at Harborview, but this is probably because they are usually older and because unlike at Harborview, our team at the VA has patients in the ICU.
This week two of the patients on our team died. I was with one of the interns to pronounce the patient dead. This requires making sure that the person's pupils are not reactive to light, and then listening for heart and lungs sounds. Both of the patient's on our service had severe liver disease, and they and their families had agreed that they receive only "comfort care". In addition to being DNR (meaning that if they stop breathing or their heart stops, we will not perform CPR or go to extreme measures to prolong their life), they are taken off all monitoring and are made comfortable assuming by treating any pain that they may be in. These people are usually extremely sick, with nothing that can be done to cure them or restore some quality of life. Making them "comfort care" allows them to die naturally, without the trauma of a code (emergent resusitation), which usually breaks ribs, can puncture lungs, can be tragic for the family to see. Moreover, codes usually either don't revive the patient, or lead to a proctracted period of respiratory support in the ICU, with the family having to decide what to do.
When I was on call almost two weeks ago, I admitted a patient who had renal failure which was caused by urinary retention due to benign prostatic hypertrophy (BPH - watch the evening news and you'll see ten commercials for BPH drugs). He also had blood in his urine and was severely anemic. He was stable when he was admitted, and basically all we had to do for him was drain the 3L (that is a massive amount, by the way) of urine out of his bladder with a catheter to relieve the pressure on his kidneys and then watch his renal function hoping that the damage hadn't been permanent. One of the great advantages of being a medical student is that I have lots of time to talk to the patients, and I had gotten to know this gentleman very well. Once I got over the fact that he was originally from Canada, I learned that he had been quite an athlete and outdoorsman, and had done extensive mountaineering and hunting in Alaska. He told me he decided at a young age that he would live for love and adventure and had been successful on both accounts. He had recently been working as a gardener (he is 74), but had experienced gradually worsening fatigue in the past six months or so. As you might infer, I took quite a liking to this gentleman.
That night while I was reading up on renal failure and hematuria, his urine became more and bloody until the bag which his collected it looked like it was filled with blood. He continued to feel fine, but when his labs came back in the morning, he had become dangerously anemic (for you medical types, his Hct dropped from 25 to 15) and needed to be transferred to the ICU. It was a little harrying to discuss the new plan with my senior resident, which now focused on immediate planning should he go into shock. This entailed placing two large-bore IVs, one in each arm, calling the blood bank and writing his orders for ICU transfer. This was my first patient whose condition I watched rapidly deteriorate and it affected me more than I would have anticipated. Meanwhile, the patient himself was nonplussed and without new symptoms. I think he realized that I was more alarmed than he, and was even a little amused by this.
We transfused several units of blood into him, and several days later his urine cleared. His kidney function has improved, but not to normal and now he is waiting to be seen by the urologists to determine the cause of his bleeding.
Experiences like this are one reason I would not want to be an ER physician. It's a special experience to take care of patients throughout their time in the hospital, to see them every morning, ask them how their doing, check their labs every day and modify the plan. Sometimes when you meet them, you can't make a diagnosis, but over the course of hours or days, the pieces start to fall into place. Sometimes the patient gets better, sometimes you can only stabilize them, and sometimes they are found to have a chronic disease (like renal failure) or worse, a terminal diagnosis. No matter what, it's a unique and privileged experience to be with a patient as they go through what is often a life-changing experience.
Thriller
This post is a shout-out to Diana and her crazy ways. On October 27th, about 100 people in Seattle, including Diana and her friend Allison, performed a choreographed dance to the Michael Jackson classic, "Thriller". They joined a couple thousand other people around the world who did the dance at the same time in an attempt to break the world record for most people dancing at the same time. Apparently, 200,000 Canadian children danced the hokey-pokey at the same time a couple years ago, so they didn't break the record. They held practices once a week for two months to learn the over-six minute dance and then they performed at a couple locations in Seattle, including the Seattle YMCA and Westlake center. Oh yeah, and if you're not familiar with Thriller, the dancers are supposed to all be zombies.
Here's a link to a video of the dance at Westlake Center.
http://youtube.com/watch?v=NN-o7a93i0M
Here's a link to a video of the dance at Westlake Center.
http://youtube.com/watch?v=NN-o7a93i0M
Saturday, October 27, 2007
My people
(For reference, "Medicine" refers to internal medicine as a specialty; "medicine" to the field in general. Hopefully that will prevent some confusion.)
I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.
For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.
Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.
I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.
The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.
Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.
I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.
For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.
Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.
I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.
The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.
Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.
Wednesday, October 10, 2007
To treat the patient, communicate first . . .
One of the great things about medicine is that you meet so many different kinds of people, and your job requires that you learn something about them.
When I was on call recently, I went down to the ER with the intern on my team to see a man who needed to be admitted for new onset diabetes. Diabetes is one of the most common diseases to see in medicine, certainly top 5 at least. What is less common is to meet a grown man who is deaf (from birth), mute, illiterate, and who does not know American Sign Language (ASL). Think about that for a minute. This man neither hears words nor sees their written representations. Can he have any conception of language? When I met him he was with a "patient advocate", a social worker who also happens to be deaf. They were able to communicate somewhat, primarily through gestures and picture cards, but since he was mute, his interpretation of what the patient said was communicated to me through writing. I found this situation sort of intriguing, but it's also frustrating because he was a sick man with the onset of a new chronic disease which requires complex management for the rest of his life. How do you explain to someone who communicates through gestures and pictures that the cells in his body have become insensitive to insulin, which is required for those cells to utilize glucose, which are needed to make energy? What are cells? What is glucose? What the hell is energy?
