medicine


The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (“Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.

. . . ok, got it?

That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal – maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)

Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.

When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.

When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)

This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.

I’m convinced I’m a white cloud, and I’d like to know how to change that.

“White cloud” is residents’ slang for a person who doesn’t seem to have patients come in, surgeries or codes happen, or patients transfer to the ICU or die on them. I think it really developed more as a corollary to the original phrase, “black cloud,” which is someone who attracts bad luck: when they’re on call, their team picks up more than their fair share of new patients; their patients always go to the OR, or the ICU, or die.

Being a white cloud is nice for a while, since it means less work – fewer admissions, transfers, and postop orders to write. But it really adds up to worse education. Getting slammed all day and night with admissions and disasters isn’t fun while it’s happening, but it’s extremely educational. A quiet day where no one crashes, no disastrous transfers land on the doorstep, and almost no one gets admitted to your service is pleasant, but not useful.

As long ago as third year, I knew I was a white cloud. On OB, even though I was crazy to deliver babies, they would rarely come on my shift. When it was another student’s turn on labor and delivery, they’d have four or five babies in eight hours. When I was on, six women would labor for twelve hours, and five of them would deliver after I had to leave. On trauma as a student, the gunshot wounds always came in on other people’s nights. On medicine call, I always got rule-out chest pain and COPD exacerbations. The other students picked up the fancy autoimmune complications, complicated cardiac issues, new cancer diagnoses, and so on.

This year, for being nearly done with a surgical internship at a tertiary care center which routinely picks up the disasters of several counties and states surrounding, I have had remarkably few people die on my hands, and have been present for remarkably few emergency trips to the OR. It’s always on someone else’s service that the patients develop bleeding that requires operation, perforated viscus, mesenteric ischemia, intra-abdominal sepsis, etc, or come in hypotensive and coding from the transport. It’s nice, I suppose, because I really don’t like it when my patients crash.

But I can’t believe that this white cloud effect is going to persist for my entire career. If it is, I should start marketing myself as a means to reduce the morbidity and mortality of almost any operation. (And it’s not because I do anything special. One of the chiefs is extra-paranoid about her patients, and boasts of having the lowest morbidity/mortality as a result. I’m not that good.)

This weekend, of course, is a case in point. Last weekend, the team on call got slammed. They doubled their list, and spent half the weekend in the OR. Two or three people ended up in the ICU, and all kinds of drama occurred on the floor. But now that I’m on call, we had one admission and one OR. No disasters. Everyone got out of the unit. What’s up with that?

I really should start tallying the morbidity and mortality of my patients compared to my fellow interns. Either I need a bonus from the hospital for improving their statistics, or I should get rid of this superstition about white and black clouds.

I’m just afraid that the other shoe is going to drop sometime. Like in two months, when I’m alone at night, and patients will start doing things that I’ve never seen or heard of before, because I have such incredibly good luck on call.

(Actually, I do know how to change this. Go around talking about “quiet night,” “being bored,” and “nothing interesting in the ER.” This really works very well, so well that the rest of my team curses me every time they hear me say it; so I don’t do it so much anymore. It tends to produce four ER consults in a row, and two or three admissions at once. I’m not sure what it does to the ICU; I haven’t tried it there.)

I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)

Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.)

I’m beginning to fantasize about adding a lecture to the series of “basic medical things you really ought to know, in case you weren’t paying attention to this part in medical school” that the hospital sets up for the interns during July. In addition to the [valuable] medical things like, when it’s time to intubate, how to think about renal failure (since thinking seems to be the only thing you can really do about it), management of acute coronary syndrome, and so on, I would like there to be a lecture on, “how to consult surgery appropriately.” It would include such basic concepts as

1) don’t call it a rigid abdomen unless it is
2) on the other hand, if you think it is a rigid abdomen, please call us now and not six to twelve hours later
3) please don’t consult us about the possibility of bariatric surgery for a morbidly obese patient during his hospital stay for another medical issue! this requires six months of outpatient preparation, and does not require an urgent in-house consult
4) please don’t mention the words “elevated lactic acid” if you want to be taken seriously; in fact, just don’t check it at all
(sorry, non medical readers; it is the fond belief of medical people that elevated lactic acid is a sign of infarcted bowel, which if true would require immediate laparotomy; however, it is the firm opinion of surgeons, at least at this hospital, that lactic acid can be elevated for many reasons, including renal insufficiency and general low-flow state, and is of no value compared to the clinical exam and, ok, the CT scan; nevertheless, people persist in checking it, and then stat-paging us because the patient, who is sitting up eating, needs to go to the OR now)
5) try to strike a happy medium between consulting us the second you get a positive c diff test, and waiting until the patient is septic on multiple pressors to ask us about a possible colectomy

As you can tell, the main problem with my scheme is that it would be next to impossible to give this lecture without being incredibly arrogant and snarky. So perhaps it’s just as well that no one tries.

