Cardiology Block 6: PE

October 29, 2011

There is one patient I will never forget from my month on the cardiology consult service.  Most of the patients I saw had CHF (congestive heart failure) or new arrhythmia. I was called to see Mr. Grady for another typical cause- to manage his high blood pressures. Mr. Grady* was in his fifties, a man who seemed too young to have suffered from multiple transient ischemic attacks.  He had been admitted to the hospital because of a stroke.

Transient ischemic attacks and strokes are related.  High blood pressure damages arteries at a microscopic level.  This silent destruction puts a patient at risk for plaque formation which can rupture causing clots that prevent blood flow.  Transient ischemic attacks affect smaller vessels and the body is able to clear them within 24 hours.  An ischemic stroke, however, affects the blood supply to a larger area and will not improve within 24 hours.  At first, these two events may be indistinguishable.

Mr. Grady had avoided treatment for a few extra days because of prior transient ischemic attacks- he was sure his symptoms would improve on their own.  However, they continued to get worse.  His right facial and arm weakness became so severe, that he was unable to speak clearly or use his right hand.

When he came into the hospital, it was too late to give TPA (tissue plasminogen activator), a substance that can be injected along a small catheter into the blocked vessel.  His brain tissue in the affected areas had been deprived of oxygen more than 48 hours, and at that point his recovery would mainly be determined by physical therapy.

While he was in the hospital, he was found to have extremely high blood pressure.  He was a morbidly obese man, who was already experiencing mild symptoms of congestive heart failure at his young age.  He was taking appropriate medications including aspirin, a beta blocker and a cholesterol lowering drug.  Yet his blood pressure was found to be high.

I performed a complete history and physical exam.  He was cooperative and oddly cheerful considering the recent bad news that his symptoms of weakness might be permanent.  As I completed my review of symptoms (ROS includes a long list of questions to assure no symptom is missed), I asked about any hearing loss.

“Huh?” he said, jokingly.  Then he let out a rumbling laugh, which made me smile.  He didn’t have any complaints.

He was morbidly obese and sweaty, but he seemed comfortable.  Heartbeat was distant, but regular. No shortness of breath. Lungs clear. Abdomen soft. No swelling in his hands or feet. His neurological exam supported the obvious findings from his stroke.

Asymptomatic hypertension.  The fellow examined him and confirmed my diagnosis and plan.  We would increase his beta blocker, add a second drug, and get more tests to rule out other causes.

That afternoon I was checking test results, and his ABG (arterial blood gas) showed high carbon dioxide and low oxygen levels.  ”Oh no!” I thought.  I called the fellow immediately and told him I was worried about a PE (pulmonary embolism, or blood clot in his lungs).  The fellow responded quickly when he saw the results, paging  his team to begin high doses of heparin for anti-coagulation.  He was sent for the confirmatory imaging study, a CTA (computed tomography angiogram).

I couldn’t erase the image of him from my mind.  He didn’t exhibit the traditional signs of a pulmonary embolism.  His heart rate was normal, his breathing had been fine and his legs weren’t swollen to indicate venous clotting.  He was laughing, for goodness sakes!  But why hadn’t I thought of checking more aggressively for a PE?! He was sweaty and obese, he had clots in his brain and he had been immobile for a few days.

We went to reassess the patient with our attending.  Just a few hours had passed, but Mr. Grady looked awful.  He was breathing on an oxygen face-mask, and he could barely say two words between breaths.  His eyes seemed bigger, and he was not smiling or laughing anymore.

The attending immediately mumbled under her breath that we had to transfer him to the ICU.  Then, I’ll never forget her reassuring remarks, “Don’t worry Mr. Grady.  I know it’s scary to go to the ICU, but everything will be alright.  We just need to monitor your breathing better.”

Those remarks lingered hauntingly in my mind the next day. Everything wasn’t alright. Mr. Grady quickly got worse and died early the next morning.  His scans showed huge clots in both lungs.

The worst part was that when I looked back at his EKG, there were signs of right heart strain, which the fellow and I had contributed to his heart disease.  I felt partially responsible for this man’s death. Why didn’t I advocate for ruling out a PE immediately?  Even as the medical student, I might have made a life or death difference.