People sometimes ask me, half-joking, if my life is anything like what they see in Grey's Anatomy. Rest assured, it is not. I have not seen anyone making out in the on-call room, my scrubs are not tailored just for me, and not every patient I see requires surgery. But I have seen some cases that are strange or interesting enough to be on tv, and I have met some people who I just as easily could have seen on tv.
One final important note:
Red Sox 1, Indians 0
Yankees playing golf
When I was on call recently, I went down to the ER with the intern on my team to see a man who needed to be admitted for new onset diabetes. Diabetes is one of the most common diseases to see in medicine, certainly top 5 at least. What is less common is to meet a grown man who is deaf (from birth), mute, illiterate, and who does not know American Sign Language (ASL). Think about that for a minute. This man neither hears words nor sees their written representations. Can he have any conception of language? When I met him he was with a "patient advocate", a social worker who also happens to be deaf. They were able to communicate somewhat, primarily through gestures and picture cards, but since he was mute, his interpretation of what the patient said was communicated to me through writing. I found this situation sort of intriguing, but it's also frustrating because he was a sick man with the onset of a new chronic disease which requires complex management for the rest of his life. How do you explain to someone who communicates through gestures and pictures that the cells in his body have become insensitive to insulin, which is required for those cells to utilize glucose, which are needed to make energy? What are cells? What is glucose? What the hell is energy?
People sometimes ask me, half-joking, if my life is anything like what they see in Grey's Anatomy. Rest assured, it is not. I have not seen anyone making out in the on-call room, my scrubs are not tailored just for me, and not every patient I see requires surgery. But I have seen some cases that are strange or interesting enough to be on tv, and I have met some people who I just as easily could have seen on tv.
One final important note:
Red Sox 1, Indians 0
Yankees playing golf
Sunday, October 7, 2007
On Call
Tomorrow I'm on call, and I thought I would clarify what that means.
I always thought that when you were on call, you brought your pager home and went into the hospital if you were paged. I was very wrong. What being "on call" means is that between 12:30 p.m. and 4:30 a.m. my team admits any patients who have to come into the hospital (only on the Medicine service, though, surgical pts are admitted to the Surgery team on call). 95% of the patients we admit come through the Emergency Room.
So this is how it happens: my senior resident gets a call from the ER that someone needs to be admitted. That person might have a serious pneumonia, or bowel obstruction, or they are vomiting blood, or cellulitis, or any number of other medical problems. (Very sick and unstable patients are admitted to the ICU). Anyway, the senior resident calls the intern on our team, who grabs me, and we go down to the ER and interview the patient. After that, we write some admission orders, which includes practical information like where the patient will go, how often their vital signs should be taken, what meds they will take, what they can eat, etc. I then have to write a complete history, a write-up of their physical exam, and then a discussion of the patient's diagnoses and what I intend to do so make them feel better. Right now when I'm on call, I admit two patients and "follow" them until they are discharged. The morning after they are admitted, I present their story at the patient's bedside to the rest of my medical team, and we discuss the plan. Every morning after that I give my team an update and we make any changes until the patient goes home.
The last time I was on call, I admitted my two patients and was done with my work around 3:30. At that point, I went to the on-call room where there are some beds, and slept for a few hours before rounds at 7.
In spite of the lack of sleep, being on call is usually fun. It's exciting, it's busy, it's unpredictable. In some ways, it's a lot like fishing. Early in the night it's pretty low key, you're waiting for something to happen, and then a call comes from the ER. Our team admits around 10 patients per night, and I'm only really involved for two, so when someone else admits a patient, it's just like when someone your fishing with catches a big one right next to you. There's more certainty on call than when you go fishing, because it's almost a certainty that I'll admit a patient. Then when you get a call, there' s a little time to wonder what's on the end of the line. Even after you've learned a little about the patient from the ER team, you really don't know what to expect until you meet them.
This brings me to one of those dirty little secrets in medicine: the more sick the patient is, the rarer their condition, the more exciting that patient is. I try to be very careful with my language, but if you ever hear a doctor or medical student say they have a "very interesting patient", that patient is either very sick, has a very rare disease, is unique for some other reason (like they were injured in a very unusual way, for example), or some combination. The last time I was on call one of my patients had a very rare skin and muscle disorder along with diverticulitis (a potentially serious infection of the colon). There's definitely part of your brain that is trained by medical school to think, "sweet, this guy has dermatomyositis! Are those Gottron's papules?!" Dermatomyositis is not usually a life-threatening illness, but thinking something like "wow, that woman has necrotizing fasciitis!" is a bit more troubling because it is often fatal. You see the problem.
In medical school we learn about disease so that we can help real people, but there is something about that learning that depersonalizes patients. Every medical student wants to see a case of necrotizing fasciitis, but no medical student wants any person to have necrotizing fasciitis. I resolve this dilemna by reminding myself that disease is inevitable, and that if it is to exist, I should know about it. The key is to remind yourself that it is the patient who has the disease, not the other way around. That doctors have to remind themselves of this seems ridiculous to people outside the medical profession but it frequently happens.
As I mentioned, I'm on call tomorrow, so I need my sleep tonight. I'll post again soon.
I always thought that when you were on call, you brought your pager home and went into the hospital if you were paged. I was very wrong. What being "on call" means is that between 12:30 p.m. and 4:30 a.m. my team admits any patients who have to come into the hospital (only on the Medicine service, though, surgical pts are admitted to the Surgery team on call). 95% of the patients we admit come through the Emergency Room.
