tag:blogger.com,1999:blog-67931796585303534452024-03-12T20:27:33.903-07:00The Reflex HammerA medical student's remarks on health and the medical professionUnknownnoreply@blogger.comBlogger199125tag:blogger.com,1999:blog-6793179658530353445.post-23340193698050400242014-09-18T11:39:00.001-07:002016-09-23T00:08:31.849-07:00Doubt, but verify<i>(My entry to an essay contest.</i>)<br />
<br />
I struggled with knowing when I should believe my patients on the locked psychiatric ward. Some of my patients were reliably forthcoming and honest. Other patients’ stories were clearly unrealistic (one told me that he was being chased by black, chainsaw-wielding government robots that travel through walls). And others made prosaic claims (such as their name and age) that sounded credible, but proved untrue. After being misled several times by my patients, my attending physician advised me to become more of a skeptic. I began taking what my psychiatric patients said not just with a grain of salt, but with a heaping helping.<br />
<br />
One day, I met a new patient, Jensen, who had been committed to the psychiatric ward that morning. He was a lanky, disheveled-looking methamphetamine addict who subsisted on begging and theft. He lived in a distant town. Fresh out of prison, he had decided to come to our hospital because he had recently contemplated suicide. A staff member who interviewed Jensen on intake suspected that he was malingering in an attempt to score a warm bed and a square meal.<br />
<br />
When I interviewed Jensen, I asked why he had contemplated suicide. He replied that he had become depressed ever since his daughter had been raped and murdered by his best friend. I assumed a look of sympathetic concern and expressed my condolences. My empathy was forced, though. I doubted Jensen’s story. And I especially did not want to be fooled by yet another patient.<br />
<br />
Over the course of the interview, I delicately obtained more details about the supposed crime: where it had occurred, who had been arrested, where the case had gone to trial. Afterwards, I hopped onto a computer and queried an internet database of news articles. Several articles came up that confirmed Jensen’s grisly story. I felt horrified and sickened. I also wondered whether anyone could experience what Jensen had gone through without being plunged into despair.<br />
<br />
Discovering the veracity of Jensen’s story forced me treat his pain as real, and to engage with it. When I met with Jensen that afternoon, I felt more sympathy towards him. I told him that my heart went out to him for what he had suffered. Despite our different backgrounds, I felt as though I was beginning to understand him. We seemed to connect particuarly well.<br />
<br />
The tragedy that had befallen Jensen gnawed at me that day. It marred my sleep that night. As I mulled over his story, Jensen struck me as someone who had endured a near-mythical degree of torment. Jensen’s life story seemed to be an allegory, one that embodied society’s ills and condemned the cruelty of man.<br />
<br />
When I visited Jensen the next morning, he begged me to be released from the hospital. He told me that a friend had offered to drive him home, but only if he were discharged that morning. At rounds, my team decided that Jensen no longer appeared to pose an acute threat to himself. We acceded to his request and discharged him.<br />
<br />
<hr />
<br />
I was able to provide Jensen with more humanistic care because I verified his story online. Was looking online the right thing to do here? I am not completely sure, but I think it was. When I am curious about how a former patient is doing, or when I want to better understand a patient’s story, I sometimes feel tempted to search online. I nearly always resist the urge, though. “Googling” a current patient is an act fraught with ethical and practical concerns. Some information found online is inaccurate or misleading, and it could inappropriately bias a clinician. Some patients may feel it is improper for their doctors to be searching for them online.<br />
<br />
I also worry about the potential to violate patient privacy. Companies routinely store and analyze data that include the search phrases a user types in and the exact location of their computer. If a clinician seated at a hospital computer performed a series of searches on a patient, private companies (and our government) could probably piece together confidential medical information such as where that patient received their medical care and what diagnoses they carried. (I tried to protect Jensen’s privacy by using vague search terms that could not be tracked back to him.)<br />
<br />
In the acute psychiatric setting especially, though, online searches could have tremendous utility as a fact-finding tool. Already, psychiatrists routinely solicit “collateral information,” which might include hospital records, police reports, and conversations with family members. The collateral information can reveal whether a patient’s statements comport with reality, clarifying between diagnoses such as psychosis, antisocial personality, and malingering. Another benefit of an online search is that it can vindicate a patient such as Jensen who makes genuine statements that are not believed.<br />
<br />
On the whole, I am leery of clinicians’ “Googling” their patients. But I think there are infrequent circumstances in which searching online is warranted, my encounter with Jensen among them. I am grateful for how confirming Jensen’s story helped me connect with him more deeply, and helped me lend a sympathetic ear.<br />
<br />
<hr />
<br />
Shortly after Jensen was discharged, I hopped into my car to run an errand. Pulling up to a red light near the hospital, I recognized the panhandler standing in the center median. It was Jensen. He saw me, and smiled and waved. I rolled down my window. I explained that I could not give him money, but told him where he might be able to get a free bus pass home. He thanked me. I wished him the best.<br />