A fellow and several other doctors had seen this patient too.  What if one person had chosen to order the confirmatory test right away?  Then we would have started heparin sooner, and maybe we would have saved Mr. Grady’s life.  The lectures and exams in medical school never prepared me to face challenging situations like this one.

Dear Mr. Grady, I’m sorry I missed your pulmonary embolism.  I’m sorry we told you everything would be alright.  I’m sorry I never got a chance to tell you, “I’m sorry.”  You’ve changed the way I’ll think about pulmonary embolisms forever.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

3 Comments | 4th Year, Death & Diseases, Family & Internal Medicine | Permalink
Posted by Liz

My Lost Pager

October 17, 2011

Every once in a while, there are hospital stories that must be told, no matter how humiliating.

It was the end of my ICU rotation month.  I was rather sleep deprived and exhausted, and then every medical student’s worst fear came true.  I couldn’t find my pager… not in my white coat pocket…. not in my backpack… not at home.

I dreaded telling my coordinator that I had lost my pager. After all, I was trying to prove I could be a competent future physician.  What if I couldn’t even keep track of a small block of plastic?

I searched for 3 days, and then a small miracle took place.  I sent text pages to my lost pager, “If found, please call (my cell phone). Thanks, Liz”

For days, I received no calls.  Finally during my next-to-last 30-hour call shift, I got a call at night from an unknown number on my cell phone.  I answered thinking perhaps somebody found my pager.

“Hello?” I said.

“Who is this?” a gruff male voice replied, ”I keep getting paged to this number.”  At the same time I heard the voice on my phone, I could also hear it behind me!

So, I turned around and saw a white-haired man, the night-shift respiratory therapist.  I had not interacted much with him and I didn’t know his name, so I walked over and tapped him on the shoulder.

“What? I’m on the phone,” he said.

“Yes, I know.  You’re actually talking to me right now.  You found my pager!” I told him excitedly.

“What are you talking about.  This is MY pager,” he said. So, momentarily I wondered if I had been paging the wrong number all day. We were both confused about what was going.

“Well that’s weird, because I’m pretty sure I sent the page to myself,” I said.  Finally, he turned the pager over to examine the identifying number on the back.

“Hmmm… what is going on here? Pulmonary student?  Who is that?”

“That’s me!  That’s my pager. I’ve been looking for it ,” I told him.  I noticed at this point that he had a second pager clipped to his pocket.  So I asked, “Did you know you have two pagers?”

“Oh! I DO?!  Well then this one isn’t mine,” he said, handing me my pager.

“Thank you!” I exclaimed elatedly, “How did you find it?”

“I don’t know.  I must have picked it up from somewhere,” he responded, “How did you lose it?”

“I don’t know,” I answered, “It must have fallen out of my pocket somewhere.”

Can you imagine the confusion that would have ensued if I hadn’t been on call and standing right behind him when he called?  Incredible.

Moral of my story: After losing my keys (then getting them back) and losing my pager (and getting it back), I have faith that sometimes lost things find their way back home.  Also even the most organized people can uncharacteristically lose track of things sometimes.

2 Comments | 4th Year, Creative Fun Stuff | Permalink
Posted by Liz

Light Plus Magnification

October 15, 2011

I received a mysterious package last week.  The envelope enthusiastically stated “PRODUCT SAMPLE ENCLOSED!”  The letter inside began, “Dear health professional…”

What on earth was this?  First of all, I’m not quite a medical professional yet.  Secondly, if you knew me, you’d know that in general I don’t like wasteful clutter, even free clutter.  And I especially don’t like being bribed by companies to use their products.

I make a point of never using pharmaceutical pens or accepting free pharmaceutical food.  If I want to prescribe a drug for my patients, I’ll do it because I believe in the drug, not because I want any free stuff.

But I’m a curious person, and this was a curious event.  So I opened the package, and guess what was inside?

(You’ll never guess.)  I’ve never even heard of one of these before…

Momentarily I was tempted to toss it… I’m not sure how I got labelled as a “health professional” in need of this oh so useful object. Honestly it seems more of a tool for getting an earring out of a drain than anything medical.