So this is how it happens: my senior resident gets a call from the ER that someone needs to be admitted. That person might have a serious pneumonia, or bowel obstruction, or they are vomiting blood, or cellulitis, or any number of other medical problems. (Very sick and unstable patients are admitted to the ICU). Anyway, the senior resident calls the intern on our team, who grabs me, and we go down to the ER and interview the patient. After that, we write some admission orders, which includes practical information like where the patient will go, how often their vital signs should be taken, what meds they will take, what they can eat, etc. I then have to write a complete history, a write-up of their physical exam, and then a discussion of the patient's diagnoses and what I intend to do so make them feel better. Right now when I'm on call, I admit two patients and "follow" them until they are discharged. The morning after they are admitted, I present their story at the patient's bedside to the rest of my medical team, and we discuss the plan. Every morning after that I give my team an update and we make any changes until the patient goes home.
The last time I was on call, I admitted my two patients and was done with my work around 3:30. At that point, I went to the on-call room where there are some beds, and slept for a few hours before rounds at 7.
In spite of the lack of sleep, being on call is usually fun. It's exciting, it's busy, it's unpredictable. In some ways, it's a lot like fishing. Early in the night it's pretty low key, you're waiting for something to happen, and then a call comes from the ER. Our team admits around 10 patients per night, and I'm only really involved for two, so when someone else admits a patient, it's just like when someone your fishing with catches a big one right next to you. There's more certainty on call than when you go fishing, because it's almost a certainty that I'll admit a patient. Then when you get a call, there' s a little time to wonder what's on the end of the line. Even after you've learned a little about the patient from the ER team, you really don't know what to expect until you meet them.
This brings me to one of those dirty little secrets in medicine: the more sick the patient is, the rarer their condition, the more exciting that patient is. I try to be very careful with my language, but if you ever hear a doctor or medical student say they have a "very interesting patient", that patient is either very sick, has a very rare disease, is unique for some other reason (like they were injured in a very unusual way, for example), or some combination. The last time I was on call one of my patients had a very rare skin and muscle disorder along with diverticulitis (a potentially serious infection of the colon). There's definitely part of your brain that is trained by medical school to think, "sweet, this guy has dermatomyositis! Are those Gottron's papules?!" Dermatomyositis is not usually a life-threatening illness, but thinking something like "wow, that woman has necrotizing fasciitis!" is a bit more troubling because it is often fatal. You see the problem.
In medical school we learn about disease so that we can help real people, but there is something about that learning that depersonalizes patients. Every medical student wants to see a case of necrotizing fasciitis, but no medical student wants any person to have necrotizing fasciitis. I resolve this dilemna by reminding myself that disease is inevitable, and that if it is to exist, I should know about it. The key is to remind yourself that it is the patient who has the disease, not the other way around. That doctors have to remind themselves of this seems ridiculous to people outside the medical profession but it frequently happens.
As I mentioned, I'm on call tomorrow, so I need my sleep tonight. I'll post again soon.
Monday, October 1, 2007
Medicine introduction
I don't have much time right now, but I've just finished my Psychiatry rotation and now I'm on Internal Medicine. Again, I'm at Harborview, the large public hospital here in Seattle.
I know a lot of people are confused about what Internal Medicine is, but for now I'll just say that these are the doctors who take care of you if you have to be admitted to the hospital for common problems likes pneumonia, or pyelonephritis (kidney infection), heart attack, stroke, etc. Of if you're at Harborview your patient may have many of these problems concurrently. In just one day, I've been amazed how complicated some of the patients are. Medicine doctors often consult other specialties (infectious disease, neurology, orthopedics, surgery, etc), but ultimately it is usually the medicine doc who has to put it all together, incorporating the recommendations of consultants to form a master plan.
More soon but I need some sleep.
I know a lot of people are confused about what Internal Medicine is, but for now I'll just say that these are the doctors who take care of you if you have to be admitted to the hospital for common problems likes pneumonia, or pyelonephritis (kidney infection), heart attack, stroke, etc. Of if you're at Harborview your patient may have many of these problems concurrently. In just one day, I've been amazed how complicated some of the patients are. Medicine doctors often consult other specialties (infectious disease, neurology, orthopedics, surgery, etc), but ultimately it is usually the medicine doc who has to put it all together, incorporating the recommendations of consultants to form a master plan.
More soon but I need some sleep.
Monday, September 24, 2007
every doctor needs to know about . . .
Suicide.I'm in the last few days of my psych rotation and I realized I can't finish without saying something about suicide. I've switched to a different unit, where there is much less psychosis, and much more suicidality and substance use. Here are some quick facts about suicide:
- 9th leading cause of death in the US (30,000 people per year).
- 3rd leading cause of death in individuals 15-24, accounting for 13% of deaths in this age group (following accidents, 46%; and homicides, 15%)
- 95% of people who commit suicide have an existing psychiatric diagnosis.
Like every Catholic kid, I was taught that suicide is the worst sin a person can commit since there is no opportunity to ask forgiveness. I remember it being presented as a choice people make, akin to stealing or adultery. But like everything in life, it's much more complicated. One of my patients (who had paced across the bridge) did incredibly well during his hospitalization. His depression was treated, he participated in therapeutic groups, he sobered up, and he was discharged into an inpatient alcohol treatment program. Unfortunately, there is no evidence that inpatient treatment actually prevents suicide, and studies have shown that psychiatrists can't predict which individuals with suicidal ideation will go on to attempt. Thus, although it is one of the most common problems seen in psychiatry and primary care, it remains one of the most baffling. Every depressed patient should be asked about suicide, and every doctor should know the right questions to ask.