<br />
Jensen was standing in the median because he had invented the story about his friend with a car who would pick him up. He had correctly predicted that the ruse would speed up his discharge. And so, despite my efforts, yet another patient ended up fooling me. The difference was that now, I did not mind.<br />
<br />
The light turned green. I drove off, never to see Jensen again.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-31404389707285229602014-09-10T09:33:00.002-07:002014-09-10T09:36:41.511-07:00EbolaThe excellent PBS program <i>Frontline</i> has put out <a href="http://www.pbs.org/wgbh/pages/frontline/ebola-outbreak/">an insightful and tragic documentary</a> about life in a Sierra Leone field hospital that has been overwhelmed by Ebola. <br />
<br />
And the WHO has recently put out <a href="http://www.who.int/mediacentre/news/ebola/8-september-2014/en/">a situation assessment</a> of the state of the virus in Liberia.<br />
<br />
Also, I recommend <a href="http://blogs.msf.org/en/staff/authors/benjamin-black">the well-written blog</a> of a Médecins Sans Frontières ("Doctors Without Borders" in the U.S.) obstetrician who until recently was on the front lines.<br />
<br />
Together, these items paint a sobering picture of the state of the current Ebola outbreak.<br />
<br />
Ebola outbreaks can be halted (and have been halted on the past) through known methods, in particular by isolating sick patients and following up with their close contacts who may have been exposed, as well as by partnering with communities to stop risky behaviors such as funeral practices that involve touching the dead body. Although vaccines and experimental therapies are promising, we need not wait on them. Perhaps with significant investment from the international community, the tide will turn in the battle against Ebola.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-63362072707488654222014-09-02T22:45:00.001-07:002014-09-28T20:32:36.842-07:00The unacceptableWalking one day, I spotted one of the Google self-driving cars. It looked similar to the other cars in the road, except that mounted atop the car was a spinning apparatus that constantly scanned its surroundings.<br />
<br />
I was quite glad to see it.<br />
<br />
<hr />
Another day, while walking from the hospital, I heard a medical helicopter overhead and looked skyward. The helicopter was swooping towards the landing pad with haste. I figured that this was not a routine transport, but a medical emergency. I spun around and headed to the trauma bay to see what was up.<br />
<br />
An alert on the emergency department's computer screen filled me in on some of the story: the helicopter was carrying a child who had been struck by a car and was now in cardiac arrest.<br />
<br />
The trauma bay was buzzing with activity. A pharmacist was busy drawing up medications. The trauma surgeons were contemplating their plan of action. The X-ray tech was wheeling in his machine. I perched myself in an out-of-the-way corner.<br />
<br />
The patient arrived, bloodied and pale. Worried personnel were doing chest compressions. A nurse hooked the patient up to the heart monitor, and the head doctor asked the medical team to stop compressions (so that the heart monitor could detect the patient's heart rhythm). The patient was still. We looked at the heart monitor: it showed simply a flat line. An ultrasound confirmed that the heart had no activity. There was nothing to be done. "Time of death..." intoned one of the physicians.<br />
<br />
This patient had been killed by a car while walking to school, becoming one of the approximately <a href="http://www.cdc.gov/nchs/fastats/accidental-injury.htm">33,783</a> motor vehicle fatalities that occur each year in the U.S.<br />
<br />
<hr />
A leading social scientist once wrote, "the history of public health can be written as a constant redefinition of the unacceptable."<br />
<br />
I submit that this patient's death by car should be considered not just a tragedy, but an unacceptable tragedy. <a href="http://thereflexhammer.blogspot.com/2012/01/drive-towards-safety.html">As I've written previously</a>, a major solution to these automobile deaths lies on our doorstep: the autonomous car. With a concerted push for further research and development, many of the cars on the road could drive themselves, identifying hazards and preventing crashes.<br />
<br />
But to get there, we need to decide that automobile fatalities are unacceptable. New York City has taken a commendable step in this direction, inaugurating the <a href="http://www.nyc.gov/html/visionzero/pages/home/home.html">"Vision Zero" program</a>. Below is an excerpt of the City's justification for the program:<br />
<blockquote class="tr_bq">
<div style="text-align: justify;">
<span style="font-family: Georgia,"Times New Roman",serif;">The primary mission of government is to protect the public. New
York’s families deserve and expect safe streets. But today in New York,
approximately 4,000 New Yorkers are seriously injured and more than 250
are killed each year in traffic crashes. Being struck by a vehicle is
the leading cause of injury-related death for children under 14, and the
second leading cause for seniors. On average, vehicles seriously injure
or kill a New Yorker every two hours.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Georgia,"Times New Roman",serif;">This status quo is unacceptable. The City of New York must no longer
regard traffic crashes as mere “accidents,” but rather as preventable
incidents that can be systematically addressed. No level of fatality on
city streets is inevitable or acceptable. This Vision Zero Action Plan
is the City's foundation for ending traffic deaths and injuries on our
streets.</span></div>
</blockquote>
<br />
