I must apologize for not posting in the past few weeks, residency is starting to catch up with me. Anyway, I'll continue on with the physical exam.
I usually examine patients in a systematic way so that I don't forget anything. My way of doing it is from top to bottom. So after I examine the eyes, I'll move down to the nose. There isn't a whole lot to do in the nose except, well look inside of it. Here I'll use the little instrument that is usually hanging on the wall that has a light with a magnifying lens. It's the same instrument used to look in the ear. Looking into the nose gives you a look at the mucus membranes. These are the thin membranes that can bleed when you're having a nose bleed. Many people are prone to nose bleeds because the membrane is so thin here, and all it takes is a small break in the mucosa. This is also the area that can become inflamed when you're having a cold. In this case, the membrane will look red and have lots of, well, snot dripping from it (exudate would be a more medical term). Allergies have a different appearance. When somebody has bad nasal allergy symptoms, the nasal mucosa will look blue and have a boggy appearance. So if a patient comes in to see you with a lot of nasal discharge and you want to distinguish a viral infection and an allergic reaction, you can just have a look in the nose. Another thing that you may notice in the nose is the septum. This is the wall of tissue that separates the right and left nostrils. It is usually continuous until you get to the back part of your nasal cavity (you shouldn't be able to feel with your finger where the septum ends). But people who snort cocaine or other things chronically may have eroded this septum and have a hole in it. So looking in the nose can give you even more information about a patient than what his nose is like.
Next I'll examine the mouth. Looking at the lips is important because there are certain symdromes and other diseases which will give you focal lesions of the lips. One syndrome called Peutz-Jeger syndrome is associated with multiple polyps of the GI tract which will eventually become cancerous. This syndrome is also associated with purple-ish lesions of the lips and oral mucosa. So if you see something like this when you examine the lips, you may be able to diagnose this syndrome and save somebody's life from colon cancer.
After looking at the lips, a thorough exam would include taking a brief glance at the teeth and gums. Obviously, dentists do the majority of the dental work, but teeth and gums are a part of the body and can have major impacts on otherall health. Usually I just have a quick glance at them just to make sure there are no rotting teeth or large abscesses. Then I move on to the back of the mouth. This is the part where the doc takes the tongue depressor and sticks it to the back of your mouth. What we are trying to do is smoosh the tongue down so that we can see the throat. If the throat is red, the patient may have a cold (sore throat) from a viral infection. You can also see puss combined with redness, which would probably indicate strep throat. The difference between strep throat and a viral infection is that one is caused by a bacteria (strep) and can be treated with antibiotics, whereas the viral infection does not really have a treatment. The presence of puss is usually a tip off that there may be a bacterial infection, but patients with strep throat are also usually much sicker than patients with a viral infection. While looking at the back of the mouth, you should also be able to see the tonsils.
The tonsils are basically lymph nodes that sit in the back floor of your mouth. Lymph nodes become enlarge in infection (as they would in strep throat). You can also get abscesses forming on the tonsils. Abscesses are focal collections of puss. Puss (or exudate) is thick proteinacious material that is basically the products of your immune system trying to fight a bacterial infection. If you look at it under a microscope, you'll see dead white blood cells (your immune cells) and dead bacteria as well as some live cells too. An abscess occurs when your body notices the production of puss and tries to wall off the focus of infection in an attempt to stop it from spreading. You can think of it like a blister filled with infection. The bad thing about abscesses is that the walls surrounding them are thick and prevent antibiotics from penetrating into the abscess. So treating the infection is not as simple as prescribing a pill. To treat abscesses, you have to pop them. You need to drain that puss. Many would argue that you don't even need to treat an abscess with antibiotics if you can drain it (I think most doctors would give antibiotics in addition, though). So an abscess on the tonsil can be a serious thing because it requires draining.
The next thing that I examine is the neck. Here, I will check for lymph nodes. There are a collection of lymph nodes running along the underside of the jaw, chin, and along the neck muscles. These can also become enlarge in infections like colds or strep throat. In fact strep throat will cause specific lymph nodes to become enlarged more frequently than others. Cancers (lymphoma) can also cause lymph nodes to become enlarged. It is important to characterize the enlarged lymph node. Does the lymph node hurt when you push on it? Are the lymph nodes mobile or do they seem fixed to the underlying muscle (this would imply tumor invasion into surrounding tissues). A careful exam for lymph nodes would also include feeling at the back of the neck since there are lymph nodes that live back there too. Many clinicians have different techniques for feeling for lymph nodes. Some will use the tips of their fingers and use a rolling motion up and down the neck. Others will just slap their entire palms down on the neck and massage the neck to feel for any irregularities.
The thyroid gland also lives in the neck. It can become enlarged in certain diseases. It can have nodules, or focal bumps in it. It can also have nodules if there is a cancer growing in it. Unfortunately examining the thyroid can be tricky. I can't say that I am entirely confident with my ability to feel it and that's because it is a very spongy tissue and doesn't have very defined borders to it. Obviously an endocrinologist who feels thyroids all day long is probably quite adept at it. The thyroid gland lies in the midline right at or a little under the Adam's apple. There are a couple of techniques for examining the thyroid, one of which is to stand behind the patient and use one set of fingers for each side of the neck with the palms by the patient's ears. The other way is to just stand next to the patient and use one hand to feel that area. Usually we will ask the patient to swallow and try to feel the thyroid moving up and down.
Another important thing to examine in the neck is the carotid arteries. These arteries are sort of important because they feed blood to the brain. On TV, when they are checking to see if somebody is dead, they are putting their fingers on the neck and trying to feel the pulse of the carotid artery. You should be able to feel your own if you put 2 fingers on your Adam's apple (women have Adam's apples too, they're just less prominent) and move maybe 3 centimeters to either side and push gently. If you can't feel it, start moving around until you feel a bounding pulse. If you still can't feel it, you're either not feeling in the right place, or you're about to die. Anyway, examining the carotid artery includes feeling for it, but also trying to characterize it. Does it feel strong? If it's a wimpy little pulse, there may be some atherosclerosis in the vessel. This can be a serious thing because if the blood vessel becomes narrowed enough, there may be decreased blood flow to the brain which could cause stroke. Parts of the cholesterol plaque may also break off from the carotid artery and plug up the arteries in the brain. Listening to the carotid artery with a stethoscope can give some clues about the heart. As blood leaves the heart on its way to the carotid artery, it goes through a set of valves which are designed to prevent back flow in the vessel. These valves can become diseased or "stenotic". This means that the valve area becomes narrowed and the blood has a smaller diameter to get through. You can see how this would be a bad thing. When you listen to the carotid artery, you may be able to hear what is called a bruit (pronounced broo-ie) which is a blowing sound that the blood makes as it shoots through the stenotic valve and into the carotid artery. You will also be able to hear the bruit in the heart (in which case it would be called a murmur), but the fact that you can hear the bruit in the carotid artery and the heart tells you that there is stenosis of a specific valve.
Next thing I examine in the head is the ears. Again, it's important just to look first. Many clinicians just take the light, have a quick look in the ears and that's it. But looking at the outside is important too. Many skin cancers can start in the ear since it is constantly exposed to sunlight. The ear is divided into 3 portions: the inner, middle, and outer ear. I wont go into the anatomic structures within each compartment, but the inner ear basically can't be examined directly. The outer ear is the part of the ear that you can stick your finger into. Patients (especially diabetics or swimmers) can get infections of the outer ear. You may see puss running out of the ear. Or if you tug on the outside of the ear, there may be pain from an "outer ear infection". Deep to the outer ear, past the ear drum is the middle ear. When physicians stick the light into your ear, they are trying to look at the ear drum, which can be a window into the middle ear. If there is an inner ear infection, the ear drum may be red. If there is a bacterial infection in the middle ear, there may be puss behind the ear drum. Some patients may also have a perforated ear drum which can also be seen. The middle ear is prone to infection because it has a tube which connects it to the nasal cavity (the Eustacian tube). This gives bacteria a road to follow up to the middle ear, which is nice and dark, enclosed, and moist--perfect conditions for an infection. That's why many ear infections start off as an infection in the nose or throat and then travels up to the ear.
Testing the actual hearing function is also important and may be obvious in gross hearing loss, but it can also be subtle. I like to have the patient close their eyes and tell them to raise their hand when they hear something. Then I take my fingers and rub them together about a foot away from each ear. If they can hear it, I take that as being fairly normal. If somebody comes in with a complaint of hearing loss or if I know there are underlying deficiencies, there are more sophisticated tests using tuning forks that can be done, but the underlying physiology is a little beyond this blog, I think.
