28 May 2013

Non-judgmental regard

When I first met the patient, two armed corrections officers with serious expressions were standing at his bedside. I wondered why he was in jail. I'm sure the other members of my medical team were curious as well. But we all knew that it would be highly unprofessional for us to ask. After all, what he stood accused of should have had no bearing on how we treated him. This attitude exemplified "non-judgmental regard," a precept of medical practice that I've been grappling with for years.

From a post of mine in August 2011:
...[I find] the most extraordinary and difficult tenet of modern medical ethics [to be] "non-judgmental regard." Physicians are supposed to take patients exactly as they are, without judging or discriminating. In principle, then, the armed robber and the man he injured, in neighboring beds in the ER, are provided the same degree of care. The morbidly obese smoker with a heart attack should be treated with the same earnestness as the thin one. Judgments of worth or character are independent of treatment...

Because I've decided to become a medical student, I have to make medicine's ethical precepts my own. But I have a difficult time with shedding judgment. I don't treat people equally in my own life. I have friends, acquaintances, and enemies, and I care about some of them more than others. In clinic, some patients' stories touch me more than others'. One patient had developed a crippling Parkinsonian tremor, probably secondary to his addiction to meth that he had tried and failed to kick. His circumstances were wrenching and I especially wanted to help this man. My next patient, a woman with conjunctivitis who lambasted me for fumbling at first with the blood pressure cuff, was less inspiring. Some patients are especially kind to me in a way that I particularly want to reciprocate...

I couldn't shake my curiosity about the patient, and ultimately did discover why he was in jail. He was a convicted murderer.

My professional ethics dictated that this revelation shouldn't matter to me. But I felt conflicted. After all, whenever someone is assigned to me or my team as a patient, I care about them. I smile at them when I see them. I stop by their room, sometimes several times a day, to say hello and to see how they're doing, to see how I might help. And I sincerely want to see them become healed. But, for a murderer? On a rotation so busy that I felt I was neglecting my friends and family, could I justify lavishing this kind of endearment upon a murderer?

I reflected on the ideals of our legal system, which stipulates that every person deserves legal representation. I reflected on the ideals of our penal system, which hopes to reform prisoners into moral and functioning members of society. I also reflected on the ideals of religion, which strives to improve all men's souls. Should medicine, the art of healing, be any less noble and discriminate among who it cares for?

What has kept me going throughout medical school, and what compels me to set my alarm for 4 AM some days, is an idea. It's a belief that medicine is a worthy calling, a profession that can improve others and improve myself. This medical profession behooves me to care for even the most depraved among us, no matter how vexing that might feel. We must respond to hate with love. We must strive to relieve suffering and to do no harm.

If you do read my full post from 2011, you'll see how ambivalent I was about treating all patients the same. My thoughts have since shifted. I more firmly believe now that non-judgmental regard is an aspiration worth pursuing.

26 May 2013


In the wee hours of the morning, the emergency department intercom came to life, crackling that a patient with serious trauma would be arriving within minutes. A dozen of us rushed over to the trauma bay and started suiting up in gowns and face shields. Someone said that the victim had suffered multiple gunshot wounds. We ran around grabbing equipment: blood, an ultrasound machine, chest tubes. I went to the ambulance bay and spotted the patient's stretcher being wheeled in. "The patient arrived!" I shouted.

"Patient's here!" they echoed.

The patient loud yelling was muffled by his oxygen mask. That he was screaming was actually a good sign, because it meant that his airway was intact and that he was breathing. The doctors set to work, placing IVs, hooking the patient up to "the monitor" (the machine that displays vital signs), checking for gunshot exit and entry sites, palpating pulses. One doctor yelled that the patient's breath sounds were muffled on one side, a sign that the patient had hemothorax (blood accumulating in the chest). Another doctor got out a scalpel and, making a deep incision, jammed in a plastic tube to drain the blood. This made the patient scream, but he seemed to be drifting off. Another doctor injected anesthetics that paralyzed the patient and put him to sleep, while another intubated the patient and hooked him up to a ventilator. Standing at my out-of-the-way perch at the end of the bed, I checked the patient's feet. They were cold and clammy. This confirmed what we already knew: that the patient was in shock, probably due to internal bleeding. The doctor checking for gunshot wounds kept finding more and more, over ten by now in the patient's abdomen, chest, and extremities. One doctor yelled that he had a large hematoma (pool of blood) in one of his arms and no pulse in that hand. Bad news. A bullet must have severed the main artery to the arm. Two doctors using the ultrasound machine pointed excitedly at the screen. "Free blood in Morison's pouch," one yelled. "We have a positive FAST exam!" This meant that the patient was bleeding heavily into his abdomen. He'd have to go the operating room right away.