Tuesday, September 18, 2007
some northern exposure
This weekend I got a break from the psych wards with two friends and we climbed Mount Daniel in the Central Cascades. Nothing too tricky in terms of the climb, but spectacular views and we barely beat the weather that came in the night after we summited. When you get a clear day like this in the Cascades it's something special.
The picture above gives you some northern exposure (find out why this is a cheesy pun below). You can see to Canada, including Mt. Baker over my right shoulder and Glacier Peak over my left. The picture below is taken looking south, with Mt. Rainier beyond the lakes in the distance.
This might have been the last trip of it's kind this summer, as fall has unofficially arrived in Seattle. It's crisp and rainy, and it's almost time to turn on the heat in the building.
One other bonus of this trip is that in order to get to the trailhead, you have to drive through Roslyn, WA, which as it turns out is where Northern Exposure (the tv show) was filmed. We ate at The Brick, a great bar in town and stopped by the local brewery. Worth the trip even if you can't do the climb.
The picture above gives you some northern exposure (find out why this is a cheesy pun below). You can see to Canada, including Mt. Baker over my right shoulder and Glacier Peak over my left. The picture below is taken looking south, with Mt. Rainier beyond the lakes in the distance. 
This might have been the last trip of it's kind this summer, as fall has unofficially arrived in Seattle. It's crisp and rainy, and it's almost time to turn on the heat in the building.
One other bonus of this trip is that in order to get to the trailhead, you have to drive through Roslyn, WA, which as it turns out is where Northern Exposure (the tv show) was filmed. We ate at The Brick, a great bar in town and stopped by the local brewery. Worth the trip even if you can't do the climb.
Monday, September 17, 2007
Yes, they still do that . . . . and it works
This morning I went with one of my patients for his ECT, or electroconvulsive therapy. Yes, it is probably what you're thinking it is, though it may not look like what you imagine. So what is it? Most simply, it is when a patient's brain receives a series of electronic pulses which cause a seizure, and for unknown reasons, that seizure causes changes in the brain which are known to be effective for certain psychiatric conditions. In fact, studies have shown that it is the most effective treatment for refractory (meaning not responsive to other treatment) depression.
Here's what happens: the patient goes down to the anesthesia recovery room where they get an iv and have their vital signs monitored. A series of sensors which monitor brain electrical activity are put on the patient's head (EEG), and an adhesive pad is put on their temple. The anesthesiologist administers one drug for pain, another to make the patient unconscious, and the third to paralyze him. At this point the patient cannot breathe on his own and has to be "bagged". The psychiatrist, who has already adjusted the settings of the device which supplies the shock, then pushes a button and the shock begins. The patient then has a seizure, which since he is paralyzed, is seen primarily on the readout on the EEG, but can also be seen by sustained contractions of some facial muscles and neck. The seizure lasts from 25 to 90 seconds and the "quality" of the seizure correlates with the success of the treatment. After a few minutes, the patient awakens, remembers nothing, and suffers no ill effects aside from a temporary difficulty with memory acquisition.
How ECT works is not known exactly, but as it was explained to me, there are two main theories. The first is that the brain is like the heart, and like cardiac myocytes, neurons work in synchronous electrical harmony which can sometimes become out of sync. Like shocking a heart beating arrythmically, "shocking" the brain may re-synchronize neuronal electrical activity (an oversimplification of course). The second theory is that the increase in some neurotransmitters which is clearly seen after the seizure is responsible for the therapeutic effect. Regardless, it is well recognized that ECT is the best treatment for depression and is an excellent option for some chronic, severely depressed patients.
You'll no doubt be happy to know that ECT these days is never performed against the patient's will and doesn't resemble what you remember from One Flew Over The Cuckoos Nest. But it can be an excellent choice for some patients and it still done every day at Harborview.
Here's what happens: the patient goes down to the anesthesia recovery room where they get an iv and have their vital signs monitored. A series of sensors which monitor brain electrical activity are put on the patient's head (EEG), and an adhesive pad is put on their temple. The anesthesiologist administers one drug for pain, another to make the patient unconscious, and the third to paralyze him. At this point the patient cannot breathe on his own and has to be "bagged". The psychiatrist, who has already adjusted the settings of the device which supplies the shock, then pushes a button and the shock begins. The patient then has a seizure, which since he is paralyzed, is seen primarily on the readout on the EEG, but can also be seen by sustained contractions of some facial muscles and neck. The seizure lasts from 25 to 90 seconds and the "quality" of the seizure correlates with the success of the treatment. After a few minutes, the patient awakens, remembers nothing, and suffers no ill effects aside from a temporary difficulty with memory acquisition.
How ECT works is not known exactly, but as it was explained to me, there are two main theories. The first is that the brain is like the heart, and like cardiac myocytes, neurons work in synchronous electrical harmony which can sometimes become out of sync. Like shocking a heart beating arrythmically, "shocking" the brain may re-synchronize neuronal electrical activity (an oversimplification of course). The second theory is that the increase in some neurotransmitters which is clearly seen after the seizure is responsible for the therapeutic effect. Regardless, it is well recognized that ECT is the best treatment for depression and is an excellent option for some chronic, severely depressed patients.
You'll no doubt be happy to know that ECT these days is never performed against the patient's will and doesn't resemble what you remember from One Flew Over The Cuckoos Nest. But it can be an excellent choice for some patients and it still done every day at Harborview.
Tuesday, September 11, 2007
From the roof
I took this picture today from the roof of our building because the weather has been nearly perfect for the past few days, and as you can see, there's quite a view. Unfortunately, we rarely go up on the roof since it's not meant for people to hang out on. This is looking south from our neighborhood (Queen Anne) toward downtown. If you look closely behind the skyscrapers, you can see the edges of Mt Rainier, about 80 miles away.