That about covers the exam of the head. I will usually return to examining parts of the head later on when I do the neurological exam. The neurological exam is much more complicated and can be subtle, so I usually chose to do it separately and all at once.
My hands are getting typed-out, so I think I'll continue on with the chest and abdomen next time. Again, feel free to leave comments if you think this topic is getting boring.
Saturday, September 1, 2007
Friday, August 10, 2007
The Physical Exam
First of all, I wanted to thank those of you who have left some kind comments about my blog. I want to hear from more of you about what types of things you like hearing about. Do you prefer hearing more of my stories and less of the science behind medicine? I thought that I might spend one blog describing a specific drug, how it works, and why it has certain side effects. Or maybe pick a study that is in the popular press and describe the real significance of it. Tell me what you guys want.
Anyway, for this post, I thought I'd explain how a physical exam is done.
Everyone who has seen a doctor has had a physical exam in some form or another. But I would bet that hardly anybody has ever had a proper thorough examination. A true physical exam done carefully should take over half an hour. But they don't because physicians don't have that much time, so they only examine the pertinent parts of the body.
The truth is that most physical exams are normal. Most of the information that doctors use to diagnose illnesses comes from the history, or the story. Where is the pain? When did the pain start? What makes the pain better? Have you ever had this pain before? 80% of diagnoses can be made by history alone. So the interview is the most important part of each encounter. The physical exam is used mostly to confirm what is learned from the history. More importantly, the physical exam is used to make the patient feel comfortable with the physician.
There are very few professions where you are allowed to physically touch people. And as physicians, we use that to our advantage. We use the power of touch to make people feel like we are special people. We give patients confidence in our ability and make them feel like they are being taken care of. When I listen to people's hearts and lungs, I always put my arm on the patient's shoulder. It may seem like I am trying to stabilize myself while listening, but I am really trying to make a connection with my patient.
Even though the physical exam is a secondary part of each encounter, it can truly be crucial to making certain diagnoses. A careful clinician can tell subtle differences in the way somebody is talking and diagnose a stroke. Or listen to the heart and diagnose a faulty heart valve. Or push on somebody's belly and tell whether a person is bleeding internally or just constipated. It is a difficult skill that takes years of experience to get good at. So here's how you do it:
The physical exam starts the second you walk into the room and introduce yourself.
Observe the patient. Are they sitting quietly or are they bouncing around the room like a bipolar maniac? Is their speech slurred from a stroke? Is their face drooping from Bell's palsy? There are many things that you can tell just by looking at a patient. Even race can play an important role in making a diagnosis since most ethnicities have diseases more common to them. It's very important to get an overall picture of who your patient is.
After the initial introduction, most physicians will sit down and just talk to the patient and get some history. After the history is taken, comes the formal physical exam.
I like to do my physical exams starting from the head and working my way down to the toes. I use a methodical approach so that I don't forget anything. When you examine a body part, you always start with observation (just like how you started the entire encounter).
When you examine the head, you start out by just looking at it. Are there deformities? Does the patient have a cleft palate? Does the patient have a bleeding laceration across their face? Are the creases in the face symmetric? (Asymmetry of the folds around the lips may be a subtle sign of a facial droop which may indicate a neurologic impairment like stroke).
Then I start with the eyes. I tell the patient to keep their head facing ahead and follow my finger with their eyes only. Then I hold up my index finger about a foot in front of their face and start moving it around. Meanwhile I observe the movement of the patients eyes. Certain neurological conditions will cause paralysis of the muscles which control the movement of the eyes. If the patient has a brain tumor pinching off a certain nerve, a patient might not be able to move one eye in one direction. Or if the patient is having vertigo, they may have nystagmus, which is a twitching movement of the eye.
Of course one of the most important tests of the eyes is whether or not they can see. But presumably you tested this when you walked into the room and decided if the patient was blind. So next you can test the visual fields. A patient may be able to see right in front of them, but certain types of brain tumors can pick off the peripheral eye fields. So when you put up 2 fingers at the edge of somebody's view, they might not be able to see it. This is typically tested by comparing the patient's visual fields with your own. So you stand facing the patient and hold up your fingers right at the edge of your visual field, an equal distance from the patient. Theoretically this should be the edge of the patient's visual field as well. So you ask them how many fingers you are holding up and test whether or not they can see that area of their visual field.
An important part of the eye exam which is hardly ever done is called the fundoscopic exam. This involves a special light and magnifying lens that looks at the back of the eye, the fundus. The fundus is actually the retina, where the nerves of the eye pick up light and turn them into electrical signals that your brain can interpret. The retina also has many tiny blood vessels which can tell you about the patient's cardiovascular system. Patients with high blood pressure may have certain changes on their blood vessels which can be determined on the fundoscopic exam. People who get "red-eye" when they have photographs taken of them are getting red eyes because the camera is picking up portions of the patient's fundus which is red from all of the blood vessels. Swelling of the brain can also be diagnosed by looking at the back of the eye since nerves can be seen which connect the eye with the brain.
The reason why the fundoscopic exam is hardly ever done is that it is incredibly hard to do proficiently. To do it properly, a light must be shined into the patient's eye and the scope must be placed right up against the physician's face and then the other end of the scope is placed right up against the patient's face. In the end, the doctor and patient's faces are practically touching with a little lighting instrument held in between. The fundoscope must be held very precisely and with little movement to see all the parts of the fundus. This exam is always done when you go to the eye doctor, but most primary care doctors wont bother with it unless there is a specific reason.
I realize that this post (like all my other posts) is getting kind of long already, so I'll continue the post next week and describe more of the physical exam.
Let me know if you want to hear more of it or if you want me to abandon this topic and move onto something else.
Anyway, for this post, I thought I'd explain how a physical exam is done.
Everyone who has seen a doctor has had a physical exam in some form or another. But I would bet that hardly anybody has ever had a proper thorough examination. A true physical exam done carefully should take over half an hour. But they don't because physicians don't have that much time, so they only examine the pertinent parts of the body.
The truth is that most physical exams are normal. Most of the information that doctors use to diagnose illnesses comes from the history, or the story. Where is the pain? When did the pain start? What makes the pain better? Have you ever had this pain before? 80% of diagnoses can be made by history alone. So the interview is the most important part of each encounter. The physical exam is used mostly to confirm what is learned from the history. More importantly, the physical exam is used to make the patient feel comfortable with the physician.
There are very few professions where you are allowed to physically touch people. And as physicians, we use that to our advantage. We use the power of touch to make people feel like we are special people. We give patients confidence in our ability and make them feel like they are being taken care of. When I listen to people's hearts and lungs, I always put my arm on the patient's shoulder. It may seem like I am trying to stabilize myself while listening, but I am really trying to make a connection with my patient.
Even though the physical exam is a secondary part of each encounter, it can truly be crucial to making certain diagnoses. A careful clinician can tell subtle differences in the way somebody is talking and diagnose a stroke. Or listen to the heart and diagnose a faulty heart valve. Or push on somebody's belly and tell whether a person is bleeding internally or just constipated. It is a difficult skill that takes years of experience to get good at. So here's how you do it:
The physical exam starts the second you walk into the room and introduce yourself.
Observe the patient. Are they sitting quietly or are they bouncing around the room like a bipolar maniac? Is their speech slurred from a stroke? Is their face drooping from Bell's palsy? There are many things that you can tell just by looking at a patient. Even race can play an important role in making a diagnosis since most ethnicities have diseases more common to them. It's very important to get an overall picture of who your patient is.
After the initial introduction, most physicians will sit down and just talk to the patient and get some history. After the history is taken, comes the formal physical exam.
I like to do my physical exams starting from the head and working my way down to the toes. I use a methodical approach so that I don't forget anything. When you examine a body part, you always start with observation (just like how you started the entire encounter).
When you examine the head, you start out by just looking at it. Are there deformities? Does the patient have a cleft palate? Does the patient have a bleeding laceration across their face? Are the creases in the face symmetric? (Asymmetry of the folds around the lips may be a subtle sign of a facial droop which may indicate a neurologic impairment like stroke).