The X-ray crew cleared the room so that they could obtain an image. Taking advantage of the pause in the action, I threw out my bloodied gown and gloves, ditched my white coat, and put on my operating room attire. Then I guided the patient's hospital stretcher into the giant elevator that would whisk us up to the operating suites.

In stark contrast to the din of the past few minutes, the elevator ride was quiet. There were only three of us in the elevator, each of us stock-still, deep in his own thoughts. I gazed at the patient's vacant face and realized I didn't even know his name. "Who are you?" I wondered. "Who did this to you?" Was it a drug dealer? The police? An ex-girlfriend? I invented version after version of this man's story. With each iteration, I asked myself, couldn't this scenario have been avoided, through forward-thinking laws, more schooling, better funding for social services? Why are we so cruel to each other, why must guns even exist? This anonymous young man, blood oozing from his side and a machine breathing for him, seemed to indict our society's ills. There had to have been some opportunity we missed to prevent his being pumped with so many slugs of lead. And now, at an ungodly hour when we should all be asleep, dozens of us were working furiously on this man's behalf. Why was it only now, when he was already in the clutches of death, that we were sparing this man no expense?

The chime of the elevator interrupted my ruminations. As the doors opened onto the sterile halls of the operating suites, I steeled myself for the grim hours in the operating room that laid ahead.

25 May 2013

I blame names

Try your hand at a question from one of our anatomy exams: What nerve supplies the obturator internus muscle (a muscle in the pelvis)? The correct answer is the "nerve to obturator internus." It's like answering who is buried in Grant's Tomb.

As a time-strapped medical student, it feels like a godsend when a medical term is named in an obvious way. Even a lay person can intuit the meaning of medical terms like "urinary tract infection," "vocal cord paralysis," and "foot drop." Unfortunately, the meanings of medical terms are rarely so obvious.

Sometimes I can decipher the meaning of a medical term by looking at its Latin or Greek roots. "Nephrectomy", the surgical removal of a kidney, is a combination of "nephro-", from the Greek root for "kidney", and "-ectomy", from the Greek root for surgical excision. By knowing roots like these, I can decipher the meaning of a new term. Thus, a ureterectomy is the surgical removal of a ureter. A nephroureterectomy is the surgical removal of a kidney and a ureter. An appendectomy is the surgical removal of the appendix. Similarly, I can tell from its name that the supraclavicular artery runs above the clavicle, and that the ovarian artery supplies the ovary. It's fantastic.

But even this approach can run me into trouble. In 1806, a dermatologist named a particular skin disease "mycosis fungoides", from the roots for "mushroom" and "fungus", because it looks like a fungal infection. We now know that it is a type of lymphoma, with nothing to do with fungus or infection. But the name has stuck. Similar examples abound.

Often a medical term has no connection its meaning. Sometimes this is because the disease is named after its discoverer. Berger's disease affects the kidney, whereas Buerger's disease affects the small arteries of smokers.

The worst offenders are when medical terms are simply numbered in the order of their discovery. Our white blood cells have a category of proteins on their surface called "cluster of differentiation". The various proteins have been numbered from CD1 up to CD350. For some CD proteins, we need to have memorized which subcategories of cell types express them: for example,

CD3: T-cell;
CD4: Helper T-cell (depleted in AIDS);
CD8: Killer T-cell;
CD15: Reed-Sternberg cell (seen in certain leukemias);
CD30: Reed-Sternberg cell;
CD56: Natural killer cell;

and so on.

Exams like our national boards are chock-full of questions that test whether you realize that "lupus anticoagulant" is erroneously named, or that IL5 stimulates allergic reactions while IL10 tamps them down. Memorizing all of this takes a lot of time.

I maintain that time spent memorizing these silly names is time not spent learning other things, like how to heal patients. Medical nomenclature is needlessly complex. We should try to make our names for things easier to decipher.

17 May 2013

Schedule change

Most nights my eyes snap awake around 4:30 AM. I look over at my clock and realize that there's no point in going to back to sleep, because my alarm will be going off in a half-hour or so. I rush over to my computer so that I can use these precious extra minutes to read up on the day's surgical cases. I need to study the procedures and the patients' case histories so that I can give an intelligent response when the surgeons quiz (or as the profession calls it, "pimp") me in the operating room.

I'm grateful to my body for (largely uncomplainingly) accommodating the demands of the surgery rotation: the long hours standing in the operating room, the waking up early and going to bed late, the postponing meals. I haven't had to leave a surgery partway through to use the bathroom, I haven't fallen asleep during a procedure, and I haven't felt like I was going to pass out in the operating room. I've kept my cool during tense and frustrating moments. But each of these little victories has been hard-fought, requiring planning, vigilance, and conscious acts of will. I understand now how invigorating it is to be in the operating room, and I've felt very alive those times a surgeon has had me suture an incision or electrocauterize some tissue.  But the longer I spend on my surgery rotation, the less I comprehend how surgeons and surgical residents are able to keep it up for so many years.