But I decided to document this moment which I’ll entitle “LIGHT PLUS MAGNIFICATION!” as the first of many odd unwanted moments coming my way.  Another strange unforeseeable joy of becoming a doctor.  Ok, I admit that I did rather enjoy pretending for a few seconds that I freakishly wanted to stick it into my husband’s ear to search for “foreign objects.”  Then he ran away from me… far away!

2 Comments | Creative Fun Stuff | Permalink
Posted by Liz

I Passed Step 2 CK!

October 4, 2011

Last week, exactly seven weeks and one day after my exam date, I finally received an e-mail with a link to download my score report.  SEVEN WEEKS felt like a looong time to wait.  And the waiting time wasn’t pretty.  

I would like to tell you that after my first Step 1 Board Exam, I mastered the skill of standardized testing with grace and tranquility.  But who does?  Even though I intuitively knew I would pass, the consequences were so great that my mind began whispering “what if…?  For example, what if I had unknowlingly skipped part of the test?!  … or answered every question wrong?!”

Board exams are like carrying around a heavy weight until the weight is lifted when I finally know the results.  And I knew my score report would be delayed because of new types of questions recently added to the exam. However, I was able to count exactly two of these new question types on my exam.  TWO.

So the logical (or slightly neurotic) part of me thought it might not really take so long for them to analyze data from TWO extra questions.  I began checking my e-mail every score release day (Wednesday) starting the 3rd week after my test.  And ever since  Wednesdays have been the bain of my existence… until this past week!

When I finally saw the score report, I was using my iPod touch… and I couldn’t access the file.  Noooo!  I was reminded by a medical student who recently told me that he was unable to open his report on his smart phone, and had to spend an entire afternoon seeing patients.  Every patient encounter began and ended with the thought, “What is my SCORE?!”

I am a mindful person.  I like to live in the present.  Board scores induce uncharacteristic thoughts and behaviors that make me feel self-absorbed and emotional.   Although Step 2 was easier than my first Board Exam, it was not as easy as I’d hoped.  

But, the good news is that I’ll soon forget how long those SEVEN WEEKS  (and one day AND four hours) felt.  I passed, and I’m officially done with Step 2 forever!  Here somebody usually asks, “are there more tests?”  YES!  But for now let’s move forward from the topic of exams to other exciting updates about 4th year.

2 Comments | 4th Year, Exams & Boards | Permalink
Posted by Liz

ICU Block 5: Death

September 23, 2011

One of the best parts of this rotation has been dealing with death and difficult news.  As a future family doctor, this knowledge has been as valuable as learning about ventilator settings and treatment of systemic diseases.  And death is about much more than the patient- it includes their families, especially when the patient is unconscious!

Death is a difficult topic in medicine.  Medicine seems to tuck death away into a quiet corner- where students, doctors and other patients can forget it’s there.  In fact, I’ve read entire books written about the subject of death in medicine.  One thing is certain- death is scary, yet it is an inevitable part of human life which is profoundly sacred and fascinating.  Even the physiological and logistical details are interesting.

One telling detail showing how we “hide” death was how the dead bodies were transferred out of the rooms in the ICU. At first glance, there was a “Christ-like” phenomenon taking place. As soon as I heard that a patient had died, he seemed to vanish.  His bed was empty or filled by a new patient. I never saw any bodies wheeled out from the rooms.

I had opportunity to solve this mystery by carefully-timed observation.  I felt like a child trying to discover how a magician does his tricks.  One day I saw how the nurse removed everything from the patient’s body.  Then, she folded the sheets over the body, and with the help of another nurse transfered the patient to a “body table,”  a metal shelf, over which a table-top concealed the body underneath.  The cleverly designed object seemed too small to hold a body.

Perhaps the most morbid detail of a hospital death is how it can be controlled.  Medicine has developed technologies that breathe, feed, detoxify, keep blood pressure elevated, etc.  Depending on a family’s wishes, a patient’s body- their physiological shell- can be kept alive long after personality and function has vanished for weeks, even months.

One patient* was flown by helicopter to the hospital after being found unconscious for an unknown amount of time.  She was practically lifeless when found, but EMS brought her back from death with blood products, chemicals, fluids and then took her on the most expensive ride of her life!  It turned out that she hated doctors and had purposely avoided western medicine.  She had not wanted to be saved like this, but we didn’t figure this out until days later.  I felt like we had wronged her.