I need to stop reading The ICU Book, or at least stop quoting it to my fellow residents. The author has now demonstrated to his satisfaction (though not entirely to mine; I’m still lagging a couple equations behind) that blood gas measurements are entirely useless, and in fact detrimental to patient care, and that most medications used for acute onset atrial fibrillation have no value whatsoever. I think his next chapter is about how giving people oxygen is in fact bad for them.

Everyone talks a lot about communication among members of the healthcare team, but usually they’re referring to communication between doctors and nurses. In my experience, most doctors do a decent – or at least a passable job – at this, since you usually have to tell the nurse what needs to be done in order for it to happen. Also, as in the old military paradigm, the troops do a better job if they know what the plan is, so they can make intelligent adjustments to unexpected circumstances.

I’m a little more puzzled by the communication between different groups of doctors – or lack of communication. It’s not at all uncommon for an ICU patient to have anywhere from three to six different specialists “following” him (I always cringe when I write that – it sounds like a stalker is loose in the hospital), and floor patients, if complicated, will have their own small entourage. These specialists rarely talk to each other, or even to the primary (ie, admitting) service. They all round at random hours of the day, and leave notes in the chart, and expect these notes to enlighten everyone else as to their thoughts.

Of course, since the notes are illegible, no one is very enlightened. I’ve decided that it saves time not to try to read the subjective part, or the physical exam, or the labs. If I can just sort out a few key phrases in the plan section of the note – continue, stop, start some medication or other – I’ve got enough to report on. Then, if I can figure out the signature, I can even tell whom I might page if I have urgent questions. It’s gotten so I recognize the handwriting of all the ID specialists (I think the whole group buys special pens), the critical care attendings we see most often, and the endocrinology and urology PAs. For the rest, if I recognize what their plan is, it might give me a clue as to which specialist would be interested in that subject, and then I see if the operator knows which resident is involved with that specialist.

The only times we actually talk to each other are as follows: 1) Two attendings meet each other at lunch; in this case they will discuss the patient in detail, and mysteriously produce a plan, and then blame their residents for not acting on it, already. 2) An attending decides to round so early that his path and mine actually cross, in which case I’ll ask a great many questions, for my education, and to figure out the plan. This is indeed very informative, but if I don’t time it just right, I won’t see him the next morning, and so will lose track of his plans. 3) There’s something so critical going on that I play tag via the operator, paging every resident and fellow who seems connected to the attending we originally consulted, until I track down someone who knows what the plan is. 4) The consulting service has such an important idea that they page me to tell me to act on it. This is fairly rare, and usually annoying when it happens: is it really that much simpler to page the intern to tell me to write orders, than to just write the orders yourself? But I’m glad to hear from them, so I don’t complain.

My approach is: 1) To write very neatly. I actually scare myself because mine are almost the only legible notes in the chart, so everyone always reads mine for information, and I can only hope that I’ve correctly interpreted and quoted everyone else’s chicken scratch. I would hate to be the only person the lawyers can pin down as saying xyz. But at least no one is in doubt as to what I thought; my attending may have thought something different, and his note below mine may be a beautiful arabesque of loops and squiggles; but my plan is what counts, since that’s what everyone reads. 2) To call other services quickly when I have questions, and especially when we have any plans for patients who are admitted to a medicine service. I can only imagine how frustrating it would be to come in and find that the surgeons have kidnapped your patient into the OR, so I try to let them know what our plans are. 3) To hang around the patients’ rooms whenever feasible, since this makes it more likely that I will actually catch the other services as they round.

I’m not sure what better approach there could be. Legibility is the holy grail of medical records – desirable, and unattainable. But at least one’s pager number should be written legibly, so it’s not such a daunting task to track the writer down and ask what he was thinking – or some other diplomatically worded question which doesn’t imply that the time spent writing in the chart was worthless. (Also, this is where talking to the nurses comes in handy. If everyone talks to the nurse, she (or he) then serves as a repository of easily accessible information – if you can find the nurse. Sometimes this is easier than finding the chart, other times vice versa.)

Oh yes. And everyone politely writes at the end of their note, “appreciate consult,” or “appreciate cardiology input,” or “will follow endocrine’s recommendations.” At least we’re courteous in our illegibility. (Sometimes this helps because you know what letters have to be involved there, so, like the old codes, you can extrapolate back to the main body of the note.)