Thursday, September 6, 2007
Of interest
1. Check out pandora.com. It's a great free website which lets you create your own radio station based on music you like. You enter an artist or song, and then it chooses other songs for you based on similar tonal patterns or other musical themes. You rate each song as it comes up, and it chooses new songs based on that history. It's wild.
2. The Seattle PI reported today that Darrel Everybodytalksabout (real name, I swear), a death row inmate here in WA who was convicted of murder, had his conviction unanimously overturned by the state supreme court. Why do I mention this? Because when Diana was a senior at UW, she tutored him at the King County Jail and he always insisted he was innocent. Incidentally, he was a "transient" at the time of his arrest. Click here to read the story.
2. The Seattle PI reported today that Darrel Everybodytalksabout (real name, I swear), a death row inmate here in WA who was convicted of murder, had his conviction unanimously overturned by the state supreme court. Why do I mention this? Because when Diana was a senior at UW, she tutored him at the King County Jail and he always insisted he was innocent. Incidentally, he was a "transient" at the time of his arrest. Click here to read the story.
A moment on my soapbox, if you will
One of the principal goals for the psychiatry clerkship is to learn how to interview patients with mental illness. It's difficult to ask someone if they are hallucinating or if they are thinking about killing themself. How do you ask those questions when someone thinks your Ed Norton?
For those of you who don't know (or don't remember), I worked for one year at a daytime homeless shelter in Tacoma, WA called Nativity House. Before I started, my biggest fear was working with the mentally ill - I thought of them as unpredictable at best, and violent at worst. I had no idea how I was supposed to talk to them. What I soon realized is that you talk to them like everyone else. Being a medical student on psychiatry isn't really that different from being a volunteer at Nativity House, only now I have to ask a whole new set of questions: do you see things other people don't? do you have any thoughts about hurting yourself? what's your mood like today? I ask in the same way I'd ask about someone's chest pain, because like chest pain, hallucinations and suicidal thoughts are symptoms of a medical problem.
The mentally ill fall into a problematic gap in our society. Unlike other people with serious, disabling, even life-threatening illness, they usually don't come to the doctor on their own. They often have to be brought to the hospital by ambulance or police car. Many people with mental illness, especially the homeless, have active delusions or hallucinations or they may have serious communication or social problems, yet to a certain extent, they are "functional". They find their way to shelters at night, to kitchens for meals, and navigate major cities and transportation systems. Could they find a job? Some could and many do, but the people I knew at Nativity House who were chronically unemployed I couldn't imagine anyone hiring. The problem is that most of the people with what I would call sub-acute mental illness won't go see a doctor, either out of fear, distrust, or most likely, they wouldn't know how. Many of them try to treat the voices, the fear, or the anxiety they experience with drugs. At this point, what most people see from the window of their bus or SUV is a drunk lunatic who probably smells and should just get a job.
It's ironic that many people don't consider mental illness in the same way as diabetes, heart disease, or other medical conditions. There is often just as much of a genetic component to mental illnesses as for other illnesses. It seems like common sense, but nobody chooses to have schizophrenia, or to get manic or be depressed.
You'll hear very few medical students say they want to go into psychiatry. Statistically, less than 2% of my medical school class will choose psychiatry as their specialty. I'm not sure why, but it just doesn't seem as doctorly to folks - they'd rather suture something. Even now, maybe some of you are wondering (be honest, even worrying?) if I'm interested in psychiatry. But I'm not going to tell you - I'd rather you just get used to the idea.
For those of you who don't know (or don't remember), I worked for one year at a daytime homeless shelter in Tacoma, WA called Nativity House. Before I started, my biggest fear was working with the mentally ill - I thought of them as unpredictable at best, and violent at worst. I had no idea how I was supposed to talk to them. What I soon realized is that you talk to them like everyone else. Being a medical student on psychiatry isn't really that different from being a volunteer at Nativity House, only now I have to ask a whole new set of questions: do you see things other people don't? do you have any thoughts about hurting yourself? what's your mood like today? I ask in the same way I'd ask about someone's chest pain, because like chest pain, hallucinations and suicidal thoughts are symptoms of a medical problem.
The mentally ill fall into a problematic gap in our society. Unlike other people with serious, disabling, even life-threatening illness, they usually don't come to the doctor on their own. They often have to be brought to the hospital by ambulance or police car. Many people with mental illness, especially the homeless, have active delusions or hallucinations or they may have serious communication or social problems, yet to a certain extent, they are "functional". They find their way to shelters at night, to kitchens for meals, and navigate major cities and transportation systems. Could they find a job? Some could and many do, but the people I knew at Nativity House who were chronically unemployed I couldn't imagine anyone hiring. The problem is that most of the people with what I would call sub-acute mental illness won't go see a doctor, either out of fear, distrust, or most likely, they wouldn't know how. Many of them try to treat the voices, the fear, or the anxiety they experience with drugs. At this point, what most people see from the window of their bus or SUV is a drunk lunatic who probably smells and should just get a job.
It's ironic that many people don't consider mental illness in the same way as diabetes, heart disease, or other medical conditions. There is often just as much of a genetic component to mental illnesses as for other illnesses. It seems like common sense, but nobody chooses to have schizophrenia, or to get manic or be depressed.
You'll hear very few medical students say they want to go into psychiatry. Statistically, less than 2% of my medical school class will choose psychiatry as their specialty. I'm not sure why, but it just doesn't seem as doctorly to folks - they'd rather suture something. Even now, maybe some of you are wondering (be honest, even worrying?) if I'm interested in psychiatry. But I'm not going to tell you - I'd rather you just get used to the idea.