Then I start with the eyes. I tell the patient to keep their head facing ahead and follow my finger with their eyes only. Then I hold up my index finger about a foot in front of their face and start moving it around. Meanwhile I observe the movement of the patients eyes. Certain neurological conditions will cause paralysis of the muscles which control the movement of the eyes. If the patient has a brain tumor pinching off a certain nerve, a patient might not be able to move one eye in one direction. Or if the patient is having vertigo, they may have nystagmus, which is a twitching movement of the eye.
Of course one of the most important tests of the eyes is whether or not they can see. But presumably you tested this when you walked into the room and decided if the patient was blind. So next you can test the visual fields. A patient may be able to see right in front of them, but certain types of brain tumors can pick off the peripheral eye fields. So when you put up 2 fingers at the edge of somebody's view, they might not be able to see it. This is typically tested by comparing the patient's visual fields with your own. So you stand facing the patient and hold up your fingers right at the edge of your visual field, an equal distance from the patient. Theoretically this should be the edge of the patient's visual field as well. So you ask them how many fingers you are holding up and test whether or not they can see that area of their visual field.
An important part of the eye exam which is hardly ever done is called the fundoscopic exam. This involves a special light and magnifying lens that looks at the back of the eye, the fundus. The fundus is actually the retina, where the nerves of the eye pick up light and turn them into electrical signals that your brain can interpret. The retina also has many tiny blood vessels which can tell you about the patient's cardiovascular system. Patients with high blood pressure may have certain changes on their blood vessels which can be determined on the fundoscopic exam. People who get "red-eye" when they have photographs taken of them are getting red eyes because the camera is picking up portions of the patient's fundus which is red from all of the blood vessels. Swelling of the brain can also be diagnosed by looking at the back of the eye since nerves can be seen which connect the eye with the brain.
The reason why the fundoscopic exam is hardly ever done is that it is incredibly hard to do proficiently. To do it properly, a light must be shined into the patient's eye and the scope must be placed right up against the physician's face and then the other end of the scope is placed right up against the patient's face. In the end, the doctor and patient's faces are practically touching with a little lighting instrument held in between. The fundoscope must be held very precisely and with little movement to see all the parts of the fundus. This exam is always done when you go to the eye doctor, but most primary care doctors wont bother with it unless there is a specific reason.
I realize that this post (like all my other posts) is getting kind of long already, so I'll continue the post next week and describe more of the physical exam.
Let me know if you want to hear more of it or if you want me to abandon this topic and move onto something else.
Sunday, July 29, 2007
The On-call Experience
There are few things in the field of medicine that are as miserable as being on-call. People get sick at all times of the day, and so hospitals remain operational all day long, all week long, and every single day of the year, without any breaks. And that means that hospitals require doctors, nurses, technicians, and ancillary staff to be present at all times.
For the non-physicians, this isn't quite as bad because they mostly work in shifts. So there will be someone who works the 5pm-1am shift and then another person who works the 1-9 shift. Not too bad if you can manage being nocturnal.
But for doctors, it's a different story. When we're on-call, we arrive just like any other day, at 7am and we work the regular day, cover the night, and then even work into the next afternoon. So in the end, what was 4 nursing shifts becomes one physician 30 hour shift. And depending on the call schedule, we do it every third day.
It doesn't seem to make a lot of sense to have doctors be so overworked and tired all the time, but we do it for the patients. Sick people who are admitted to the hospital can be very complicated. Medication lists can be 20-30 drugs long and each patient has their own set of medical problems, allergies, histories, and social issues. We have to know our patients extremely well because if the patient suddenly turns south in the middle of the night, we have to be able to think quickly and not be fumbling with the chart.
If doctors worked in shifts, they would not know their patients as well. The night doctor has no idea what happened during the day. Furthermore, they are just "covering" until the morning arrives, so there really is no incentive to learn about the patient. The patient may very well sleep through the night without any active issues.
So that's why doctor's have to work the grueling hours that they do.
Time has a different meaning when you're on-call. In a 9-5 job, when 4:30 hits, your eyes start to gloss over and all you can do is think about going home. And then when 5 o'clock arrives, you're already in your car, hoping nobody saw you leave early. When you're on-call and 5pm hits, you realize that you're equally as tired but that you're not even half way done with your "work day". The busiest, most difficult part of your call hasn't even begun.
At 5am, when things finally start to settle down in the hospital and you can think about getting a few minutes of sleep, you realize that in just another hour, people will be arriving to start a new day. So you decide just to stay up and get some work done so that you can go home as soon as possible.
The post-call morning is probably the worst and best part of a call. It's the best because in just a few hours you could possibly be going home and getting some sleep. It's the worst because you haven't slept, you were incredibly busy, and you have to remember what happened to all the patients overnight to report to the next team. Your vision gets kind of blurry, you get this sick feeling in the pit of your stomach, and you date things incorrectly because you forget that a whole day has passed since yesterday.
Morning rounds is the worst because some attendings like to take their time and do some teaching, some chatting, and read their newspaper. I've never been so close to falling asleep while standing in my life. Then when it's finally time to present your patients, you enter this zone of cloudiness where you are talking, but don't even realize what is coming out of your mouth. You respond to questions that weren't asked and you start to laugh at things that aren't even funny.
I like to call it the post-call psychosis. If you ever get a chance to sit in on morning rounds, find out who is post-call and observe their behavior. It's due to a combination of sleep deprivation and elation that you may get to go home soon.
The truth is that you get used to it--you wouldn't survive if you didn't. And not all calls are that bad. My hospital was a small community based hospital, so there were random nights when you could steal 4-5 hours of sleep. The alarm would go off at 6am and I would be shocked at how refreshed I felt. My first instinct was always to check my pager to see if it ran out of batteries. There's also a certain camaraderie that comes with working nights. There aren't as many people around, so you tend to bond with the people around you.
And the best learning happens when you're on-call. While there is always back-up if you need it, for the most part, you are alone. So if you get a call from a nurse that your patient is becoming cyanotic, you have to be the one to find a solution. You can try different things to see what works and gradually build your own approach to treating patients with certain problems. If you fail, well, the patient will pay for it. But truth is that in today's litigious society, hospitals are so careful that you are hardly ever with some kind of supervision. In most cases it's the nurses who will tell you what to do. Instead of saying, "Your patient is cyanotic, what do you want to do?", they will say, "Your patient is cyanotic, do you want me to give him a nebulizer treatment?" And for the beginning intern, all you have to do is say yes.
So while being on-call is a painful, exhausting, arduous experience, it is something that is important both for the care of patients and for the training of a young doctor. Right now, I'm a radiology resident, so call is a little bit rarer and less terrifying. But looking back on my internship, I actually have some fond memories from being on call. But I wouldn't want to do it again.
For the non-physicians, this isn't quite as bad because they mostly work in shifts. So there will be someone who works the 5pm-1am shift and then another person who works the 1-9 shift. Not too bad if you can manage being nocturnal.
But for doctors, it's a different story. When we're on-call, we arrive just like any other day, at 7am and we work the regular day, cover the night, and then even work into the next afternoon. So in the end, what was 4 nursing shifts becomes one physician 30 hour shift. And depending on the call schedule, we do it every third day.
It doesn't seem to make a lot of sense to have doctors be so overworked and tired all the time, but we do it for the patients. Sick people who are admitted to the hospital can be very complicated. Medication lists can be 20-30 drugs long and each patient has their own set of medical problems, allergies, histories, and social issues. We have to know our patients extremely well because if the patient suddenly turns south in the middle of the night, we have to be able to think quickly and not be fumbling with the chart.
If doctors worked in shifts, they would not know their patients as well. The night doctor has no idea what happened during the day. Furthermore, they are just "covering" until the morning arrives, so there really is no incentive to learn about the patient. The patient may very well sleep through the night without any active issues.
So that's why doctor's have to work the grueling hours that they do.
Time has a different meaning when you're on-call. In a 9-5 job, when 4:30 hits, your eyes start to gloss over and all you can do is think about going home. And then when 5 o'clock arrives, you're already in your car, hoping nobody saw you leave early. When you're on-call and 5pm hits, you realize that you're equally as tired but that you're not even half way done with your "work day". The busiest, most difficult part of your call hasn't even begun.
At 5am, when things finally start to settle down in the hospital and you can think about getting a few minutes of sleep, you realize that in just another hour, people will be arriving to start a new day. So you decide just to stay up and get some work done so that you can go home as soon as possible.