09 May 2013

Non-standard operating procedure

It is my surgery rotation. My team consists of a number of surgery residents and myself. Until today, I had been spending the rotation observing my team's residents in clinic, on the wards, and in the operating room.

At our academic hospital, when a surgeon (an attending physician) operates, they are expected to have an assistant (typically a surgery resident). My team made a last-minute request to have a procedure added to the day's operating room schedule. By the time the operating room coordinators granted the request, everyone on my team was tied up, except me. Who would assist? The surgeon asked me to change into scrubs and meet her at the operating room.

I was beaming as I raced to the cafeteria to cram in some food (one should not operate on an empty stomach) and then scampered up the stairs to the operating suites.

Few medical students ever have the chance to serve as "first assist." This procedure was a good one for me because it was relatively brief and low-risk. I threaded catheters and stents through the patient's body, tasks that involved a fair amount of dexterity. I also inserted tubing that drained the patient's bladder, and mixed and injected medications. The surgeon and I had to communicate well, because our tasks involved complicated steps and movements that we needed to perform simultaneously. She also had to trust me, because my hands often were out of her field of view.

The procedure ended, and the patient was moved off the operating table. I thanked the surgeon for letting me join her and she congratulated me on a job well done. She said that the next time we did the procedure, I would be the primary surgeon and she would assist. I don't think she was joking.

04 May 2013

The comfort of the dying

Doctors are expect to comfort the dying. Sometimes, the dying comfort the doctors.

The attending physician introduced me to one of his patients. While standing at the patient's bedside, and with the patient listening, the doctor recounted "this unfortunate patient's" case history. The patient had hemophilia, meaning his blood didn't clot properly on its own. During childhood, the patient had contracted Hepatitis C from contaminated blood transfusions (with today's screening methods, the risk of this occurring is remote). Now the patient had incurable and widely metastatic liver cancer, probably because of his Hepatitis C infection. Although his body was ravaged and wasted, his mind remained perfectly intact. The patient had spent most of the preceding years in and out of the hospital.

The doctor performed a physical exam and made sure that the patient's pain was well-controlled. The doctor then informed the patient that it was his last day on duty before he took off for a week. The patient smiled, and while looking us both in the eye, he thanked us and told us that he truly appreciated the excellent care that he had received at our hospital. We shook hands and left.

Medicine could no longer help this patient avoid death, and part of me felt like my profession had failed him. But the patient was not upset with us. He even mustered up the effort to thank us for our care. His words had conviction and purity, and we received them with particular solemnity and reverence. It was one of the most heartwarming moments I've experienced as a medical student. The words of a dying man mean a lot to us.

Patient privacy

I attended a talk by author Salman Rushdie concerning the role of the novelist. He said that the novelist must remember above all that a novel is about individual people. Although people's lives are increasingly affected by abstract influences like political upheaval and globalization, only through the lens of a person's story can the novelist explore these trends and changes.

One of my favorite parts of being around patients is hearing their narratives, and there are many that I would like to recount through my blog. After all, medicine offers rich material for stories. Illness, death, and birth are replete with drama. Our reactions to these dramatic events give a window into our souls. And the story of people's illnesses are inextricably linked to societal influences: the veteran who is dying because of complications from Agent Orange exposure, the illegal immigrant who cannot obtain insurance, the young girl who receives a donated kidney. By exploring the individual stories of patients, we make sense of the human experience and also make sense of society.

The major issue I encounter is that my ethical, professional, and legal obligations disallow me from jeopardizing patient privacy. I sometimes protect patient privacy by altering or fabricating details of their cases, but I hate to do it because I perceive myself a sort of journalist, one who should strive for truthfulness and accuracy. And so, the more unique a patient's story, the more blandly I have to write about it, because I otherwise risk jeopardizing the patient's anonymity and confidentiality. Two of my favorite medical bloggers recounted powerful patient stories, and included details that were critical to the stories but which I thought might be personally identifying. On a hunch, I searched around the internet and determined the patients' names within minutes. This is no good. I want my blog to be so discreet that a patient who read my blog wouldn't think that a story was about them. I further insulate the people I discuss by keeping my identity and location anonymous.

Although I find myself wanting to write about my patients, I instead write about myself, about wider societal issues, and about news stories. I think it makes my blog less compelling, in the way that a history textbook is less compelling than a good novel. Nearly two years into my blog, I'm still experimenting with the medium.