medicine


The majority of the time, incidental findings are benign, nothing to worry about: small meningiomas, renal cysts, ovarian cysts on CT scans gotten for other reasons, granulomatous scars on xrays, and so on.

But every now and then, they turn out really bad. I think this has to be the worst kind of bad news you can give a live patient: they came to the hospital because of something else entirely, and now you have to explain that because of this test you did, you found out that their life is going to change forever. With other bad diagnoses, at least the patient knew they were sick with something. But out of the blue. . .

When I saw that the admission diagnosis was new-onset seizures, I jumped at the chance to see Anna. Previously I’d seen several patients with a history of seizures, for whom management consisted of verifying that these were nothing different, and adjusting their medications. Anna, on the other hand, would need a complete workup. Twenty-something isn’t too old to develop epilepsy, but it’s unusual.

In a hospital gown, lying in bed surrounded by anxious relatives, Anna looked a lot younger than me, although she’s actually a few years older. The whole time we talked, she looked surprised and bewildered. She’d been babysitting her niece, when all of a sudden she felt hot and dizzy. The next thing she knew, there were EMTs walking into the room. Her older sister had walked in and found her in what sounded like a grand mal seizure. That was it. No risk factors in her family or social history (ie, no epilepsy in the family, no heavy alcohol or drug use recently).

The CT scan done in the ER showed nothing, but just to be thorough, because some causes of seizures can’t be seen on CT, we got an MRI too. That’s when the problems started. When Dr. Army looked at the MRI, he had to recheck the patient’s name and history, because it looked like a prototypical multiple sclerosis MRI. So we went back in Anna’s room and asked a bunch of questions, looking for overlooked symptoms of MS. She couldn’t remember anything significant. Her job has long hours and she’s on her feet a lot, so there’s fatigue and leg pain, but who knows what caused it? Then Dr. Army went over the neuro exam and, being twice as strong as me and more thorough, managed to elicit some left-sided weakness in a few unconnected muscle groups.

So she got a lumbar puncture. Attempted by yours truly, and for once I felt absolutely no guilt about practicing on patients. She needed the procedure (we didn’t make it up for my benefit; hospital lore has it that surgery residents are prone to such proceedings, but I can’t imagine why, since all the ones I’ve ever met have done so many procedures they’re bored sick of them, and would rather imagine away the ones that do exist, rather than create unnecessary ones), and Dr. Army gave me a very careful lecture on the subject beforehand (another reason to love him: he subscribes to the school of not giving the medical student too many instructions right in front of the patient, for both parties’ sakes). I got a lot closer than I ever have before, not running into bone two inches in, but I still couldn’t find the spinal canal. Dr. Army, of course, hit it right away.

CSF studies showed nothing. The particular study for MS, oligoclonal protein bands by electrophoresis, won’t be back will next week. Her EEG looked normal, so Dr. Army gave her the option of going home without any medications, and waiting to see whether she would have another seizure. Of course she jumped at the possibility. He had previously explained to her and her family about the plaques on the MRI, and their probable significance. Anna looked overwhelmed; as if new seizures weren’t enough, she has to adjust to the idea of having a crippling disease, when she felt perfectly well.

That was Wednesday. She was discharged Thursday, while I was gone for Match. I came in on Friday, and got a very bad feeling when I saw her name back on our list. She had come in to the ER overnight, having had a second seizure at home, which her mother claimed had lasted for ten minutes. (Ten minutes is bad; you hope seizures stop in five minutes or so; more than that is a sound reason for calling 911.) Then, after being on a dilantin drip for an hour in the ER, she had another seizure, although much briefer.

She was not happy. Three seizures in three days, after we’d told her she should hopefully be ok for a while – on top of the MS. Dr. Army wasn’t happy either. These seizures were coming too fast, starting too abruptly. He was starting to wonder whether there wasn’t some significance to the MRI findings other than MS. Most neurologists say that MS predisposes to seizures, but Dr. Army is slightly iconoclastic, and he thinks there’s no connection. So the MS plaques and concomitant seizures weren’t self-explanatory, for him. Further workup indicated. . .

That was my last day in the hospital. Next week I’m supposed to be in the outpatient offices. I hope I can track down Anna’s labs as they come back. I hope there’s nothing else unusual to turn up. She’s had enough for now.