She was the first patient I helped “pronounce” dead. The whole process was anticlimactic.  She still felt warm.  The resident and I listened – no heart sounds. We looked – no breath or pupillary response. And then we wrote a factual note, that didn’t tell her story at all.

Why does our medical culture treat death as an enemy?  I wonder about the ethics of keeping people alive, or assuming people want to be saved when they are obviously so ill or frail.  Maybe the default action should take a different course.  Most of all, this experience inspired me to be more frank with patients about death, to teach and encourage people to talk about their desires and ideas – before they, perhaps, become speechless in an ICU.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

Leave a Comment » | 4th Year, Death & Diseases | Permalink
Posted by Liz

ICU Block 5: Sadness

September 18, 2011

I gazed past the attending through the clear glass sliding doors into a darkened room.  A woman in room 3 stole my attention from ICU rounds. I wasn’t supposed to be looking at her.  She was saying good-bye to her husband, the father of their grown children (who were now fathers themselves).

This patient* was the smiling pilar of the family photos taped to bed 3′s rail (but the man inside the bed looked nothing like the photos now).  She was alone in the room, unaware of my wandering eyes, speaking to him, giving him permission to die, I imagined.  She held his hands, and raised tissues to her eyes.

For a moment during rounds that day, I lost myself in her sadness.  There was the inevitable truth- that someday I will say good-bye to everyone I love.  I wasn’t aware that my eyes became wet until a tear formed, and its sensation brought me back to attention.

The patient in bed 3 was not one of my patients, but I was aware of his “daily ICU goals” which entailed extubation that afternoon, a morphine drip and a peaceful death in the presence of his loving wife and children.  I quickly blinked the moisture back, inhaled and maintained composure.  Doctors don’t cry, at least not in front of patients or during rounds!

I think the intern caught the tear that was in my eye that day.  She looked at me as though she understood something about what I was experiencing.  Later inside an elevator she asked, “So how are you liking the ICU?”  I gave a “vanilla” answer (typical and unoffensive).  She responded softly, “But it’s so sad, isn’t it?”

“Yes!”  I agreed. Unlike the older residents and physicians, she still seemed connected to the softer side of the ICU.  And for our short ride up 5 flights- we spoke about it.  That was all I’ve said to anyone at the hospital about death during this rotation.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

5 Comments | 4th Year, Death & Diseases | Permalink
Posted by Liz

Published Medical Reflection

September 8, 2011

For fans of the blog:

Today marked a historical day for my medical journey (.com) – my first published medical reflection, adapted from this blog!  My story was published in AMSA’s (American Medical Student Association’s) magazine, The New Physician, a national publication for medical students.

Since many of you are not medical students, I doubt you’ll be seeing it in print.  In fact, even most medical students probably won’t see it in print.  When do medical students have time for creativity and reflection? Rarely.

In case you’d like to be exceptional, here’s the online version for your enjoyment –  pages 16-18.

Feels nice to finally have my writing efforts lead to something in print to complement the website. Thanks to you all- for your continued encouragement and support of my creative writing in medical school.

Sincerely yours,

Liz

1 Comment | 4th Year, Creative Fun Stuff | Permalink
Posted by Liz

ICU Block 5: The Vent

September 6, 2011

Let me show you how to record the plateau pressures,” my resident instructs, “just wait until the patient is exhaling, and push the ‘inspiratory pause’ button.”  I watch as the air stops flowing.  The chest waits in silence, and the line flattens.  I hold my own breath too.  And after a long few seconds, a neon green number appears on the monitor.  The breathing machine resumes like nothing happened.

The “vent” or ventilator is a machine that helps patients breathe – in extreme cases it provides all the impetus for breathing.  In the Intensive Care Unit, many patients require a ventilator.  And ventilators demand careful attention to physiology – daily recordings of tidal volume, oxygen percentage, arterial blood draws, pressures and pushing the “inspiratory pause” button.

I considered myself fortunate when my first two admissions were patients who weren’t on “the vent.”   I was able to talk to them.  They were awake, not sedated with a pastic tube in their throats.  Unfortunately I could not avoid the inevitable.