New York gets it. I hope the rest of the country will follow. And perhaps within my lifetime the automobile fatality can go the way of smallpox, eradicated for good.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-18551866066322770702014-05-09T15:41:00.005-07:002014-05-09T15:50:49.080-07:00Let's shake on itA construction worker came into our primary care clinic complaining of left elbow pain that was worse with activity. Based on his description, the location of his pain, and my exam, I thought it was lateral epicondylitis ("tennis elbow"). I couldn't remember the best physical exam maneuvers for lateral epicondylitis, so I excused myself from the room and opened up my physical examination textbook. The book described a simple maneuver called the "Handshake Test."<br />
<br />
I went back in and shook the patient's right hand. Then I asked to shake his left hand. The next moment, he was doubled over in pain.<br />
<br />
Diagnosis made. Sometimes it can be that simple.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-20062252716363502402014-05-07T23:27:00.005-07:002014-05-08T07:32:03.393-07:00Death by paperworkA patient was admitted to our hospital service with a large mass that had been growing for months, as well as significant weight loss. When I examined him, it was obvious that he had an aggressive form of cancer. But had it metastasized?<br />
<br />
With this particular type of cancer, the prognosis is fairly good if the primary mass is removed and there is no evidence of metastasis. But the prognosis is bleak if the cancer has spread. This patient was lucky, because there was no evidence of spread.<br />
<br />
This patient was uninsured, which is why he had put off seeing the doctor for so long. But he was eligible for Medicaid and had never bothered to apply. After getting a tissue sample, we discharged him home, and advised him to get insurance as quickly as possible, so that the surgeons could remove the mass immediately. I figured it would take a few days for the state to process his insurance forms.<br />
<br />
I turned out to be dead wrong. Processing the patient's insurance application apparently took months. By the time the patient came back, the mass had grown nearly 20 times bigger, and it had metastasized. His prognosis had gone from optimistic to terrible.<br />
<br />
People get sick, and some inevitably die. Yet some die needlessly, and for the stupidest of reasons.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-47864886011350037312014-05-02T22:23:00.002-07:002014-05-03T01:18:23.071-07:00The siesta methodOn the trauma surgery rotation, rounds start early. At 6:00 AM, to be exact (and medical students had best be exact, lest they show up late and incur the attending physician's scorn).<br />
<br />
But when I was on the rotation, the workday also ended mercifully early. Often, we finished before noon. Some of the medical students would go home straight away. Others would hang around, studying for the upcoming surgery exam and waiting for trauma cases to roll in. But by the time evening fell, all of the students would have already filtered out of the hospital.<br />
<br />
That is, except for me. Almost by accident, I was on a different schedule from my classmates. I have named it "the siesta method," and it is a true winner.<br />
<br />
To make sure I had time to see my patients before rounds and prepare my presentations to the wards team, some days I would set my alarm for 3:50 AM. By the end of the workday, I was knackered. Too spent to study or hang around, I would grab lunch and then head straight to the medical student call room to nap. Several hours later, I would wake up to find that nightfall had descended. I would groggily grab dinner and shuffle to a classroom where I could study for my upcoming surgery exam.<br />
<br />
Sometimes, though, the wail of an ambulance or the distant chop of a helicopter would shatter the nighttime silence. <i>A trauma case! </i>Trauma cases excited me much more than studying. I would sprint to the emergency room to see what new case had been brought in. Indeed, most trauma cases come in at night, in large part because night is when people most commonly consume alcohol.<br />
<br />
During the day, as many as six medical students would arrive at a trauma case. But at night, I was the only medical student there. I got to stand near the patient and even participate in the resuscitation efforts. The residents took notice. They were impressed that a medical student had decided to stay so late, when they could be at home. I got a reputation as "that med student who's always here." The attendings noticed as well. They encouraged me to "scrub in" to (i.e. participate in) their surgeries. "We've never seen a medical student here this late," one explained. "We really appreciate it, because it gives us more opportunities to teach." <br />
<br />
Some nights were quiet. On these nights, I would go home and catch up on sleep until my 3:50 AM alarm. Other nights, when the trauma bay was buzzing, I would stay up all night, enjoying a ring-side view of the fascinating cases that came in.<br />
<br />
By sleeping twice a day, I ensured I was getting sufficient sleep. If I pulled an all-nighter, I would simply sleep for longer the following afternoon.<br />
<br />
Eventually I finished the trauma rotation, and went back to sleeping only once a day, at night. But I miss the excitement of the trauma cases, and look back fondly on my siesta system. It ended up being a fantastic way to learn surgery.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-69083814067415991862014-04-25T13:42:00.001-07:002014-05-08T07:56:57.968-07:00Fast asleepAn attending physician who I had just met was going to evaluate me in
a "observed patient encounter." For about an hour, he would watch me
perform a history and physical examination on a hospital patient that I
had never met. Then, I would have to present my findings to him, arrive
at a diagnosis and treatment plan, and write a detailed note. I
explained that my performance on the activity would constitute a
substantial portion of my clerkship grade.<br />
<br />
The
attending had never done this activity before. He was willing to