I really wasn’t at all nervous, just glad at the prospect of getting the waiting over with, and being able to attach my dreams of apartment-hunting and internship to a specific location.

Okay, I wasn’t nervous until they called my name.

We had the big auditorium full, with the whole class present in one place (for the first time in almost two years), along with spouses, children, parents, and some grandparents. After a few false starts (drawing envelopes of people who were couples matching, so didn’t want to open it until their partner got theirs), things went smoothly. Since my name wasn’t one of the first called, I relaxed and enjoyed cheering for my friends. A lot of people got exactly the place they wanted, and others got into specialties so competitive that the precise location isn’t worth being very upset about.

And then the dean read my name. I couldn’t see anything except the stairs (determined not to fall down them). When I took the envelope my hands were shaking as badly as anyone else’s all day. It took me three tries to get the piece of paper open enough to read the name inside.

Thank you Jesus. My first choice.

I figured out why the dean was holding the microphone in everybody’s face: it was as much as I could do to read the words out loud, without thinking of microphones or anything else. I found my way back to my seat without seeing anything in the vicinity – not even two of the academic surgeons who had turned up for the occasion, and who thus found out that I didn’t rank their program as high as they’d wanted. . .

The last envelope was drawn, entitling its owner to the pot of some hundreds of dollars that had accumulated, as we all made donations to the poor person who had to wait till the very end. Then wild congratulations all around. There are several people from my school going to the same city as me, some to the same hospital. It will be nice to have some familiar faces around. I want to find out who the other interns at my program will be; I’ve probably already met them on interviews.

(I can’t believe they’re really going to let me do surgery. They – whoever they are – don’t know what they’re in for.)

(Of course, they won’t ‘let me do surgery.’ They’ll let me tag around, and babysit the post-op patients, for several months or a year. That’s ok. At this point, as expected, I would kill – or die, whichever is less sociopathic – to be let in the OR again, in any capacity whatsoever. I’ll be a scut-monkey for a year happily, if they’ll just let me wear scrubs, and listen to their cases, instead of the medicine ones.)

I’m thinking about our white coats. Way back at the beginning of first year, they had this ceremony to give us our white coats. All the families came, and we lined up nervously in alphabetical order, meeting our classmates for the first time, sorting each other’s names out. One by one we walked up on stage, and the dean helped us put on our short white coats, with our name in embroidery on the front, and the school’s badge on the sleeve. They were pristine white, and the embroidery was bright and shiny, almost as shiny as our faces when we officially became medical students.

For the first two years, I jumped at the chance to wear my white coat. Once a week, it had to be worn to clinical classes. I would hang it carefully over the back of the seat in the car, and put it on as soon as I got out of the car. After class, I would take it inside and hang it neatly in the closet. One of the best things about shadowing preceptors was getting to wear the white coat in a real office, where everybody would see it and know that I was something special and official. (Ok, so that’s what I thought; of course most people have no idea what it means, or how it differs from a doctor’s coat, or a nurse’s jacket, or a tech’s lab coat.)

During the last two years, my coat has fallen on increasingly hard times. It’s lucky if it gets washed every two or three months, and the collar and cuffs have turned permanently gray. (It’s ok, it doesn’t matter, only two more months, and I’ll be entitled to three clean coats, with an MD embroidered after my name.) Nowadays I carry it into the hospital, and put it on at the last moment before setting off to see patients, because the pockets are so heavy and unwieldy with information I don’t dare leave out. The breast pocket is dragged out of shape by having an ID card on a yo-yo constantly pulling out of it, and carrying my cell phone, and holding my penlight. The other pockets are stretched by a PDA, handfuls of pens (they die so quickly when you write page-long notes every hour), kleenexes, every patient list I printed for the last two weeks, random notes and schedules, an Arabic book I wish I were studying, a reflex hammer, meal tickets, and a spare candy for if we round straight through mealtimes.

In the car, my coat gets thrown across the nearest seat, any whichway, the main concern being not to let the phone, beeper, PDA, reflex hammer, penlight, or Arabic book fall out in an unseen location. Forget about wrinkles. The only reason it sees the back of the seat anymore is if someone else needs a ride.