My third patient* had a translucent hose which poured from his mouth, the crimped tubing filled with beads of saliva like morning dew.  The ventilator hummed, “puff… shhhhhhhhhh… puff… shhhhhhhhh… puff…”  His eyes were closed. I called his name, and he did nothing.  But when I took his hand and asked him to squeeze, I felt his hand close around mine instantly.  What does this mean?  Is he aware?

Before morning rounds I frantically tried to figure out the ventilator recordings.  What is PSV? AC? PCV? Why are there two tidal volumes in the same box?  I considered asking the overnight nurse, but she did not seem to be in a good mood, and all the residents were busy trying to write progress notes and prepare patients.

During rounds I saw every patient.  The older doctor who led us spoke reassuringly to every patient, including those who were sedated.  I observed her crystal tone. “Good morning, Mr. ___.  Can you open your eyes?  Can you squeeze my hand? Can you wiggle your toes?”  She always said, “That’s very good,” regardless of whether they responded to her commands.

I learned that lighter sedation helps patients recover more quickly, and surprisingly helps patients have a less traumatic experience.  This shocked me because some of the patients seemed too alert for my comfort -hands tied at sides, so they couldn’t pull out their tubes.  Some patient shifted their legs, as if they were uncomfortable.

My first day I saw an older lady* kicking her legs in the air, so I went to find her nurse: “Your patient is moving her legs.  Maybe she needs something?”  The nurse looked at me blankly and replied, “Oh her, naaa, she’s just swimmin’.”

One man* seems completely alert.  He is wide-eyed, and responds to “yes” or “no” questions by slightly moving his head.  ”Are you uncomfortable?” the doctor asks.  This man – with a tube filling his mouth, needles in his arms and pins in his leg – shakes his head, “no.”

It’s weird for me.  The sedation makes people become odd creatures.  They are caught somewhere between awake and asleep, in an altered reality where I’m not sure what they can feel or hear.  What is going on inside their minds?  How can I comfort them?

The ventilator screens do not answer these questions.  I do what I have been instructed.  I try to imitate the reassuring crystal voice.  Then, I wait for the exhale, push the “inspiratory pause” button and record the numbers.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

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Posted by Liz

ICU Block 5: The Unit

September 4, 2011

I did not want to do an Intensive Care Unit (ICU) rotation.  My reasons for choosing this rotation fall into the category of “things I’d like to be more comfortable with before graduating.”  The ICU or “the unit” (as hospital workers say) is where the sickest patients go, many in the tender world between life and death. These moments offer tremendous learning opportunities on detailed human physiology and end-of-life care.

I dove into my ICU rotation embracing the deep, icy water.  The temperature or unknown darkness of the water didn’t bother me.  My heart didn’t beat any faster.   I knew my abilities to swim through unknown, murky situations.

Morning rounds last four plus hours.  My team covers ten plus patients, sharing epic oral-reports of each person’s state, ventilator settings, physical exam, lab setting, imaging studies, medications and a plan for each system of their body.

My second day I am on overnight call, the type of “on-call” that is becoming a thing of the past. Regulations were put in place this year, so first-year residents, “interns,” cannot work more than 16-hours without time off.  Medical students can, although I’ve only done this for my OBGYN and psychiatry rotations.  Someday I’ll tell people that I worked 30-hour shifts, and although my hours were nothing compared to doctors who trained before me, people will still gaze with disbelief.  As a teenager I remember thinking my 8-hour shifts at the coffee shop were long.

After I have been at work for about 18 hours, things quiet down and I find an empty call room.  The call room isn’t great.  The mattress and pillow are coated with crispy plastic, and the bed sags in the middle.  There is a broken computer in the room, a tennis racket, and a 5-inch-thick copy of Harrison’s “Internal Medicine.”  I get cozy and begin reading the “Critical Care” chapter of Harrison’s to help me fall asleep.  Before I get to sleep, the sharp “cheeeeeep  cheeeep” of my pager sounds – a new admission.

She’s young*, but you wouldn’t guess based on her history.  End stage renal disease. Cancer. Radiation. A hundred medications. Previous history of months between ICU and rehab centers for infections. Wound care for open wounds.  And not surprisingly – alcoholism, drug abuse, depression and anxiety.