participate, but felt that he was not the right man for the job. "I've
just met you," he explained. "This would be better done by a doctor who
has worked with you for a week or two, and knows your abilities and your
personality." Then, the attending waxed philosophical. "This stage of
your medical training can't be very enjoyable," he said, "what with
complete strangers evaluating you all the time."<br />
<br />
"That part isn't very fun," I replied. "You probably don't miss being a third-year medical student."<br />
<br />
He
stiffened. "Not to diminish what you're going through," he said, "but when I
was a third-year medical student, it was much, much worse."<br />
<br />
I am sure that he is right.<br />
<br />
I think the best example is overnight call. Historically, a rite of passage in medical school has been pulling long shifts, many of them overnight. Some of my residents talk about having taken overnight call every third night as medical students, meaning they worked all day, through the night, and into the following day.<br />
<br />
My experience has been different. Some nights, I voluntarily stayed late or through the night. During all of third year, though, I was only scheduled for one overnight shift. And even that time, I didn't have to stay overnight. When I showed up at 7 PM, my very nice resident told me that I could go home. (I stayed anyway, for kicks.) Part of the reason is my medical school, which has (humane) policies that discourage overnight call. It is quite possible that I will pull zero overnight shifts as a fourth-year medical student. All bets are off for residency, though.<br />
<br />
Am I losing out on some educational opportunities by only being on the wards during the day? Probably. But not much teaching happens at night. And I am glad that I was able to spend nearly all of my nights as a third-year medical student comfortably in bed, asleep. Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-52003233740400404162014-04-16T22:40:00.000-07:002014-05-04T11:11:19.657-07:00Pressure groupTake a guess: what is the leading killer of US women?<br />
<br />
The answer is heart disease.<br />
<br />
<br />
Take another guess: which cancer kills the most US women?<br />
<br />
The answer is lung cancer.<br />
<br />
<br />
Many people, when asked either question, would give "breast cancer" as the answer. And a large reason why is the high visibility of breast cancer. There are prominent fundraisers and charitable foundations. NFL players wear pink uniforms each year to raise breast cancer awareness. Lung cancer, which almost exclusively kills smokers, has much less awareness.<br />
<br />
Part of the reason, too, is that there are many more breast cancer survivors than there are lung cancer survivors, because breast cancer is much more survivable. It is the survivors and their family members who raise visibility for their respective disease and raise money for it.<br />
<br />
These advocacy groups, in raising awareness, have ended up distorting the public's view of what actually kills people. In an attempt to inform, they misinform.<br />
<div style="text-align: center;">
_____ </div>
<div style="text-align: center;">
<br /></div>
<div style="text-align: left;">
A group of ovarian cancer survivors came to our school, as part of an event sponsored by an advocacy organization. Students were required to attend. Although I was expecting it to be simply an opportunity for cancer survivors to share their stories, the event instead was intended to show medical students how little we know about ovarian cancer, and to teach us how to diagnose it and treat it. This deviated from how we are usually taught in medical school: usually faculty members lecture us on an organ system or on a set of diseases. In this case, the cancer survivors, who were not doctors, were going to devote the full hour to their one particular disease.<br />
<br />
The survivors were highly critical of the medical care they had received from their doctors. They argued that their doctors should have screened them more
aggressively, treated them more aggressively, and operated more
aggressively. They instructed us what we should do instead, with advice that I found to be ill-informed. They also instructed us to order more CT scans on our patients, and to rely heavily on a blood test (CA125) that is largely useless. They urged us to suspect ovarian cancer in any patient complaining of (vague and common) symptoms like bloating or weight gain, and to suspect patients of any age of having ovarian cancer. One survivor said that antibiotics had helped with her cancer symptoms, and another claimed that the reason she got cancer was because her husband had died a few months before. Another thought she might have caught cancer from her friend. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
I was upset that our school arranged for this session. Although the speakers were definitely well-intentioned, they were only able to view clinical practice through the lens of their cancer. The result was that they gave bad clinical advice that probably distorted the clinical judgment of myself and my classmates, who are still early in our careers. Misinformation is a difficult thing to unlearn.<br />
<br />
I feel like I have to be wary of advocacy groups, because they only lobby on behalf of a particular constituency. An advocacy group's aim might not align with mine, which is to provide the best care to not just a subset of my patients, but to <i>all</i> of my patients.</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-42745518407474451492014-04-01T21:05:00.001-07:002014-04-03T13:36:27.993-07:00BilateralI was asked to assist with a bilateral standard mastectomy (surgical removal of both breasts) for a patient with cancer in one breast. There were two surgeons: the senior attending surgeon, who was to remove the cancerous breast, and the senior resident, who was to remove the healthy breast. <br />
<br />