And in a few months, I’m going to throw it out (where to, exactly? it would be a waste, and heartless, to truly dispose of it; but who needs a short white coat hanging permanently in their closet?), and replace it with new coats, long coats, befitting the dignity of a really and truly grown-up doctor. I’m tired of my short coat, and I’m sure it’s tired by now, too. It’s been through four years of medical school, and has served as not just as an item of apparel, but a portable brain, portable desk, shield against both bodily fluids and shrinking confidence, passe-par-tout, roll-up pillow, and blanket for cold call rooms. It’s earned an honorable retirement, but somehow I doubt it’ll get one.

Five of us girls, mostly would-be surgeons, sat around and talked nonsense for half an hour, then ate lunch together (determined not to hit the computers at noon precisely), then hunted for private corners in the hospital to check our status by ourselves, and then met up again in the lounge, and figured out by each other’s smiles that it was ok to ask, “Did you match?” All our classmates at this hospital right now did, so that’s good. Statistically, at least one member of the class probably didn’t. . .

One of my friends called his parents: “Can you believe it? I’m really going to be a surgeon!” My feelings exactly.

Today the people who didn’t match participate in the Scramble, which is exactly what it sounds like: a mad dash between unmatched applicants and residency directors whose slots didn’t fill up, all scrambling to save something decent out of the mess.

Thursday, we will all open our envelopes together, including those who matched in the scramble.

Why do we have to wait three more days to find out where? I haven’t heard a good explanation yet.

——————
This week there’s a different attending covering. Knowing him to be military, I was anticipating a stiff week. Actually, he’s young and friendly, very educational, and subscribes to the novel theory that the medical students are not substitute residents, don’t need to see every single patient who’s vegetating on the list, and can be sent home by 4pm. The other student and I adore him already. Too bad that this is the week where we get a day off, for Match.

He and I also had a splendid conversation about the evils and subterfuges of drug companies, how they twist data, and advertise relative risk reduction, covering up the smallness of the absolute risk reduction. We agreed about the ridiculous invention of new diseases in order to market designer medications: premenstrual dysphoric disorder, for instance, and restless leg syndrome, as well as the downward redefinition of hypertension and hyperlipidemia, in order to diagnose ever-increasing numbers of Americans with life-long diseases requiring continual treatment. What a money machine. The other student rolled her eyes, but was too tired to argue with our fest of unorthodoxy.

Last night I met the patient who’s probably going to be the first to die while I’m actually taking care of them.

Mrs. Buckley is in her 80s. She and her husband are still living in their home. Yesterday morning she suddenly collapsed, in the middle of a sentence. CT scan at the ER didn’t show anything remarkable, although by this time she was intubated and barely responsive to painful stimuli. An emergency MRI was arranged, and I caught up with her in the radiology suite, as Dr. Isakson had sent me to see her right away. The main thing to be seen were her eye movements, constantly rolling back and forth, back and forth, unfocused, unaware of surroundings. The nurses and I were very puzzled by this, but Dr. Isakson later dismissed them as “roving eye movements,” indicating brainstem function without cortical input.

I went to talk to her family and try to get some more history. They were all sitting in a small “family room” in the ER (why are the family rooms always dark brown and green, with low lighting? I wonder whether this color scheme helps, or not). In spite of myself, it was a rather dramatic entrance, because they all thought I would have something new to say. . . And all I could do was ask her poor husband to relive his last moments with his wife again.

Dr. Isakson broke his rule, and looked at the MRI pictures as soon as they were done, before seeing Mrs. Buckley. Now, when an elderly person drops down and doesn’t regain consciousness within a few minutes, it’s never a good deal. For Mrs. Buckley, it was a very bad deal. The entire front half of her brain was dark: no blood flow, totally ischemic. The MRA (angiogram) confirmed the unbelievable: both internal carotids were completely invisible. Only the vertebral arteries were visible, joining into the basilar artery that lies at the base of the brain and feeds the brainstem. The only possible explanation was that one carotid had become chronically occluded, and then that day a clot from somewhere suddenly occluded the other side. The end. (It would be too improbable for two such huge clots to enter both carotids at once.) Once she was settled in the ICU, we found that her neuro exam matched pretty closely: absolutely no cerebral function, and already a few brainstem reflexes disappearing.

