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.
Sunday, July 29, 2007
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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