The post-call morning is probably the worst and best part of a call. It's the best because in just a few hours you could possibly be going home and getting some sleep. It's the worst because you haven't slept, you were incredibly busy, and you have to remember what happened to all the patients overnight to report to the next team. Your vision gets kind of blurry, you get this sick feeling in the pit of your stomach, and you date things incorrectly because you forget that a whole day has passed since yesterday.
Morning rounds is the worst because some attendings like to take their time and do some teaching, some chatting, and read their newspaper. I've never been so close to falling asleep while standing in my life. Then when it's finally time to present your patients, you enter this zone of cloudiness where you are talking, but don't even realize what is coming out of your mouth. You respond to questions that weren't asked and you start to laugh at things that aren't even funny.
I like to call it the post-call psychosis. If you ever get a chance to sit in on morning rounds, find out who is post-call and observe their behavior. It's due to a combination of sleep deprivation and elation that you may get to go home soon.
The truth is that you get used to it--you wouldn't survive if you didn't. And not all calls are that bad. My hospital was a small community based hospital, so there were random nights when you could steal 4-5 hours of sleep. The alarm would go off at 6am and I would be shocked at how refreshed I felt. My first instinct was always to check my pager to see if it ran out of batteries. There's also a certain camaraderie that comes with working nights. There aren't as many people around, so you tend to bond with the people around you.
And the best learning happens when you're on-call. While there is always back-up if you need it, for the most part, you are alone. So if you get a call from a nurse that your patient is becoming cyanotic, you have to be the one to find a solution. You can try different things to see what works and gradually build your own approach to treating patients with certain problems. If you fail, well, the patient will pay for it. But truth is that in today's litigious society, hospitals are so careful that you are hardly ever with some kind of supervision. In most cases it's the nurses who will tell you what to do. Instead of saying, "Your patient is cyanotic, what do you want to do?", they will say, "Your patient is cyanotic, do you want me to give him a nebulizer treatment?" And for the beginning intern, all you have to do is say yes.
So while being on-call is a painful, exhausting, arduous experience, it is something that is important both for the care of patients and for the training of a young doctor. Right now, I'm a radiology resident, so call is a little bit rarer and less terrifying. But looking back on my internship, I actually have some fond memories from being on call. But I wouldn't want to do it again.
Sunday, July 22, 2007
The Man with No Legs
About two weeks into my rotation at the state prison hospital, I admitted a patient who had no legs. He was probably around 70 years old and had lost both of his lower limbs to diabetes. Diabetics can have very bad circulation to their extremities and their immune systems are not as strong as most people's. So a simple skin infection that most of us would be able to fight off can result in gangrene and even death if not treated properly. When the infection gets advanced enough, amputation can be the only option.
That wasn't the only problem this guy was having. He had presumably had a stroke some years ago because he was basically non-verbal and only occasionally communicated by grunting. It was hard to tell if he was paralyzed because he would only occasionally obey commands. You could tell that he had been neglected in prison because his lips were so dry that they were sloughing off and he had barely any fat or muscle mass. I can just imagine him laying in bed for days on end without any attention. There was definitely no way this guy could take care of himself and somehow I doubt the prison guards fed and bathed him.
In any other situation, a patient like this would already have an advanced directive telling health care professionals not to resuscitate or intubate. It would be cruel not to, because people like that have no quality of life and no hope for recovery. You can keep people alive indefinitely on a ventilator if you really wanted to, but what's the point? You've got to draw a line somewhere. In fact physicians have the right NOT to treat someone if they think it is medically futile.
I learned that prisoners of the state do not have the right to sign their life away. This is presumably because they are serving a sentence and signing a DNR would mean cutting the sentence short. Sort of ridiculous, but I guess some silly lawyer out there had something to do with that rule (god forbid a physician should be able to decide anything in healthcare). So here he was, basically a big bag of skin and bones with absolutely nothing to live for except his life sentence.
He had actually been admitted for hyponatremia, which means low blood sodium. It's a very complicated process which actually has nothing to do with the amount of sodium that you eat. Rather, it has to do with how much water you drink and how your body handles the water in your body. You may have heard of marathoners getting water intoxication when they chug large amounts of plain water. They become hyponatremic because they drink so much water that the sodium in their body gets diluted out. That's why it's better to drink gaterade because it has about the same concentration of sodium as the body. Hyponatremia can be incredibly dangerous if not treated properly. It can lead to seizures, brain swelling, even death. But there I was, an eager intern fresh out of medical school ready to take it on.
It was day 5 of his admission and I happened to be on call that night. I was laying down in the call room, trying to get some sleep, when I got a call from one of the nurses.
"You better go see Mr. G, he's in V-tach".
V-tach (or ventricular tachycardia) is one of those buzz words in medicine that makes doctors poop in their pants. The lifespan of your heart goes something like this: you're born, your heart beats a few billion times, you go into V-Tach, and then you die. So it was strange to get a phone call like this. Yes, I better go see him--I better run my ass up to the prison ward and resuscitate him. I was half asleep when I got the call, but I instantly shot out of bed, threw my stethoscope around my neck, and sprinted up 5 flights of stairs. By then, a "code" had been called over the loudspeakers (to announce it to all 2 doctors in the hospital) and a special protocol in the prison had been enacted.
For those of you who missed my last blog, the prison ward lives behind two large jail doors which require special authorization to pass through. Ordinarily it takes a good 2 minutes to get through those doors because you have to wait for one to close before the other one opens. The protocol for codes is that all prisoners are put back in their rooms immediately and all guards stand in the hall with their shotguns at the ready. Then, both doors swing open and a guy with a machine gun stands at the entrance.
Somehow that night, the protocol didn't go quite as planned. When I arrived on the prison floor, the jail doors were still closed. I could see the guards scrambling behind the glass because they couldn't get the doors open. Meanwhile, every second that passed was another thousand brain cells that my patient was losing. It was 3 minutes before they got the door open. I sprinted down the hall like I had never sprinted before. Things were flying out of my pockets, but I ignored them because I just had to get into the room. When I finally busted into the patient's room, there was a nursing student and a full-time nurse standing above the patient with a blood pressure cuff, trying to take some vitals. It had been at least 8 minutes since I was called and all they were doing was measuring the guy's blood pressure?
I shoved them aside in a dramatic fashion and felt for a pulse. No pulse. It doesn't take a blood pressure cuff to know that that means no blood pressure.
"He's got no pulse, grab a backboard and put it under him NOW!"
Ordinarily I'm a very quiet, unassuming guy. I speak rather slowly and never shout. But I was going on pure adrenaline that night. I had never even seen a real code let alone run one, but I modeled myself after what I had seen on TV.
I knew what to do because I had recently been trained in ACLS (that's CPR for doctors).
"Starting chest compressions"
-crrrrrrack-
I had taken CPR as a high school student, and I knew that it wasn't unexpected to break ribs when giving CPR, but I hadn't expected it to be that easy or quick. It was a little bit like pushing down on a rice crispy treat.
Giving real CPR is much faster than on TV. You have to pump the chest 100 times a minute, which is almost twice per second. So it gets tiring very quickly. But I went at it, pumping as fast as I could and hoping that all of a sudden, he would grasp for air and magically come back to life. Meanwhile, I was shouting at the nurses to go grab a mask so that I could ventilate the guy. It seemed like they were just standing around watching me. Nurses are supposed to be trained at the same stuff that I was trained in. So theoretically when I had arrived in the room, the nurses should have already been doing CPR and preparing the appropriate drugs for me to order. But things were a little different there.
There was no mask in the room, so they had to go run and find one. Meanwhile, I was demanding that they draw up epinephrine and atropine into a syringe. They fumbled around with it, not able to open the medicine vial or get appropriate IV access. It was completely embarassing to be part of this effort, but it seemed like I was the only person doing anything appropriate. Ultimately, it took them 12 minutes before they pushed the first round of epinephrine (something which probably should have been done before I had even arrived).
Next step was to intubate the man. In between chest compressions, I was shouting at the nurses to get an intubation kit. They finally found one and I ordered someone else to substitute for me in giving CPR. I opened the intubation blade (which I had only played with a few times before on a dummy) and found that the light wasn't working. It had run out of batteries. Trying to intubate someone without a light is like trying to find a needle in a haystack-in the dark. But I had no choice. I had one of the nursing assistants hold a pen light over my head while I tried to intubate. I knew the motions and knew where the structures were supposed to be. But without a light, I couldn't see anything and just kind of pushed the tube in where I thought it should go. Magically, it went into the right tube and the guy had been successfully intubated.