What made the procedure particularly interesting was that the mastectomies were done simultaneously. I had the opportunity to compare the surgeons' techniques as they performed the identical procedure, side-by-side, at the same time. <br />
<br />
Unsurprisingly, the more-experienced surgeon did a better job. He made better use of the tissue planes that separate the different layers of the body, making for a cleaner and safer surgery. He worked faster, his dissections were more elegant, and he nicked fewer arteries and vessels, meaning he let less blood. The end result looked nicer.<br />
<br />
The experience raised a question that author Atul Gawande discussed at length in his excellent books <i>Complications</i> and <i>Better</i>: how much of a role should trainees should have in performing surgeries? Attendings tend to do a better job than residents at operating. But if residents weren't allowed to operate, how would they ever hone their skills and become attendings?Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-20364833954887216232013-12-02T23:41:00.001-08:002016-09-23T00:14:14.854-07:00FallThe outpatient pediatrics clinic where I was spending the day had fancy electrified exam tables that could be raised and lowered using a foot pedal. Although I was supposed to be seeing patients on my own, the doctor I was paired with would only let me observe her. She would be the one asking the questions and examining the patients.<br />
<br />
The doctor finished examining a 4-year-old girl while I watched. The child was perched on the exam table, which was about 4 feet off the ground. The child and parent were to wait where they were until the medical assistant came in to administer the child's flu vaccination. I walked over to the foot pedal and began lowering the table, because I was worried the child might fall. The doctor motioned for me to stop. "You know," she said, "the child still needs to get her vaccinations." I wanted to argue. The assistant might not arrive for 20 minutes. And when the assistant did arrive, it would take her seconds to raise the table back up. But in working with this doctor, it had become clear that she did not want my input. I simply stepped away from the pedal and then followed her out the door.<br />
<div style="text-align: center;">
_____</div>
<div style="text-align: center;">
<br /></div>
An hour later, I watched the doctor finish examining an infant, an active crawler who was perched on the high-up exam table. Again, the patient and her parent were to remain where they were until the medical assistant arrived to administer the infant's vaccinations. This time, I didn't bother making a move for the foot pedal.<br />
<div style="text-align: center;">
_____</div>
<div style="text-align: center;">
<br /></div>
Ten minutes later, while in with another patient, the doctor and I heard a loud CLUNK that seemed to shake the walls of the clinic. There was a piercing wail and some panicked yelling. I headed to the room holding the infant, because I instantly knew what had happened. When I later examined the inconsolable infant, a bump on the scalp indicated to me that she had landed on her head. The exam table was about 40 inches off of the hard ground. The patient's parent was quietly sobbing.<br />
<div style="text-align: center;">
_____</div>
<div style="text-align: center;">
<br /></div>
At a well-child visit, this infant had suffered a potentially life-threatening injury. It was an injury that I had foreseen but had been forbidden from preventing.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-21957247996336531672013-11-13T16:52:00.002-08:002014-01-04T23:44:32.345-08:00SnapshotI examine a patient who I had rounded on earlier that day. Visiting patients in the afternoon is enjoyable. Unlike in the early morning, patients are awake and eager to chat. They also appreciate having someone check in on them. I ask my patient about her plans when she gets discharged from the hospital. She is going to be starting nursing school. What made her decide to become a nurse was her serious illness, which has made her spend considerable time in the hospital. After a pleasant conversation about her future, I walk to the elevator bay to head to a different floor.<br />
<br />
Within moments of pressing the down button, an elevator arrives. Only once I've stepped into the elevator do I realize that it has other occupants. A man and a woman, both wearing black, are enmeshed in a tight embrace. The woman is sobbing. The man's head hangs downwards. They are immobile, never acknowledging me or so much as glancing in my direction. The somber mood makes me feel self-conscious about the whimsical children's tie that I'm wearing for my pediatrics rotation. I stand at the opposite corner, staring ahead at the doors and trying to give them their space. After some seconds that feel interminable, my floor arrives and I hop off. The couple remains frozen in place. The woman's sobs echo through the hallway until the elevator door closes.<br />
<br />
I had wandered from the story of the future nurse into the story of this couple, who had just been visited by some unknown tragedy. It's as though I had just walked into the girls' bathroom by mistake. I did not belong there. Their narrative was not one that I was meant to inhabit. Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-63353836339319315612013-11-11T07:44:00.001-08:002013-11-11T20:08:13.093-08:00Gone mommy goneA quick physical examination of the infant had revealed what the untrained observer could not have perceived: this one-year-old had a time bomb within, ticking at 120 beats per minute. A severe heart defect present since birth had gone unrecognized. The associated heart murmur was so loud that it could even be heard along the patient's back. Her heart was having to work so hard that her chest was visibly heaving. Her heart was beginning to fail. The infant had been brought to the ER for an unrelated complaint. That problem turned out to be minor, but she was quickly admitted to the hospital for a proper cardiac workup.<br />