As I begin the interview, she tells me that she doesn’t want to talk to me.  She has told her story a million times today and she didn’t even want to be in the hospital.  I can’t blame her.  She picks up the phone and begins dialing.  I try to be compassionate and acknowledge her hardships.

“Who are you trying to reach?” I ask.

“My dead friend’s mom,” she replies.  I sense this is going to require my most advanced history-taking skills.

I stand in patient silence as she dials, listens and then slams the phone down.  She repeats this process dramatically several times.

“What’s the matter?” I ask, “You can’t get through? Do you want me to dial the number for you?”

“NO!” she snaps, tears streaming down her face.  Then she begins cursing… at the phone? …at her life? …at me?

I’ve been awake going on 20-hours at this point, so I take a deep breath, tell her I can see it has been a hard day and explain I’ll try to get through my questions as fast as possible.  I feel like I am performing a painful procedure.

As I am getting her story, I watch her slowly loosening the edges of a large scab from her arm.  In between questions, she finally frees this protein-rich scale, revealing raw pink underneath. She puts it in her mouth and chews.   My stomach churns – maybe because I haven’t eaten in many hours, or maybe because her sadness and self-mutilation upset me.  Unfortunately there is no psychiatric ICU, and when I suggest we get a psychiatric consult, my resident responds, “They can do that after she is stable, not in the unit.”

There are more important things to worry about in the ICU.  Her heart rate. Blood pressure. Fever. IV-access points. Fluid resuscitation. Orders. Medications.  And so begins my month in the ICU.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

1 Comment | 4th Year, Family & Internal Medicine | Permalink
Posted by Liz

Wedding Vacation

September 1, 2011

I planned to update the blog right after I returned last weekend, but life stopped me.  After feeling my first earthquake last week, I discovered that I had coincidentally planned my trip home in the path of a hurricane.  All flights were cancelled over the weekend.  So despite summer being the season when I least expected to have a flight cancelled, I found myself spending hours on the phone talking to a machine, and eventually an agent.

Whether I liked it or not, I was “granted” two extra vacation days.  So I returned mid-week, after missing my first days in the ICU – the only rotation days I have missed.  Then, I began finalizing my electronic residency application, which is due… tomorrow!  So today was my first day in the ICU, which was going fine, well until I lost my house keys.

Sigh… it’s never easy coming back from vacation, is it?  Certainly not this time!

Vacation was wonderful, especially after such an “exciting” summer of rotations and cafe-hopping while studying for Step 2.  In case you are wondering – NO, I have not received my score yet!  But while I was away, I practically forgot about Board scores anyways.

It began with my brother-in-law’s wonderful wedding.  Despite the fact that the wedding’s timing was less than ideal for a 4th year medical student- packed between Step 2 and residency application deadlines- I planned in advance so it would work out.  

And it did!  My husband and I were part of the wedding party, so I saw the wedding from a personalized angle.  As weddings go, this one was one of the most special weddings my husband and I have been to.

Surrounded by friends and family, I was willingly submerged into an alternate reality – far away from medical school life.  A place where I had time for long meals, hot tub soaks, walks through gardens and shopping.  I visited my grandparents, my aunt & uncle, my parents & brother and my husband’s entire family.  At one point, I even found myself in conversation with a group of girls about beauty time – I momentarily forgot that normally I am lucky to squeeze in a quick daily shower.

There were only whispers of medicine -as I visited a residency program and toured the hospital facility, I suddenly felt a strange level of comfort.  I overheard one of the residents talking about a patient with uncontrolled high blood pressure, and I wanted to chime in… diuretic!  I even “had to” clean my hands with the alcohol gel as I passed through the halls.

I also had a chance encounter with another medical school blogger who I’ve come to know through blogging.  We met for the first time, and as we talked I was struck by the familiarity and ease of sharing with other medical students.  There is a common language shared between us, which I was starting to miss (a little).

I felt excited as my vacation ended because it was everything I hoped it would be.  It almost fooled me into thinking that I had the whole summer off, rather than a couple weeks!  I was ready to be back in the familiar rhythym of my busy medical school life – to submit residency applications and move forward in this adventurous year, whether I like it or not.

Leave a Comment » | 4th Year, Marriage & Life | Permalink
Posted by Liz

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