But still no pulse.
By then it had been almost 30 minutes of CPR without any success. A moonlighting senior resident finally showed up (he hadn't been notified of the predicament I was in) and told me that I should stop. So I stopped and called it.
Strangely, I was proud of myself. I had done everything appropriately and even intubated the guy without a light. I was drenched in sweat, but all I could do was look down at the poor guy. Legless, blood dripping from his IV site, his chest deformed from the broken ribs, and eyes staring straight up at the ceiling. He was dead. I think the statistic is that 90% of codes end in death, so I didn't feel that bad. In fact in many ways it was a relief that my patient had finally been allowed to die.
I later sat down with the senior resident and went over the case. He said that I had actually done a great job and that most senior residents might not have handled it as well as I had. I guess all those years of watching ER had paid off after all.
That wasn't the only problem this guy was having. He had presumably had a stroke some years ago because he was basically non-verbal and only occasionally communicated by grunting. It was hard to tell if he was paralyzed because he would only occasionally obey commands. You could tell that he had been neglected in prison because his lips were so dry that they were sloughing off and he had barely any fat or muscle mass. I can just imagine him laying in bed for days on end without any attention. There was definitely no way this guy could take care of himself and somehow I doubt the prison guards fed and bathed him.
In any other situation, a patient like this would already have an advanced directive telling health care professionals not to resuscitate or intubate. It would be cruel not to, because people like that have no quality of life and no hope for recovery. You can keep people alive indefinitely on a ventilator if you really wanted to, but what's the point? You've got to draw a line somewhere. In fact physicians have the right NOT to treat someone if they think it is medically futile.
I learned that prisoners of the state do not have the right to sign their life away. This is presumably because they are serving a sentence and signing a DNR would mean cutting the sentence short. Sort of ridiculous, but I guess some silly lawyer out there had something to do with that rule (god forbid a physician should be able to decide anything in healthcare). So here he was, basically a big bag of skin and bones with absolutely nothing to live for except his life sentence.
He had actually been admitted for hyponatremia, which means low blood sodium. It's a very complicated process which actually has nothing to do with the amount of sodium that you eat. Rather, it has to do with how much water you drink and how your body handles the water in your body. You may have heard of marathoners getting water intoxication when they chug large amounts of plain water. They become hyponatremic because they drink so much water that the sodium in their body gets diluted out. That's why it's better to drink gaterade because it has about the same concentration of sodium as the body. Hyponatremia can be incredibly dangerous if not treated properly. It can lead to seizures, brain swelling, even death. But there I was, an eager intern fresh out of medical school ready to take it on.
It was day 5 of his admission and I happened to be on call that night. I was laying down in the call room, trying to get some sleep, when I got a call from one of the nurses.
"You better go see Mr. G, he's in V-tach".
V-tach (or ventricular tachycardia) is one of those buzz words in medicine that makes doctors poop in their pants. The lifespan of your heart goes something like this: you're born, your heart beats a few billion times, you go into V-Tach, and then you die. So it was strange to get a phone call like this. Yes, I better go see him--I better run my ass up to the prison ward and resuscitate him. I was half asleep when I got the call, but I instantly shot out of bed, threw my stethoscope around my neck, and sprinted up 5 flights of stairs. By then, a "code" had been called over the loudspeakers (to announce it to all 2 doctors in the hospital) and a special protocol in the prison had been enacted.
For those of you who missed my last blog, the prison ward lives behind two large jail doors which require special authorization to pass through. Ordinarily it takes a good 2 minutes to get through those doors because you have to wait for one to close before the other one opens. The protocol for codes is that all prisoners are put back in their rooms immediately and all guards stand in the hall with their shotguns at the ready. Then, both doors swing open and a guy with a machine gun stands at the entrance.
Somehow that night, the protocol didn't go quite as planned. When I arrived on the prison floor, the jail doors were still closed. I could see the guards scrambling behind the glass because they couldn't get the doors open. Meanwhile, every second that passed was another thousand brain cells that my patient was losing. It was 3 minutes before they got the door open. I sprinted down the hall like I had never sprinted before. Things were flying out of my pockets, but I ignored them because I just had to get into the room. When I finally busted into the patient's room, there was a nursing student and a full-time nurse standing above the patient with a blood pressure cuff, trying to take some vitals. It had been at least 8 minutes since I was called and all they were doing was measuring the guy's blood pressure?
I shoved them aside in a dramatic fashion and felt for a pulse. No pulse. It doesn't take a blood pressure cuff to know that that means no blood pressure.
"He's got no pulse, grab a backboard and put it under him NOW!"
Ordinarily I'm a very quiet, unassuming guy. I speak rather slowly and never shout. But I was going on pure adrenaline that night. I had never even seen a real code let alone run one, but I modeled myself after what I had seen on TV.
I knew what to do because I had recently been trained in ACLS (that's CPR for doctors).
"Starting chest compressions"
-crrrrrrack-
I had taken CPR as a high school student, and I knew that it wasn't unexpected to break ribs when giving CPR, but I hadn't expected it to be that easy or quick. It was a little bit like pushing down on a rice crispy treat.
Giving real CPR is much faster than on TV. You have to pump the chest 100 times a minute, which is almost twice per second. So it gets tiring very quickly. But I went at it, pumping as fast as I could and hoping that all of a sudden, he would grasp for air and magically come back to life. Meanwhile, I was shouting at the nurses to go grab a mask so that I could ventilate the guy. It seemed like they were just standing around watching me. Nurses are supposed to be trained at the same stuff that I was trained in. So theoretically when I had arrived in the room, the nurses should have already been doing CPR and preparing the appropriate drugs for me to order. But things were a little different there.
There was no mask in the room, so they had to go run and find one. Meanwhile, I was demanding that they draw up epinephrine and atropine into a syringe. They fumbled around with it, not able to open the medicine vial or get appropriate IV access. It was completely embarassing to be part of this effort, but it seemed like I was the only person doing anything appropriate. Ultimately, it took them 12 minutes before they pushed the first round of epinephrine (something which probably should have been done before I had even arrived).
Next step was to intubate the man. In between chest compressions, I was shouting at the nurses to get an intubation kit. They finally found one and I ordered someone else to substitute for me in giving CPR. I opened the intubation blade (which I had only played with a few times before on a dummy) and found that the light wasn't working. It had run out of batteries. Trying to intubate someone without a light is like trying to find a needle in a haystack-in the dark. But I had no choice. I had one of the nursing assistants hold a pen light over my head while I tried to intubate. I knew the motions and knew where the structures were supposed to be. But without a light, I couldn't see anything and just kind of pushed the tube in where I thought it should go. Magically, it went into the right tube and the guy had been successfully intubated.
But still no pulse.
By then it had been almost 30 minutes of CPR without any success. A moonlighting senior resident finally showed up (he hadn't been notified of the predicament I was in) and told me that I should stop. So I stopped and called it.
Strangely, I was proud of myself. I had done everything appropriately and even intubated the guy without a light. I was drenched in sweat, but all I could do was look down at the poor guy. Legless, blood dripping from his IV site, his chest deformed from the broken ribs, and eyes staring straight up at the ceiling. He was dead. I think the statistic is that 90% of codes end in death, so I didn't feel that bad. In fact in many ways it was a relief that my patient had finally been allowed to die.
I later sat down with the senior resident and went over the case. He said that I had actually done a great job and that most senior residents might not have handled it as well as I had. I guess all those years of watching ER had paid off after all.
Saturday, July 14, 2007
My Time in Jail
My first month of internship was done in a state hospital. It was an acute medical service that took care of the patients that other hospitals didn't want to take care of - the homeless, drug addicts, crazy people, and prisoners. Actually eighty percent of the patients there were prisoners.
Any prisoner in the state who needed inpatient medical services would be turfed to this hospital. And I'm not talking about people who spent a night in jail for being drunk. These were state prisoners. They were first brought to a local ER, where they would be triaged and stabilized, and then transfered to our hospital. I hesitate to call it a hospital, because it was more like a big building which had a few untrained doctors and nurses wandering the halls.
The 8th floor was the locked ward. In psychiatric hospitals, a locked ward just means that the windows don't open and the doors lock. In this state hospital, the locked ward meant that it was basically jail. To enter the locked ward, you had to leave your keys, cellphone, and ID in a little slot. You had to sign in and state whom you were visiting and for what reason. Then they would open the jail doors.