What else is there to say about work? The amazing storm of OR cases continues. I feel bad because they’re two-person cases, which means the medical student is lucky to scrub, and certainly gets to do nothing whatsoever during the case. I remember how frustrating that was, especially going to the OR, haunting the holding area, waiting and hoping that the resident wouldn’t show up, and how crushing it was when they would blithely wander in and take over everything. That doesn’t prevent me from – wandering blithely in and taking everything, though.

I read Bongi’s post about assisting the surgeon yesterday, and consequently thought very carefully about my actions today. I think I did fairly well, not that it was a complex case. But even after just a week at this, I’m getting better at telling what the attending wants to do, and what direction the tension, or suction, or light, needs to go to help that happen. I read a fascinating article somewhere once about how the human brain can calculate what another person is going to do next. Apparently, when one watches another person’s motions, one’s own motor cortex lights up as if performing that action. So you can almost feel what’s going to happen next, because you can tell what your body would do next, if it were in that position. For example, someone holds a glass, and you can tell if they’re going to put it down, or drink from it, from just a split second of movement. You can watch someone walk down a hallway, and tell where they’re going to turn before they actually pivot. Similarly, with more experience, I can start to see where the surgeon’s hands are going next, or what part of the field they’re heading towards, before it actually happens. Fun.

I love AAPS. For one thing, Ron Paul is a member. For another thing, they send out delightfully informative, heretical, subversive pieces of news like this one: A major study shows that Zetia has no preventive effect on heart disease or heart attacks. This article also reviews the fact that most of the statistics showing benefit for statin drugs (and also for many other famous medications) are only impressive when given as relative risk reduction. The absolute risk reduction for many medications is not at all persuasive. This is the difference: if 100 people take a pill, and 100 take a placebo, and in the placebo group two people die, or have a heart attack, or develop angina, and the medication group only one person has that bad outcome, the relative risk reduction is 50%: half as many people died when they took the medication. The absolute risk reduction is 1%: 1 out of 100 was significantly affected by having taken the medication. Now if the effect you’re measuring is death, 1 in 100 may be a good cost/benefit ratio. But if the effect you’re measuring is just reduction in cholesterol, or slower development of coronary artery disease, and you can’t even show a survival benefit, it starts to look worse. Also bear in mind that the side effect rate is probably at least 2-3%, and probably higher, depending on what you count as significant side effects. This is why I can’t stand medicines.

(And yes, to be fair, I’ll apply this to surgery too: We say that you will get very sick if you have appendicitis, and don’t let us take it out. Similarly with gallbladder disease, and sigmoid diverticuli, and so on. But I suspect that the mortality/morbidity rate for these diseases untreated, or treated only with antibiotics and never with surgery, is not as high as we give patients the impression it would be. Or perhaps I’m underestimating the amount that surgical diseases contributed to the low life expectancy prior to this century. At any rate, it would now be impossible to do any kind of study of what happens to appendicitis if not surgically treated. And, the mortality can indeed get quite significant if you add in a few other medical problems. So I’ll keep doing these surgeries. But I’ll feel quite happy about not reording zocor and the rest for my patients who are hospitalized for a couple of days. If I get their blood pressure within reasonable limits, that’s enough.)

(On the other hand, I’m disgusted with myself for losing interest in general medical problems. I used to swear I would try to maintain some knowledge about overall medicine: thyroid disease, basic cardiac issues, diabetes – all that. For the first few months here, I did try to handle that stuff as much as my seniors would let me. Now, I’m beginning to care as little as the next surgeon. Diabetes? Sure, consult endocrine. Bad COPD? Sure, consult pulmonary. (Not that the consult does much good. Pulmonary always recommends nebulizers and pulmonary toilet, things we order reflexively in smokers and asthmatics. Endocrine puts the patient on insulin, and adjusts based on fingerstick results, which is really fairly basic math: addition and subtraction. And then they do their usual battery of tests (pulmonary function, or TSH/T4/ionized calcium/HgbA1c/microalbuminuria), which by this time I can predict, but admittedly have little interest in interpreting. I’ll quote you a cardiology consult I got the other day: “Recommend decreasing iv fluids when appropriate per surgery service.” Do tell. Usually when the patient has been resuscitated after surgery, we tend to turn the fluids down the next day or two, of our own accord. Thanks for that scintillating insight.) I’m studying for Step 3 right now, and am having great difficulty mustering any interest in the subject whatsoever. The review book has no chapter on general surgery. I looked three times. No wonder we get urgent consults for asymptomatic gallstones.)

(Ok, I’ll stop there, and get ready to duck the comments.)

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