Saturday, September 1, 2007
This is your brain on drugs
(A cautionary note: this post is not G-rated)
Friday night I was in the Psychiatric Emergency Room when I looked up at the patient list and saw that one of my former patients was waiting on the medicine side of the ER. The attending physician and I went to see him, and found him strapped to a stretcher in the hallway, talking to somebody who was not there. When he saw me coming, I heard him say incredulously with bug eyes, "Is that Ed Norton?". When I introduced myself, he told me I was in that Fight Club movie and addressed me as Ed Norton. Instead of answering our questions, he rambled non-sensically about "trying to kill the terrorists" and said he saw Satan. He would yell incoherently, then lower his voice and speak in very serious tones about the "international allegionary network". He was constantly moving. While we were trying to assess his mental status ("do you know where you are?", "do you have any thoughts of hurting yourself?", etc.), another man was lying on a stretcher restrained about 10 feet down the hall. He was actively lurching against his restraints, shaking the stretcher and yelling incoherently when when suddenly heard him shout, "somebody better put my dick in restraints!" I hid my laughter behind my clipboard, but our patient didn't care; he was talking to an unseen figure down the hall.
The problem with patients like these is you don't know if they are psychotic because of mental illness, because they are drunk and/or high, or both. Interviewing a patient, there's no way to tell. The truth is, in the setting of acute psychosis like this one, it doesn't really matter because you do the same thing. Ideally, erratic patients are put in restraints, sedated with medication, and have their urine sampled. In reality, they don't get sedated and thrash around in their restraints, left alone with their hallucinations. This is because the county has certified professionals who are authorized to involuntarily admit someone to the hospital, and if you treat the symptoms for which a patient would be committed (like homicidal behavior) then there's no basis for admission. In our patient's case, I brought him as much water as he would drink and eventually we got a urine sample, which was positive for numerous drugs. That'll do it. Does he also have schizophrenia? Quite possibly. After some antipsychotic medication, he was eventually dicharged to the street.
Friday night I was in the Psychiatric Emergency Room when I looked up at the patient list and saw that one of my former patients was waiting on the medicine side of the ER. The attending physician and I went to see him, and found him strapped to a stretcher in the hallway, talking to somebody who was not there. When he saw me coming, I heard him say incredulously with bug eyes, "Is that Ed Norton?". When I introduced myself, he told me I was in that Fight Club movie and addressed me as Ed Norton. Instead of answering our questions, he rambled non-sensically about "trying to kill the terrorists" and said he saw Satan. He would yell incoherently, then lower his voice and speak in very serious tones about the "international allegionary network". He was constantly moving. While we were trying to assess his mental status ("do you know where you are?", "do you have any thoughts of hurting yourself?", etc.), another man was lying on a stretcher restrained about 10 feet down the hall. He was actively lurching against his restraints, shaking the stretcher and yelling incoherently when when suddenly heard him shout, "somebody better put my dick in restraints!" I hid my laughter behind my clipboard, but our patient didn't care; he was talking to an unseen figure down the hall.
The problem with patients like these is you don't know if they are psychotic because of mental illness, because they are drunk and/or high, or both. Interviewing a patient, there's no way to tell. The truth is, in the setting of acute psychosis like this one, it doesn't really matter because you do the same thing. Ideally, erratic patients are put in restraints, sedated with medication, and have their urine sampled. In reality, they don't get sedated and thrash around in their restraints, left alone with their hallucinations. This is because the county has certified professionals who are authorized to involuntarily admit someone to the hospital, and if you treat the symptoms for which a patient would be committed (like homicidal behavior) then there's no basis for admission. In our patient's case, I brought him as much water as he would drink and eventually we got a urine sample, which was positive for numerous drugs. That'll do it. Does he also have schizophrenia? Quite possibly. After some antipsychotic medication, he was eventually dicharged to the street.
Tuesday, August 28, 2007
Short doctor
I've now in the second week of my psychiatry rotation at Harborview. The other day I was walking down the hall when I passed one of the patients on the ward with bipolar disorder. As we walked by each other, having never met, he mumbled under his breath, "short doctor". So goes life on psychiatry.
I've been assigned to one of the "care teams", which includes an attending psychiatrist, a resident in psychiatry, many nurses, a social worker, and of course me at the bottom. There are three psych wards at Harborview and my team works on 5-Center, which is referred to as the intensive care unit, meaning we accept the sickest patients. The rooms are small and have only a small bed bolted to the floor in the center of the room. There is no other furniture or a tv. Each room has a window. Many of our patients come to us from the Psychiatric Emergency Room, which adjoins the main ER, and almost all of them are admitted against their will on a 72 hour hold. Some come to us in restraints, though most don't require them for long. My job as a student is to learn about psychiatric disorders, what medications are used to treat them and what side-effects they have, how to interview a psychiatric patient, and how to assess their mental status (the physical exam in psychiatry). The only difficulty for me is that many of my patients are extremely difficult to interview.
Here are a few examples of the patient's I have seen. My first patient was a middle-aged man who flew to Seattle from the midwest so he could check into a hotel room, get drunk, and kill himself (he survived). Another patient was admitted for post-partum depression with psychosis. When she was admitted she was actively hallucinating, was convinced that she had been cursed by an evil demon, and was acutely suicidal. Schizophrenia and bipolar disorder are the most common diagnoses on 5-center.