You would think that because it was a hospital with sick people that things would be a little more pleasant. But there was nothing subtle about this ward. The jail doors were basically what you would think of. Big thick rusted bars that slammed when they opened or closed. It didn't seem like an environment fit for sick people trying to recover from illness.
The ward itself was just a long corridor with rooms on either side. There were a few single rooms for patients who had communicable diseases (there were many of those patients), but most rooms had 6 or 8 patients in them. Towards the end was a nurses station which was also locked behind bars. The air had a musty stench. It wasn't the standard septic hospital smell that I have grown used to.
There were always 10-12 prison guards on the ward at all times. When you wanted to enter a room, there had to be a guard with you. If there wasn't a guard available and a patient was crashing, you were supposed to let them die. Twice a day, there was a count. I guess it was like a roll call to make sure everyone was accounted for. I never knew exactly what happened because everyone had to leave the ward for this. There was no messing around in this facility.
The interesting thing about working there is that the patients were actually quite friendly. In fact many of them were more friendly than some of the patients that I had in the outside world. I guess it was that they appreciated a change in environment. Many of them were quite elderly and had been in prison for decades, so you can imagine how a trip to the hospital to treat a little skin infection might be an adventure. If I felt comfortable, I would ask them why they were in jail. Most of them seemed to be sex offenders. Rarely I would come across a murderer.
The actual practice of medicine there was kind of a joke. The nursing and ancillary staff were pretty much the worst that I have experienced. Because it was a state hospital, they made a decent salary and got a pension after working there for only 15 years. So many of them were just sticking around for those 15 years. They didn't care much about patients or their job. When 5 o'clock hit, they were already in their cars going home. As a physician, I would order medicines or order tests to be done. I was lucky if they got done 3 days later--most times they didn't ever happen. Not a good thing in medicine. If it was something that was crucial, I had to do it myself.
I was on call one night and the nurse paged me because she wanted to move one of the patients to a private room. She said he was being disruptive to his roommates. It was not an uncommon request, so I said OK and fell back to sleep. Later that night, I wandered up to the ward to make sure everything was OK and found that patient passed out on the floor in a pool of vomit. Turns out he was being disruptive because he was puking himself to death. The nurse didn't bother telling me that he was vomiting, but just wanted to separate him so that she could go relax. Heaven forbid I should tell her to give the poor man an anti-nausea medicine and IV fluids--that would mean working.
There was another nurse, clearly very new, who would call me at 3am for the stupidest things. One of the standard orders for inpatients is tylenol PRN. If you read my blog about prescription writing, you know that PRN means as needed. In these cases, the physician has already approved the medicine as safe for the patient, so it is up to the nurse to decide if he needs the medicine.
She would call with the same question.
"Can I give Mr. so and so some tylenol? He has a headache."
"Yes, didn't I write a PRN order for it?"
"Yes, but I just wanted to make sure with you before I gave it to him."
At 3am, this is incredibly frustrating. Tylenol is a pretty safe drug-it's over the counter. That means even a lay person can decide if they need it. It doesn't require 2 doctor's orders.
In the end, my experience at this hospital was an interesting one. Not many people can say that they met a murderer, or was a prison doctor. I'm glad I had the experience, but I probably wouldn't do it again if I had the choice.
Any prisoner in the state who needed inpatient medical services would be turfed to this hospital. And I'm not talking about people who spent a night in jail for being drunk. These were state prisoners. They were first brought to a local ER, where they would be triaged and stabilized, and then transfered to our hospital. I hesitate to call it a hospital, because it was more like a big building which had a few untrained doctors and nurses wandering the halls.
The 8th floor was the locked ward. In psychiatric hospitals, a locked ward just means that the windows don't open and the doors lock. In this state hospital, the locked ward meant that it was basically jail. To enter the locked ward, you had to leave your keys, cellphone, and ID in a little slot. You had to sign in and state whom you were visiting and for what reason. Then they would open the jail doors.
You would think that because it was a hospital with sick people that things would be a little more pleasant. But there was nothing subtle about this ward. The jail doors were basically what you would think of. Big thick rusted bars that slammed when they opened or closed. It didn't seem like an environment fit for sick people trying to recover from illness.
The ward itself was just a long corridor with rooms on either side. There were a few single rooms for patients who had communicable diseases (there were many of those patients), but most rooms had 6 or 8 patients in them. Towards the end was a nurses station which was also locked behind bars. The air had a musty stench. It wasn't the standard septic hospital smell that I have grown used to.
There were always 10-12 prison guards on the ward at all times. When you wanted to enter a room, there had to be a guard with you. If there wasn't a guard available and a patient was crashing, you were supposed to let them die. Twice a day, there was a count. I guess it was like a roll call to make sure everyone was accounted for. I never knew exactly what happened because everyone had to leave the ward for this. There was no messing around in this facility.
The interesting thing about working there is that the patients were actually quite friendly. In fact many of them were more friendly than some of the patients that I had in the outside world. I guess it was that they appreciated a change in environment. Many of them were quite elderly and had been in prison for decades, so you can imagine how a trip to the hospital to treat a little skin infection might be an adventure. If I felt comfortable, I would ask them why they were in jail. Most of them seemed to be sex offenders. Rarely I would come across a murderer.
The actual practice of medicine there was kind of a joke. The nursing and ancillary staff were pretty much the worst that I have experienced. Because it was a state hospital, they made a decent salary and got a pension after working there for only 15 years. So many of them were just sticking around for those 15 years. They didn't care much about patients or their job. When 5 o'clock hit, they were already in their cars going home. As a physician, I would order medicines or order tests to be done. I was lucky if they got done 3 days later--most times they didn't ever happen. Not a good thing in medicine. If it was something that was crucial, I had to do it myself.
I was on call one night and the nurse paged me because she wanted to move one of the patients to a private room. She said he was being disruptive to his roommates. It was not an uncommon request, so I said OK and fell back to sleep. Later that night, I wandered up to the ward to make sure everything was OK and found that patient passed out on the floor in a pool of vomit. Turns out he was being disruptive because he was puking himself to death. The nurse didn't bother telling me that he was vomiting, but just wanted to separate him so that she could go relax. Heaven forbid I should tell her to give the poor man an anti-nausea medicine and IV fluids--that would mean working.
There was another nurse, clearly very new, who would call me at 3am for the stupidest things. One of the standard orders for inpatients is tylenol PRN. If you read my blog about prescription writing, you know that PRN means as needed. In these cases, the physician has already approved the medicine as safe for the patient, so it is up to the nurse to decide if he needs the medicine.
She would call with the same question.
"Can I give Mr. so and so some tylenol? He has a headache."
"Yes, didn't I write a PRN order for it?"
"Yes, but I just wanted to make sure with you before I gave it to him."
At 3am, this is incredibly frustrating. Tylenol is a pretty safe drug-it's over the counter. That means even a lay person can decide if they need it. It doesn't require 2 doctor's orders.
In the end, my experience at this hospital was an interesting one. Not many people can say that they met a murderer, or was a prison doctor. I'm glad I had the experience, but I probably wouldn't do it again if I had the choice.
Saturday, July 7, 2007
The Alcoholic
Hospitals and ER's always have frequent flyers. These are patients who come to the ER or get admitted to the hospital repeatedly for the same reason. They are usually drunkards who need a bed for the night or stubborn elderly patients who refuse to take their medicine and have no family or friends to take care of them. The hospital where I did my internship had many such patients because we were located in one of the poorer neighborhoods.
One of these patients in particular was known to practically every physician, nurse, and security guard in the hospital. I can't give his name, but whenever anybody heard he was coming around, they rolled their eyes because they knew they were in for a frustrating and busy admission. We'll call him D.G.
D.G. is a 35 year old African American man who appeared like he was at least 50. He had gray hair, was constantly in pain, could not walk straight, and had blood shot eyes. To say that he was an alcoholic would be an understatement. He drank roughly 2 liters of vodka daily and a six pack of beer. He was incredibly frustrating to work with. He refused to take all medications, was rude to everyone, including the nicest, kindest nurses, and he always threatened to leave AMA (against medical advice) if he didn't get what he wanted. D.G. was usually able to make it a 2-3 weeks in between admissions.
Alcohol was killing him. I would be surprised if he made it past the next year if he continues to drink (and he will). Even if he miraculously decided to stop drinking, he would probably eventually succomb. His problems stemmed mainly from his liver, which had become so heavily scarred from constantly detoxifying the body of alcohol. This is cirrhosis of the liver.