Then Dr. Isakson had to talk to the family. As a neurologist, he must have to do this very often, deliver bad news with a bad prognosis and very little possibility of recovery. That’s why I’m puzzled by how diffident and uncomfortable he still seems. I mean, I don’t suppose you should ever become happy with telling such bad news; but he seems unusually ill at ease and uncertain.

Mr. Buckley was sitting on one side of the room, and hardly spoke at all during the whole meeting. His daughter seemed to take over for him, asking questions. After Dr. Isakson had repeated for about the third time, in simpler words, that Mrs. Buckley had had a massive stroke and was unlikely to recover very well at all, her husband suddenly covered his face with his hands and started crying quietly. Seeing this strong old man so broken, I felt like crying too. (Alice, what do you think you’re going to do in a surgical/trauma ICU if you start crying every time someone’s family does?) Dr. Isakson broached the subject of DNR, and the family briefly decided not to come to a conclusion until the other children’s flights came in. Then the daughter stood up and announced flatly, “I want to see my mother,” and walked out. End of meeting.

This morning, the brainstem reflexes that were present yesterday are becoming fainter. Sometime this afternoon the family will probably understand and accept the message of finality that the nurses and doctors are silently communicating, and decide to withdraw care.

I don’t know what to think. On one hand, watching the family’s pain, I’m wondering how I can stand this, for the rest of my career, reliving my grandparents’ deaths in imagination with every episode in the ICU. On the other hand, as one of my friends said when I showed her the MRA, “It’s a pretty good way to go.” Suddenly, no pain. I think her family will agree, when they’ve thought about it for a little while.

After getting my ID card and pager (having never been in this hospital before), I paged the attending, Dr. Isakson. He answered and said, “Go print off the neurology patient list. There are two new patients. Mrs. X came in in status epilepticus last night. No previous seizures. Mrs. Y had a stroke yesterday. Go see them, write the H&Ps, and call me when you’re done. They’re your patients. Just call me if you think Mrs. X is still seizing. . . You would recognize that, right?”

Ooh. Only a slight twinge of regret for vacation at the VA being over (along with continuous internet access). I have some patients. I’m supposed to figure out what to do with them.

Actually I’ve seen more pseudoseizures than real seizures. Mrs. X’s case was complicated by the fact that she has no legs left. I couldn’t tell whether her clenched hands and rigid arms indicated really bad seizures, or just chronic contractures. The fact that the nurses seemed totally unconcerned inclined me to believe it was nothing serious. She was also minimally responsive, completely nonverbal, and unable to cooperate with a neurological examination. (Do you realize how many parts of the neuro exam depend on the legs? Reflexes, strength, sensation, primitive reflexes, cerebellar coordination, gait. . . )

The main thing I figured out was that since she had a temperature of 102, we needed to rule out meningitis. Dr. Isakson’s mood on rounds took a definite turn for the worse when he discovered this. He’s a funny guy: tall, middle-aged, going bald, an experienced neurologist with lots of patients and consults and referrals; but he seems almost shy, as socially awkward as I am (which makes for some very stumbling conversations), with his feelings written on his face. He let me try to start the LP; which on an unconscious bilateral amputee lying on her side was obviously not very simple. After a couple of unsuccessful tries, he took over. After another half an hour, we gave up and sent the patient down to radiology for them to try; they didn’t get any farther. But this morning her fever and white count are gone, and she’s alert, semi-oriented (if thinking this is February, and she’s still at home counts as oriented), and chattering away, full of perseveration and incoherency. We are hopefully assuming this is baseline (no family anywhere in sight, sadly), and preparing to send her back to the nursing home on some antiepileptic drugs. Idiopathic adult onset of seizures. No one’s happy with that diagnosis.

Mrs. Y was a dignified elderly lady. I get the sinking feeling that she really doesn’t like me that much, for intruding on her, and putting her through all of these undignified tests, and being a student. She looks so self-possessed, even in a hospital gown and uncomfortable bed, that I feel rude for asking about her symptoms. Tsk. She’s been healthy, but now had a small stroke, whose symptoms are mostly gone by this morning. Unfortunately, now that she’s let doctors look at her, we discover that she has diabetes, hypertension, and hyperlipidemia. [persons over 60 are not allowed to wander around the US without taking at least five pills a day; doctors are very good at tracking down all fugitives and rectifying omissions]

This morning, another new patient: a man in his 40s, crack user, alcoholic, third stroke in the last few months. He undoubtedly has some new deficits, but I can’t help feeling that he’s exaggerating them. Shouldn’t be so cynical, Alice.