<br />
Why hadn't the heart problem been diagnosed earlier? One possibility was that the baby's physician had missed it (if so, the doctor should be investigated by the state medical board). Another possibility was that the infant had never been seen by a doctor. We quickly discovered that it was the latter, and untangled a story of striking child neglect. The state assumed custody of our patient and her parents were forbidden from entering the pediatrics ward. The infant would remain on my panel of patients until the state figured out her next move.<br />
<br />
When I rounded on the patient in the early morning, she was lying sideways in her crib, had kicked off all of her blankets, and was sprawled out on her stomach, asleep. I lowered the crib railing and roused her. With some effort, I managed to roll her onto her back so that I could perform my physical examination. Each time I placed my stethoscope on her chest or tried to palpate a peripheral pulse, she pushed my hand away with remarkable force. She eventually gave up, grabbed her bottle of juice, and put it in her mouth. After feeding for a long time, she nodded back off to sleep, still with the bottle in her mouth.<i> Wait a minute</i>, I thought. <i>Infants shouldn't go to sleep with bottles in their mouths, right? It will rot their baby teeth. She could even aspirate the liquid.</i><br />
<br />
I tugged on the bottle. The infant woke up and groggily pulled with all of her might. I relented and waited for her to fall asleep. Then I delicately tried prying the bottle yet again from her clutches. Still no luck. I considered trying more forcefully, but decided not to bother. This infant had had an incredibly rough day. She deserved some comfortable sleep.<br />
<br />
I tucked the infant back into her blankets. By the time I had raised the railing of her crib, she had already kicked the blankets off. Although I knew I only had a few minutes to round on my other patients, I spent some moments peering down at the sleeping infant, my chin resting on the crib railing. She looked innocent, even with that bottle resting in her pursed lips in an act of stubborn defiance. <i>This child no longer has parents</i>, I mused. <i>For the time being, my colleagues and I are the closest thing.</i>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-81352601496416875452013-10-16T21:59:00.002-07:002013-11-11T08:16:15.379-08:00I'll catch you if you fallMy resident and I braced ourselves for the meeting ahead. It was not going to go well. The patient had been informed that he would be involuntarily committed to a mental hospital because we believed he was a danger to himself. The patient was quite upset and had angrily demanded a meeting. Now it was time to meet with the patient as well as his family to explain what was going on. Most of the hospital staff had already gone home.<br />
<br />
My resident asked me to jot off a quick message to the attending physician, letting him know what was up. I sent a quick text message to the doctor's pager. We hurried to the patient's room.<br />
<br />
After a lengthy, impassioned back-and-forth, things were not going where we wanted. The family and the patient fiercely disagreed with our plan, and they were becoming irritated. I scurried down the hallway towards the page phone so I could notify our attending.<br />
<br />
When I got to the phone, I spotted my attending sitting comfortably at a computer in the distance. He was typing up patient notes. What a relief! I went over to him. "Just who I wanted to see!" I said. I brought the attending up to speed and directed him to the patient's room. The attending took over and did a fantastic job of calming down the situation.<br />
<br />
What was our attending physician doing in that particular hallway of the hospital, of all places? After receiving my page, he had come up to our floor without telling us. I think it was intentional that he had positioned himself out of the way, where we couldn't see him.<br />
<br />
He had trusted us to handle the meeting on our own, but was ready to help at the drop of a hat if we needed it. It was perfect.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-69256770680006474982013-10-07T20:47:00.002-07:002013-10-07T20:51:47.044-07:00Class actAt a small group session with some classmates on my rotation, we began with a "check-in" where we discuss how we're doing. I said that I was getting sick and feeling out of energy. I came home to find a bag on my porch filled with flowers, several varieties of tea, and a very nice note. Another classmate sent me a message offering to help however she could. These acts of kindness put a huge smile on my face. It's the happiest I've felt since I started my rotation. I feel good about people, about humanity as a whole.<br />
<br />
I don't think I deserve such nice classmates. But I feel blessed to have them. Hopefully I can repay the favor.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-59112372183999693112013-10-03T21:25:00.003-07:002013-11-11T08:19:32.677-08:00DSMIf someone looks euphoric, can we say they are having a manic episode? <br />
<br />
To practice psychiatry, one must become intimately familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM). This tome lays out the diagnostic criteria for various mental illnesses. It's helpful because it ensures that clinicians are speaking the same language with each other. For someone to be classified as having a manic episode, they have to exhibit a certain number of particular symptoms, such as decreased need for sleep, racing thoughts, or grandiosity. The diagnostic criteria also specify that the symptoms must last for a certain amount of time and in the absence of other potential causes such as drug intoxication. <br />
<br />