So here's how a typical day works. I arrive at the hospital at about 7:30 and look on the computer to see if we've admitted any new patients. We get a report from nursing at around 8:15 to tell us what happened overnight with our patients, and then for the next couple hours, we go around interviewing our patients. Because I am the student, this is primarily my responsibility, and as I said, it can be challenging. Sometime you should try interviewing a woman with schizophrenia and diabetes who is convinced that you are rigging the glucose meter, that the attending and resident are really judges, and that she was once a famous singer until someone removed her "vocal muscle". After the interviews are over, we write daily notes and orders on our patients and make phone calls. In the afternoons, there is often formal teaching.
The incredible thing is, most of our patients improve with medication. Recalcitrant patients who were in restraints or refused to talk to us roam the halls or talk to me (even if they can't answer my questions). The engineering student with bipolar disorder that I mentioned before eventually improved, was transferred to one of the less acute wards, and wanted to start his PhD program (this was probably too optimistic). But most of the conditions that bring patients to our ward are chronic, severe, medical conditions. Improvement is relative. Some patients might live a moderately functional life (e.g. they can work) if they are compliant with the medications which they will take for the rest of their life; some patients won't be compliant, will relapse, and be back in the hospital. The former singer I mentioned has been involuntarily committed to the hospital 25 times.
It's too bad that many of these illness aren't considered as "real" as other forms of illness. For example, schizophrenia is a devastating psychiatric disorder which often involves hallucations, delusions, disorganized thoughts, catatonia, and so-called "negative symptoms" such as inactivity, flat affect, or refusal to speak. It affects 1-2% of people, and there is no variation in prevalence by country, race, or sex. It has been described as early as the 15th century b.c. Incredibly, it accounts for 25% of hospital days in the U.S. (most schizophrenics require extensive hospitalization to stabilize them, and many relapse), and the cost of care for schizophrenics is 2% of the GDP! Yet in some states, most notably Idaho and Wyoming, treatment for schizophrenia is not covered like other medical conditions - so called mental health parity - but that issue will have to wait for next time. . .
I've been assigned to one of the "care teams", which includes an attending psychiatrist, a resident in psychiatry, many nurses, a social worker, and of course me at the bottom. There are three psych wards at Harborview and my team works on 5-Center, which is referred to as the intensive care unit, meaning we accept the sickest patients. The rooms are small and have only a small bed bolted to the floor in the center of the room. There is no other furniture or a tv. Each room has a window. Many of our patients come to us from the Psychiatric Emergency Room, which adjoins the main ER, and almost all of them are admitted against their will on a 72 hour hold. Some come to us in restraints, though most don't require them for long. My job as a student is to learn about psychiatric disorders, what medications are used to treat them and what side-effects they have, how to interview a psychiatric patient, and how to assess their mental status (the physical exam in psychiatry). The only difficulty for me is that many of my patients are extremely difficult to interview.
Here are a few examples of the patient's I have seen. My first patient was a middle-aged man who flew to Seattle from the midwest so he could check into a hotel room, get drunk, and kill himself (he survived). Another patient was admitted for post-partum depression with psychosis. When she was admitted she was actively hallucinating, was convinced that she had been cursed by an evil demon, and was acutely suicidal. Schizophrenia and bipolar disorder are the most common diagnoses on 5-center.
So here's how a typical day works. I arrive at the hospital at about 7:30 and look on the computer to see if we've admitted any new patients. We get a report from nursing at around 8:15 to tell us what happened overnight with our patients, and then for the next couple hours, we go around interviewing our patients. Because I am the student, this is primarily my responsibility, and as I said, it can be challenging. Sometime you should try interviewing a woman with schizophrenia and diabetes who is convinced that you are rigging the glucose meter, that the attending and resident are really judges, and that she was once a famous singer until someone removed her "vocal muscle". After the interviews are over, we write daily notes and orders on our patients and make phone calls. In the afternoons, there is often formal teaching.
The incredible thing is, most of our patients improve with medication. Recalcitrant patients who were in restraints or refused to talk to us roam the halls or talk to me (even if they can't answer my questions). The engineering student with bipolar disorder that I mentioned before eventually improved, was transferred to one of the less acute wards, and wanted to start his PhD program (this was probably too optimistic). But most of the conditions that bring patients to our ward are chronic, severe, medical conditions. Improvement is relative. Some patients might live a moderately functional life (e.g. they can work) if they are compliant with the medications which they will take for the rest of their life; some patients won't be compliant, will relapse, and be back in the hospital. The former singer I mentioned has been involuntarily committed to the hospital 25 times.
It's too bad that many of these illness aren't considered as "real" as other forms of illness. For example, schizophrenia is a devastating psychiatric disorder which often involves hallucations, delusions, disorganized thoughts, catatonia, and so-called "negative symptoms" such as inactivity, flat affect, or refusal to speak. It affects 1-2% of people, and there is no variation in prevalence by country, race, or sex. It has been described as early as the 15th century b.c. Incredibly, it accounts for 25% of hospital days in the U.S. (most schizophrenics require extensive hospitalization to stabilize them, and many relapse), and the cost of care for schizophrenics is 2% of the GDP! Yet in some states, most notably Idaho and Wyoming, treatment for schizophrenia is not covered like other medical conditions - so called mental health parity - but that issue will have to wait for next time. . .
Sunday, August 26, 2007
Idaho Medical School?
Dan Popkey wrote an excellent piece in the Idaho Statesman today about Governor Butch Otter's push for a medical school in Idaho. Like the students interviewed in the article, I think it makes no sense to consider a 1 billion dollar medical school when the state has been reluctant to add spots for Idaho students at UW and Utah. The state could educate just as many students per year at those schools, and have them graduate from well-established programs that are among the best in the country. In any case, here's the link to the article:
http://www.idahostatesman.com/newsupdates/story/142583.html
http://www.idahostatesman.com/newsupdates/story/142583.html
Saturday, August 25, 2007
Getting you up to date
So what have I been up to this summer?