I’m just the slightest bit annoyed. The day being slow, and one of the residents being gone, so that I could use his computer, I decided to take advantage of the fast internet connection to figure out the inner workings of the blog site I’ve decided to transfer to in May. I spent a couple of hours fiddling around inside, figuring out the pathways and shortcuts, and laboriously designing a header, and adding lots of links to the page. When I arrive home, what do I find, but that Blogcity has decided to redo their structure too, and I had to redo this blog too – otherwise you would only be seeing a bunch of gibberish, lines all intermingled and sliding off the edge of the page. . . Blogcity must be jealous of the new site.

Other than that, Dr. B noticed that my pretest results in the areas of “cardiac murmurs and how to elicit them” were very bad indeed. So he gave us a lecture on that topic, and now for the first time I understand the significance of handgrip, and why that would increase the murmur of aortic insufficiency. Very enlightening, and worth the miserable experience of guessing wildly on the test.

He told us about how at medical schools in India (where he trained), during the clinical years there are two hours of required bedside teaching every day. Unbelievable. And about how, early on, a resident took him and several other medical students to hear a patient with mitral stenosis. They all listened, and nodded, and said, “Oh, yes, definitely.” Dr. B was asked what he heard, and he described in detail the appropriate sounds for mitral stenosis. The resident then observed that he had turned the head of the stethoscope such that they could not possibly have been hearing anything through it. That seems to have made quite an impression on Dr. B.

It’s true that at the beginning (and now too, to some extent) we have no idea what anything sounds like. It’s impossible to really describe how rales are different from crackles, and how that is different from wheezes, or what counts as decreased breath sounds. It’s impossible to explain verbally the minute pause that distinguishes the first and second heart tones, or how to catch that faint stutter which is the all important S3 or S4 gallop. The only way to find out is to be told what a patient has, and then listen. Eventually by osmosis and contextualization, we figure out what’s what. I’m still not completely sure when it’s rales or crackles, or when it’s S3 or S4. The rest, I have a decent chance of catching.

I’ll have to remember that trick with the stethoscope for my students.

What a funny idea. Me, have students?

You know you’re in medical school when school doesn’t cancel for a foot of snow mixed with ice. No questions, no possibilities: everyone arrives – on time.

After several weeks with private doctors, I am listening with renewed horror to the interaction of staff/academic doctors with their patients. Or rather, the lack of interaction. How is it possible to lead a train of residents into a patient’s room and start discussing certain factors which might lead a person with the patient’s condition to have a very bad prognosis, without really introducing yourself or anyone else, or explaining why you’re there, or what you’re going to talk about?

Today the cardiology team was consulted for a patient with suspected infectious endocarditis. There are a couple possible sources for his infection, which his several physicians are all still rather confused about. The patient himself, when we met him, appeared to have very little idea why he was in the hospital at all, let alone that he had bacteremia, or needed an extensive cardiac workup. Admittedly, he’s not the brightest guy on the block; but he wasn’t comatose, and he wasn’t unwilling to communicate with us. (Except insofar as an elderly man with no teeth and an Indian with a thick accent are hindered in communicating with each other. I tried to straighten out two or three of their most egregious misunderstandings at crucial points in the history, and had to let the rest go.)

The team walked in and out two or three times, and the second attending to be brought in announced to the patient that he needed a TEE (trans-esophageal echocardiogram; better than trans-thoracic for detailed images of the heart, especially the valves), and so would not be eating for the rest of the day, and did he consent to the procedure? The poor fellow looked so puzzled, quite willing to consent to whatever we wanted, but hardly understanding what he was being asked to consent for, let alone why. So I said, He hasn’t really been told about the bacteremia or anything, or why we need to do this test. Dr. B didn’t really appreciate that interruption, but explained briefly that there were bacteria in his blood, and the nature of the test we needed. And the patient agreed.

How could his primary care team not explain the bacteremia to him? How could nobody tell him about the test results that made us suspicious of vegetations, before sending this crowd of cardiologists in to demand more tests? How can you not tell a patient about a situation which could result in emergency heart surgery? Maybe you don’t have to explain at the beginning that he might need surgery, as long as that possibility is still remote. But with such serious issues in play, frequent explanations are pretty important!