For many years, the DSM-IV has been the bible of the field of mental health. After fierce debate and negotiations, a new edition came out earlier this year: DSM-5. On the whole, the changes strike me as improvements. For example, there now is a single entity, Autism Spectrum Disorder, that replaces the confusing and seemingly artifical amalgam of five autism-like diseases found in DSM-IV. Under the old criteria for anorexia nervosa, pubescent girls had to have problems with menstruation. This criterion did not seem useful and has been dropped in the newest DSM.<br />
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When we were taught psychiatry during our pre-clinical years, we were taught the DSM-IV. But during my clinical rotations now, my attending physicians request that we use DSM-5 criteria. I think this is good. Academic institutions rightfully pride themselves on abiding by best practices. <br />
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At the end of my psychiatry rotation, we have to take a national exam that substantially impacts our grade. This exam uses DSM-IV. Part of the reason (I presume) is that it takes years to write new test questions and test them for validity.<br />
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What results is an odd and sometimes frustrating contradiction. During the day, I get grilled on the new DSM-5 criteria. But at night when I study, I have to learn the minutae of the DSM-IV, carefully mulling over details that no longer matter.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-41428626000087380282013-09-19T22:15:00.002-07:002016-09-23T00:09:18.508-07:00Testing, testingOur school makes us complete online educational modules to reduce their liability in the event that we get hurt on the job. We have to watch mind-numbing videos and then answer vapid quiz questions. Our latest module, on bloodborne pathogens, made me answer this gem:<br />
<blockquote class="tr_bq">
<span style="font-family: "georgia" , "times new roman" , serif;">Which of the following practices will prevent the transmission of HIV, hepatitis B virus, and hepatitis C virus?</span><br />
<span style="font-family: "georgia" , "times new roman" , serif;"><br /></span>
<span style="font-family: "georgia" , "times new roman" , serif;">A. unprotected sexual contact with multiple partners</span><br />
<span style="font-family: "georgia" , "times new roman" , serif;">B. individuals positive for hepatitis B, hepatitis C, or HIV donating blood</span><br />
<span style="font-family: "georgia" , "times new roman" , serif;">C. not sharing personal care items with blood on them, like razors or toothbrushes</span><br />
<span style="font-family: "georgia" , "times new roman" , serif;">D. sharing needles or syringes</span></blockquote>
My <a href="http://thereflexhammer.blogspot.com/2013/02/busywork.html">prior post</a> on the mindless busywork we have to endure as medical students.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-91885815932955478632013-09-16T21:06:00.003-07:002013-11-11T08:20:54.314-08:00Falling on my swordBefore team rounds, I went over the patient list with my resident. One patient was still sick and was not improving. "Bummer," I said, "I guess we're going to have to keep Patient X for a few more days."<br />
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"No," the resident replied. "He's to be discharged today or tomorrow."<br />
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"You really think so? He looks pretty bad."<br />
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"Yes."<br />
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"So what's my argument to the team? He's not going to improve any further, so there's not any reason for further hospitalization?"<br />
<br />
"Yes."<br />
<div style="text-align: center;">
<br /></div>
My cheeks felt flushed. This patient was not ready to go home. This was going to be a disaster. But we are often told that our job as medical student is, above all, to make our resident look good. I would get in even more trouble if I contradicted the resident's plan.<br />
<br />
During rounds I presented the patient to the team. The clinical findings I recounted couldn't mask the fact that the patient was in bad shape. Then I arrived at the portion where I present my assessment and plan: "My opinion is that the patient is ready for discharge because we cannot expect further improvement from continued hospitalization."<br />
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The attending physician (the head of our team) disagreed and started questioning me aggressively. What did I mean the patient wouldn't improve? Had I allowed enough time for the medications take effect? How could I send a patient out who's in such a condition? I didn't want to argue. The attending was right.<br />
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I looked pleadingly at my resident. Please help? The resident sat stone-faced and didn't say a word. I was on my own.<br />
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I didn't have an answer to the attending's questions. I grimly shook my head. "My mistake," I said. "We'll keep the patient for at least a few days and see how he does."Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-34304915171423107452013-09-01T21:31:00.001-07:002014-05-03T01:15:49.776-07:00Time of death<b><i>Note: This post describes patients' deaths. It has content that some would find graphic and upsetting. Please use discretion.</i></b><br>
<b><i> </i></b> <br>
<a href="http://thereflexhammer.blogspot.com/2013/09/time-of-death.html#more">Read more »</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-35615319182679642482013-08-27T10:07:00.005-07:002013-08-27T10:15:00.343-07:00World leaderThe CDC <a href="http://www.cdc.gov/diabetes/pubs/estimates11.htm">estimates</a> that 8.3% of the U.S. population (all ages) have diabetes.<br />
<br />
Surprisingly to me, the diabetes rate in the U.S. is far from the worst in the world. In fact, the International Diabetes Foundation puts the U.S. at 73rd in the world in terms of our diabetes rate.<br />