Most people know about the circulatory system and how the heart pumps blood around blood vessels to feed various organs. This is the systemic circulatory system. But there is another circulatory system called the portal system. This system is still "powered" by the heart, but it involves a different set of blood vessels. These blood vessels start at the intestine, where they pick up nutrients absorbed by the GI tract and transports these nutrients (via blood) to the liver. The liver then does a whole host of metabolic functions including detoxification of the blood. The blood then moves on and eventually joins up with the systemic circulatory system. So the liver is the middle man between the portal and systemic circulatory system.
When the liver gets scarred, blood cannot travel through it as easily as it should. So pressure backs up into the portal system. This is called portal hypertension. Normal portal pressure is about 8mmHg, which is a very low pressure when you consider that normal arterial blood pressure is around 100mmHg. So when portal pressures increase, you get a whole host of physiologic changes. There are veins in the esophagus, stomach, and rectum which are involved in the portal system. When portal hypertension occurs, these veins get engourged. They become varicose veins, just like the ones on your legs but in different locations. Because they are located just beneath a thin layer of mucosa, these varicose veins can bleed very easily. Esophageal varices can be especially dramatic because patients can start vomitting blood, and it just poors out of them. Definitely a medical emergency. D.G. has been admitted multiple times for esophageal varices. I admitted him once in the ICU and he had lost more than half of his total blood volume. Ultimately we stopped the bleeding, but he left AMA when we refused to give him a turkey sub.
Another problem with portal hypertension is that fluid starts leaking out of the circulation and into the abdominal cavity. The portal system is not equipped to handling pressures that high, so the normal equilibrium which holds fluid in the blood vessels is disturbed. The result is what is called ascites, which is just fluid in the abdomen. The liver is also responsible for making albumin, a protein found in abundance in the blood. This protein also helps keep fluid within blood vessels. So when people have damaged livers, they stop making albumin and this further encourages fluid to accumulate in the abdomen.
D.G. probably had about 10 liters of fluid in his abdomen. That's 5 large coke bottles of fluid (and that may be underestimated). The first time you see him, it is really quite striking. His abdomen is larger than a pregnant woman's (although he does walk like one). The skin on his belly has a orangey-brown color and is spread so tightly that it looks like it will rip. The underlying abdominal muscles have also been spread thin and abdominal contents have bulged out of his abdomen and form a 5 centimeter lump on the side of his belly button. His belly button also has another lump. When you palpate his abdomen, it is rock hard. Push on your own belly and feel how soft it is. Now push on a piece of concrete and imagine that is what your stomach feels like.
D.G. walks around with this protuberant abdomen. The rest of his body is skinny, wasted, and cachectic because his only source of nutrition is alcohol. He looks like a starving child from Africa. These children also have protuberant abdomens from ascites because they do not eat enough protein. In turn, the liver cannot make albumin, which needs protein as a building block.
Every 3-4 weeks, D.G. has to come back to the hospital to have the fluid in his abdomen drained. Otherwise, I suppose he would ultimately pop. This procedures is called a paracentesis. This is a procedure that residents can perform. While it is not the most difficult procedure to perform, a procedure is always met with caution because of the potential complications. Paracentesis usually involves finding a pocket of ascites (fluid) and sticking a needle through the abdominal wall and into that pocket of fluid. Occasionally an ultrasound will be used to locate that pocket of fluid because you don't want to stick a needle into any of the abdominal organs. Interns are always very nervous and shaky the first time they do it because it seems like it could have potentially devastating consequences.
With D.G., it is a different story. His abdomen is so filled with fluid that you would be hard pressed to puncture an organ before you drain a significant amount of fluid. Performing a paracentesis on D.G. is like sticking a straw into a juice box. You just aim and shoot. Nothing to be worried about. This is one procedure that D.G. is actually cooperative with because it makes him much more comfortable after the fluid is removed. We usually are able to drain 6 liters of fluid at a time. This does not make his abdomen look any smaller, but it does make it a little softer to push on. D.G. came in so often for paracenteses and they were so easy to perform that the program director at our residency thought about setting up a formal rotation so that every resident could practice the procedure.
The sad thing about D.G. is that ascites and portal hypertension are just the beginning of his problems. He has many family issues, psychological issues, and a whole host of medical problems to deal with. It is easy for physicians to just blaim patients for their bad habits and chalk it up to stubbornness, but the fact is that D.G. had a lot to be sad about. There may be an underlying reason for his addiction.
Ultimately, though there is only so much that we can do in the medical profession. We can only treat what we know how to treat. Without cooperation from the patient and his social network, we are helpless.
One of these patients in particular was known to practically every physician, nurse, and security guard in the hospital. I can't give his name, but whenever anybody heard he was coming around, they rolled their eyes because they knew they were in for a frustrating and busy admission. We'll call him D.G.
D.G. is a 35 year old African American man who appeared like he was at least 50. He had gray hair, was constantly in pain, could not walk straight, and had blood shot eyes. To say that he was an alcoholic would be an understatement. He drank roughly 2 liters of vodka daily and a six pack of beer. He was incredibly frustrating to work with. He refused to take all medications, was rude to everyone, including the nicest, kindest nurses, and he always threatened to leave AMA (against medical advice) if he didn't get what he wanted. D.G. was usually able to make it a 2-3 weeks in between admissions.
Alcohol was killing him. I would be surprised if he made it past the next year if he continues to drink (and he will). Even if he miraculously decided to stop drinking, he would probably eventually succomb. His problems stemmed mainly from his liver, which had become so heavily scarred from constantly detoxifying the body of alcohol. This is cirrhosis of the liver.
Most people know about the circulatory system and how the heart pumps blood around blood vessels to feed various organs. This is the systemic circulatory system. But there is another circulatory system called the portal system. This system is still "powered" by the heart, but it involves a different set of blood vessels. These blood vessels start at the intestine, where they pick up nutrients absorbed by the GI tract and transports these nutrients (via blood) to the liver. The liver then does a whole host of metabolic functions including detoxification of the blood. The blood then moves on and eventually joins up with the systemic circulatory system. So the liver is the middle man between the portal and systemic circulatory system.
When the liver gets scarred, blood cannot travel through it as easily as it should. So pressure backs up into the portal system. This is called portal hypertension. Normal portal pressure is about 8mmHg, which is a very low pressure when you consider that normal arterial blood pressure is around 100mmHg. So when portal pressures increase, you get a whole host of physiologic changes. There are veins in the esophagus, stomach, and rectum which are involved in the portal system. When portal hypertension occurs, these veins get engourged. They become varicose veins, just like the ones on your legs but in different locations. Because they are located just beneath a thin layer of mucosa, these varicose veins can bleed very easily. Esophageal varices can be especially dramatic because patients can start vomitting blood, and it just poors out of them. Definitely a medical emergency. D.G. has been admitted multiple times for esophageal varices. I admitted him once in the ICU and he had lost more than half of his total blood volume. Ultimately we stopped the bleeding, but he left AMA when we refused to give him a turkey sub.
Another problem with portal hypertension is that fluid starts leaking out of the circulation and into the abdominal cavity. The portal system is not equipped to handling pressures that high, so the normal equilibrium which holds fluid in the blood vessels is disturbed. The result is what is called ascites, which is just fluid in the abdomen. The liver is also responsible for making albumin, a protein found in abundance in the blood. This protein also helps keep fluid within blood vessels. So when people have damaged livers, they stop making albumin and this further encourages fluid to accumulate in the abdomen.
D.G. probably had about 10 liters of fluid in his abdomen. That's 5 large coke bottles of fluid (and that may be underestimated). The first time you see him, it is really quite striking. His abdomen is larger than a pregnant woman's (although he does walk like one). The skin on his belly has a orangey-brown color and is spread so tightly that it looks like it will rip. The underlying abdominal muscles have also been spread thin and abdominal contents have bulged out of his abdomen and form a 5 centimeter lump on the side of his belly button. His belly button also has another lump. When you palpate his abdomen, it is rock hard. Push on your own belly and feel how soft it is. Now push on a piece of concrete and imagine that is what your stomach feels like.
D.G. walks around with this protuberant abdomen. The rest of his body is skinny, wasted, and cachectic because his only source of nutrition is alcohol. He looks like a starving child from Africa. These children also have protuberant abdomens from ascites because they do not eat enough protein. In turn, the liver cannot make albumin, which needs protein as a building block.