So many doctors give overly simplistic (or non-existent) explanations to patients, and then are frustrated when other patients are unable to give them a meaningful history of what happened at the other specialist’s office, or what procedures were done at another hospital a few years ago. If we expect to get any information back from the patients, we have to give them meaningful and digestible information ourselves. Tsk. No doubt these scruples will only last until I fall behind on morning rounds or clinic a few times, and then I’ll be just as brisk as the others. I hope not. I used to hate the phrase, “seeing the patient as a whole person.” But now I understand that that’s just bureaucratese for, being polite to the patient as a human being, not just a pathological specimen.

A combination of circumstances have so conspired to make me appear unusually intelligent to the cardiology chairman, Dr. B, my most supervising attending for this rotation. Partly it’s him occasionally giving the same lecture twice, once to me and once to the residents, and asking the same questions both times. Partly it’s the female attending, who loves teaching, giving intricate lectures, even though he thinks it isn’t her responsibility. (I find them so educational that I’m going to keep attending, in spite of Dr. B’s semi-disapproval of her teaching things “above our heads.” He thinks I don’t need to read any literature, just textbooks.) And partly it’s the fact that one of the crotchety old family practice attendings I had a year and a half ago had chosen, as attendings tend to do as they get older, a few key topics to emphasize with everyone, over and over: one of his was aortic stenosis.

Besides, I hate people not answering when they’re asked questions. I feel like there’s a vacuum requiring an answer, and if I know the answer, it just pops out, if the person who was really asked hesitates for too long. Answers will also pop out, even if I don’t know that they’re correct; the threshold for that is about two seconds longer than if I’m sure of myself.

So I keep getting the right answers, when the residents don’t know. I don’t think they can like me very much, although we haven’t said much to each other. I know that I’m acting like the ultimate gunner, showing everyone else up, and I can’t seem to stop myself.

Which leads to the quote of the day: after yet another string of correct answers from me, Dr. B exclaimed, “That’s very good, Alice! You ought to be a resident!”

The residents groaned, and I blurted out, “I sort of am going to be a resident, you know.”

But it’s nice to have a little confirmation of that prospect.

One of the most nagging questions that I find arises from having women in medicine is: how to open and walk through doors.

Seriously. Anyone who’s at all familiar with academic medicine knows that there’s a set pattern for walking through the hallways and into your patients’ rooms: The attending goes first (unless he doesn’t know where he is, in which case the resident responsible for this patient points the way), followed by any fellows, followed by the residents in order of seniority/relevance to this particular patient, followed by the medical students, third years at the back. This works smoothly, until a senior male resident decides to open the door for his female juniors to walk through. Now he’s at the back of the gaggle, and of course the attending has a question for him immediately.

In a large group, seniority tends to predominate, and doors are opened and held by the people as they walk up to them, regardless of gender. It gets trickier when you’re one-on-one: female student/intern accompanying a male attending/senior. Now what? I never know whether the man I’m working with feels obliged to open doors, which I appreciate, or doesn’t pay attention to that old-fashioned rule, in which case I’m quite capable of getting my own doors. The tricky part is if I’m following a doctor, and he’s the only one who knows whether he intends to turn right or left after we get out of the stairwell, and then he opens the door. . . I’ve perfected a little dance step for moving through the door and semi-bowing appreciation, and then slipping neatly to the side, so he can resume the lead toward wherever he intends to go. (It’s kind of like the step for weaving in a Scottish set.)

Dr. Mark was probably the most chivalrous doctor I’ve met in the last year and a half. He opened and held every door for me, every time: car door, hospital door, elevator door, stair door, patient’s door, office door, examining room door, OR door. (Which reminds me of Tolkien’s observation that, setting aside its meaning, the phrase cellar door is the most euphonious combination in the English language.) After a few days with him I realized that it would save a lot of time if I would plan on him opening the doors, and thus slow down and not collide with him when he went to do so. After two and a half weeks of this, I was getting used to the arrangement.

The Indian cardiologists and fellows have no such ideas. I’m working on getting back into the groove of staying in the medical student’s proper position, half a step behind.

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