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The worst-off countries are in Oceania. The Marshall Islands, Nauru, and Polynesia are the hardest-hit. The International Diabetes Foundation estimates their diabetes rates among adults as 27.1%, 30.1%, and 37.3%, respectively. These countries' diabetes rates are nightmarish. Their obesity rates are nightmarish too: 71.1% in Nauru, compared to 35.7% in the U.S.<br />
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The reasons for this discrepancy are manifold, but a key player is the adoption of a Western diet. Whatever the cause, it's alarming that there is such a health burden around the world of diabetes. Diabetes is a huge health problem here in the U.S., where diabetic patients tend to have access to good treatments and medical care. I can't imagine what it is like for a country to have treble or quadruple our diabetes rate.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-13553463166795294462013-08-18T11:05:00.001-07:002013-08-18T11:30:43.463-07:00Picky caninesThe patient needed a refill on his narcotics--in fact, several months' worth, because he was leaving in a few days for a long trip. I pointed out that, per our records, his last prescription had been filled recently. The patient's adult son, who cohabitates with his father, chimed in. "The pills get mailed to us," he said, "and they keep getting stolen right out of our mailbox. Big problem in our neighborhood. I have to take Norco for my elbow, and the damn thieves take my pain pills, too." <br />
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I relayed the story to the doctor, pointing out that it contained numerous red flags. The doctor mused that his patients use the same excuses to explain they need an early refill on their narcotics. Stolen from the mailbox is a favorite. Another classic is that the dog ate the bottle.<br />
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"Tell me, [Reflex Hammer]," he said, "how many times has a patient told you that they need a refill on their blood pressure medication, because the dog ate it?" He paused. "It's remarkable how dogs have such discriminating taste in pills."Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-65141617906333788772013-08-17T20:29:00.006-07:002013-08-18T07:52:40.962-07:00Health stat of the dayAccording to the <a href="http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-037129.pdf">latest American Cancer Society estimates</a>, lung cancer kills more Americans each year than breast cancer, prostate cancer, colon cancer, rectal cancer, and pancreatic cancer combined.<br />
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Cigarette smoking causes 90% of lung cancers. Is it trite to reiterate that smoking kills?Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-61721976817171845542013-08-16T18:07:00.003-07:002013-08-17T12:13:58.939-07:00Unplanned and unwantedA patient who is younger than me agrees to take a pregnancy test. It is positive. She sobs.<br />
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"Until now, I've always been fiercely anti-abortion," she says. "But, there's no way I'm going to keep this baby..."Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-13282607033406069722013-08-02T22:34:00.001-07:002016-09-26T21:02:05.127-07:00Hoarders"When you go to the bathroom and use some toilet paper, do you dispose of it?"<br />
<br />
The patient hesitated. "That's a good question," she said. More seconds ticked by, still with no answer to my query.<br />
<br />
The patient was a compulsive hoarder. By her admission, her house had become virtually unlivable. She couldn't even find her medications or her telephone, because they were completely buried in an ever-accumulating pile of junk. She came to our clinic desperate for help. She couldn't bring herself to throw anything away. She had spent what little money she had on hiring a professional crew, but when they arrived she refused to let them throw away any of her belongings. She was stuck. Repeated fines from the city for keeping her yard in disarray were adding up.<br />
<br />
We did what we could: we gave her encouragement, we crafted strategies of how she could begin to tackle the problem, and we referred her to a psychiatrist (she had already been referred multiple times in the past). We even talked about different TV shows about hoarding and tried motivating her to watch an episode. We probably accomplished nothing. She might not even schedule her appointment with the psychiatrist, because she can't locate her telephone.<br />
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Some patients' problems are way beyond our powers. Practicing medicine is sometimes an exercise in helplessness.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-14374841343865247312013-07-23T22:32:00.000-07:002013-07-23T22:32:20.814-07:00ContextTo a mother, it means something is wrong.<br />
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To a passenger boarding an airplane, it means that the next few hours will be that much more unpleasant.<br />
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But to my team of anesthesiologists and surgeons packed into the operating room, hearing the crying of an infant was music to our ears. It meant that the little guy we had operated on had woken up from anesthesia and was doing all right.<br />
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Context is everything.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6793179658530353445.post-84778140233588323082013-07-21T10:45:00.001-07:002013-07-21T10:48:20.541-07:00Drug or Pokémon?Prescription drugs have ludicrous names. <br />
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Pokémon is a Japanese TV show/video game/card game featuring cartoon characters with ludicrous names.<br />
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<a href="http://www.sporcle.com/games/LinkinMarc/Drug_or_Pokemon">Distinguishing between the names of drugs and the names of Pokémon characters</a>? Devilishly hard, even as a third-year medical student.Unknownnoreply@blogger.com