After school ended in May, I spent three weeks studying for the national board exam all medical students take after the second year. You'll be happy to know (as I was) that I passed. Then it was time for a few weeks off.
Mt. Rainier
Two friends from school, John and Tom, and I set out to summit Rainier via the Inter-Emmons route, but unfortunately we did not summit. We made two attempts, and on our second we were foiled by white-out conditions and high winds at 12000 feet (that's me in the orange, on our first attempt). All in all it was worth the sore muscles and blackened toes, and I learned a lot about mountaineering, including how fast a well-worn bootpath can disappear in 50 mph winds. Hopefully we'll get another chance.
Road Trip
Two days after coming home from from Mt Rainier, Diana and I left for a road trip through Idaho and Oregon. We went to my parent's new cabin near Lowman, whe
re we enjoyed the new place, cooled off in the South Fork of the Payette, scouted out winter ski slopes, identified the resident hummingbirds, and ate some great home cooking.
From there it was on to Boise for a night with Diana's parents, and then off to LaGrande to see Diana's grandmother, aunt and uncle, and cousins. We set off some fireworks and managed to keep our limbs. We stopped through Bend, OR the next day where we visited the Deschutes Brewery, camped on the shores of Suttle Lake, and then climbed Black Butte the next day.
After that it was on to Portland to see Jason and meet his new fiance Linda. They showed us a great time and were excellent tour guides, but after that it was back to Seattle and back to work and school.
Pediatrics
This was my first rotation and although I didn't think I was that interested in peds, it turned out to be a great rotation. It was 6 wks long and I spend the first three outpatient at a clinic at Harborview (the public hospital here), and then the second three weeks inpatient at Children's Hospital. The wonderful thing about pediatrics is that every kid is different, and that every age of kid is different. Each age comes with new abilities, new problems (try looking in a two year old's ears), and different diagnoses. Children also also resilient and make doctors (and medical students) look good by getting better so fast in response to even minor treatments. I found that parents could sometimes be difficult to deal with, and especially in the outpatient setting, much of a pediatrician's time is spent reassuring parents that their kids behavior, or their ears, or their spitting up, or their poop, is normal. In the end, I enjoyed peds and I can see why many people choose it as their specialty.
Scooter!
And how could I forget to tell you that Diana and I bought a scooter? It's flippin' sweet. It gets 100 mpg and solves all my parking problems. Check it out:
After school ended in May, I spent three weeks studying for the national board exam all medical students take after the second year. You'll be happy to know (as I was) that I passed. Then it was time for a few weeks off.
Mt. Rainier
Two friends from school, John and Tom, and I set out to summit Rainier via the Inter-Emmons route, but unfortunately we did not summit. We made two attempts, and on our second we were foiled by white-out conditions and high winds at 12000 feet (that's me in the orange, on our first attempt). All in all it was worth the sore muscles and blackened toes, and I learned a lot about mountaineering, including how fast a well-worn bootpath can disappear in 50 mph winds. Hopefully we'll get another chance.
Road Trip
Two days after coming home from from Mt Rainier, Diana and I left for a road trip through Idaho and Oregon. We went to my parent's new cabin near Lowman, whe
re we enjoyed the new place, cooled off in the South Fork of the Payette, scouted out winter ski slopes, identified the resident hummingbirds, and ate some great home cooking.From there it was on to Boise for a night with Diana's parents, and then off to LaGrande to see Diana's grandmother, aunt and uncle, and cousins. We set off some fireworks and managed to keep our limbs. We stopped through Bend, OR the next day where we visited the Deschutes Brewery, camped on the shores of Suttle Lake, and then climbed Black Butte the next day.
After that it was on to Portland to see Jason and meet his new fiance Linda. They showed us a great time and were excellent tour guides, but after that it was back to Seattle and back to work and school.
Pediatrics
This was my first rotation and although I didn't think I was that interested in peds, it turned out to be a great rotation. It was 6 wks long and I spend the first three outpatient at a clinic at Harborview (the public hospital here), and then the second three weeks inpatient at Children's Hospital. The wonderful thing about pediatrics is that every kid is different, and that every age of kid is different. Each age comes with new abilities, new problems (try looking in a two year old's ears), and different diagnoses. Children also also resilient and make doctors (and medical students) look good by getting better so fast in response to even minor treatments. I found that parents could sometimes be difficult to deal with, and especially in the outpatient setting, much of a pediatrician's time is spent reassuring parents that their kids behavior, or their ears, or their spitting up, or their poop, is normal. In the end, I enjoyed peds and I can see why many people choose it as their specialty.
Scooter!
And how could I forget to tell you that Diana and I bought a scooter? It's flippin' sweet. It gets 100 mpg and solves all my parking problems. Check it out:
Good intentions
As with much of what goes on in my house, this was Diana's idea. I told her I needed some kind of project to work on, and this is what she suggested. She knows me well, because before I started my third year rotations, I openly committed myself to do some journaling about what happened. How many time have I journaled in the last 7 weeks? Zero. Plus, with my brother Lee sending out occasional manifestos from Afghanistan, I had to do something to keep up.
Hopefully this blog will keep me honest, keep my friends and family informed (turns out I'm not always so good at that either), and be occasionally entertaining. We'll see.
Hopefully this blog will keep me honest, keep my friends and family informed (turns out I'm not always so good at that either), and be occasionally entertaining. We'll see.
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