Every 3-4 weeks, D.G. has to come back to the hospital to have the fluid in his abdomen drained. Otherwise, I suppose he would ultimately pop. This procedures is called a paracentesis. This is a procedure that residents can perform. While it is not the most difficult procedure to perform, a procedure is always met with caution because of the potential complications. Paracentesis usually involves finding a pocket of ascites (fluid) and sticking a needle through the abdominal wall and into that pocket of fluid. Occasionally an ultrasound will be used to locate that pocket of fluid because you don't want to stick a needle into any of the abdominal organs. Interns are always very nervous and shaky the first time they do it because it seems like it could have potentially devastating consequences.
With D.G., it is a different story. His abdomen is so filled with fluid that you would be hard pressed to puncture an organ before you drain a significant amount of fluid. Performing a paracentesis on D.G. is like sticking a straw into a juice box. You just aim and shoot. Nothing to be worried about. This is one procedure that D.G. is actually cooperative with because it makes him much more comfortable after the fluid is removed. We usually are able to drain 6 liters of fluid at a time. This does not make his abdomen look any smaller, but it does make it a little softer to push on. D.G. came in so often for paracenteses and they were so easy to perform that the program director at our residency thought about setting up a formal rotation so that every resident could practice the procedure.
The sad thing about D.G. is that ascites and portal hypertension are just the beginning of his problems. He has many family issues, psychological issues, and a whole host of medical problems to deal with. It is easy for physicians to just blaim patients for their bad habits and chalk it up to stubbornness, but the fact is that D.G. had a lot to be sad about. There may be an underlying reason for his addiction.
Ultimately, though there is only so much that we can do in the medical profession. We can only treat what we know how to treat. Without cooperation from the patient and his social network, we are helpless.
Sunday, July 1, 2007
The Death Exam
When I was a medical student, I followed a woman who died under my care. She was in her 70's, required dialysis every other day, and was admitted because of a massive stroke.
The stroke had made her completely incapacitated, unable to speak, move, or even control her bladder. Her eyes were permanently gazed to the left when she opened them.
Ultimately her family felt that she had no hope of meaningful recovery and decided to "let her go". We stopped giving her the dialysis that she required to stay alive and one week later, she passed.
While I wasn't present the moment she died, my resident told me afterwards, and I went along with him to pronounce her. It wasn't the first time I had seen a dead body, but it was the first time I had seen the dead body of someone that I had just seen alive. Her body still had some warmth to it, but you could tell that her muscles were starting to stiffen up. You wouldn't know she were dead if you just walked into the room. She just lay there peacefully in bed with her eyes shut.
But then you put your stethoscope on her chest and nothing. As medical students, we are always working hard to refine our physical exam skills. So we listen very carefully for every detail in the heart and lung sounds. You get used to hearing strange sounds that you've never heard before, but you accept them because you're just a medical student. But to examine someone's chest and not hear anything except emptiness is completely foreign even for a medical student.
I didn't actually perform a death exam myself until I was an intern. The basics of it include listening for heart and lung sounds, and checking for reflexes which test basic brain stem function.
There are a few different reflexes that you can check. One is the corneal reflex where you take a wisp of a cotton swab and touch it to the surface of the patient's eye. If the reflex is intact, they should blink. Another is called the occulomotor or "doll's eye" reflex. This involves holding the patient's eyes open and rotating their head from side to side (as if they were gesturing "no"). If the brain stem is intact, the eyes should rotate the opposite direction of their head so that their pupils actually stay centered as if they were looking at a single point straight ahead.
Another thing to check for is response to pain. The sternum (breast bone) does not have much fat or muscle overlying it. So when you rub it (usually with your knuckles) it is pretty painful. I prefer doing this, while others do a nipple pinch, which is exactly what it sounds like. Kind of cruel and obscene if you ask me.
And that's really all there is to pronouncing somebody dead. I'm not quite sure why it takes an MD to pronounce death. It's not all that complicated to perform. But it can be incredibly difficult for other reasons.
I was on call one night in the cardiac care unit. The nurse called me because one of other interns' patients had died and they needed me to pronounce him. So I walked over to the room with my cotton swab and stethoscope. When I entered, there were about 10 family members in there sobbing, hugging the patient and hugging each other. The room was dead silent except for the sobbing. It took me by surprise, but I had to do the exam so I broke the silence by introducing myself, giving my condolences, and explained what I needed to do. I gave them the option of leaving the room while I did the exam, but they wanted to stay to be with him. Just great. They stepped aside, eyes still fixed on their loved one, and I stepped forward. I don't like audiences to begin with, and now I had to do this in front of the poor family. I proceeded in as gentle a manner as I could. I listened to the chest, jammed his eyes open, stuck the cue tip into his eyes, rocked his head back and forth, and then crushed my fist into chest. He was dead. "Time of death, 13:43." The room burst into tears as everybody broke down at my words. I once again said how sorry I was and ran out of the room, mortified.
To this day, I'm still not sure if you actually have to say the time of death out loud.
I mean, they always do it on TV. But after that first experience, now I always ask the family to leave the room when I perform the exam. It's just not right to watch your loved one being manipulated like that.
The stroke had made her completely incapacitated, unable to speak, move, or even control her bladder. Her eyes were permanently gazed to the left when she opened them.
Ultimately her family felt that she had no hope of meaningful recovery and decided to "let her go". We stopped giving her the dialysis that she required to stay alive and one week later, she passed.
While I wasn't present the moment she died, my resident told me afterwards, and I went along with him to pronounce her. It wasn't the first time I had seen a dead body, but it was the first time I had seen the dead body of someone that I had just seen alive. Her body still had some warmth to it, but you could tell that her muscles were starting to stiffen up. You wouldn't know she were dead if you just walked into the room. She just lay there peacefully in bed with her eyes shut.
But then you put your stethoscope on her chest and nothing. As medical students, we are always working hard to refine our physical exam skills. So we listen very carefully for every detail in the heart and lung sounds. You get used to hearing strange sounds that you've never heard before, but you accept them because you're just a medical student. But to examine someone's chest and not hear anything except emptiness is completely foreign even for a medical student.
I didn't actually perform a death exam myself until I was an intern. The basics of it include listening for heart and lung sounds, and checking for reflexes which test basic brain stem function.
There are a few different reflexes that you can check. One is the corneal reflex where you take a wisp of a cotton swab and touch it to the surface of the patient's eye. If the reflex is intact, they should blink. Another is called the occulomotor or "doll's eye" reflex. This involves holding the patient's eyes open and rotating their head from side to side (as if they were gesturing "no"). If the brain stem is intact, the eyes should rotate the opposite direction of their head so that their pupils actually stay centered as if they were looking at a single point straight ahead.
Another thing to check for is response to pain. The sternum (breast bone) does not have much fat or muscle overlying it. So when you rub it (usually with your knuckles) it is pretty painful. I prefer doing this, while others do a nipple pinch, which is exactly what it sounds like. Kind of cruel and obscene if you ask me.
And that's really all there is to pronouncing somebody dead. I'm not quite sure why it takes an MD to pronounce death. It's not all that complicated to perform. But it can be incredibly difficult for other reasons.
I was on call one night in the cardiac care unit. The nurse called me because one of other interns' patients had died and they needed me to pronounce him. So I walked over to the room with my cotton swab and stethoscope. When I entered, there were about 10 family members in there sobbing, hugging the patient and hugging each other. The room was dead silent except for the sobbing. It took me by surprise, but I had to do the exam so I broke the silence by introducing myself, giving my condolences, and explained what I needed to do. I gave them the option of leaving the room while I did the exam, but they wanted to stay to be with him. Just great. They stepped aside, eyes still fixed on their loved one, and I stepped forward. I don't like audiences to begin with, and now I had to do this in front of the poor family. I proceeded in as gentle a manner as I could. I listened to the chest, jammed his eyes open, stuck the cue tip into his eyes, rocked his head back and forth, and then crushed my fist into chest. He was dead. "Time of death, 13:43." The room burst into tears as everybody broke down at my words. I once again said how sorry I was and ran out of the room, mortified.
To this day, I'm still not sure if you actually have to say the time of death out loud.
I mean, they always do it on TV. But after that first experience, now I always ask the family to leave the room when I perform the exam. It's just not right to watch your loved one being manipulated like that.
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