Agraphia Medical Tragicomedy

Juan Pablo

He was 5, and had been turned away from 3 different ER's over the last month. Undifferentiated stomach pain, vomiting after eating, generally listless. We reviewed the charts from his previous ER visits and nothing stood out. Blood counts, electrolyte counts, liver and pancreas functions, all normal.

He looked almost dead to me when I first saw him. His eyes were unfocused and vacant, skin pale, stomach distended and grotesque, lips chapped and cracked. His younger brother, wide-eyed, was sobbing inconsolably. Mom and dad both seemed detached, as if this was just another hurdle they had to get over. Get through the terrible two's, go to daycare for the first time, get admitted to the hospital. Grandma, on the other hand, had a look on her face that bespoke grief and fear. Aside from the docs, I think she and the brother were the only two who realized how serious things were.

Our workup revealed the worst presentation of Burkitt's lymphoma any of the docs on service had ever seen. Over the course of the next week he fell victim to intestinal resections, a splenectomy, rounds and rounds of chemotherapy, and steadily worsening vital signs. He was put on a mechanical ventilator after day 2 of his hospitalization. He looked scared when I went in to say hi.

The grandmother cornered me the day after his admission, her face stained with tears and exhaustion. I'll never forget the words she spoke to me - "Please, doctor. Just tell me my grandson will live. I love him so much... he is my angel". She was begging for a ray of hope that I could not give.

I looked at her for a few moments, and finally said the words I never thought I would hear myself speak. "I hope so, but the cancer is bad, and it is spreading. I can't promise that he'll be ok, but I can promise that we will do everything in our power to save him". I meant it. He died a week later.

10 things that should make you think ER

A good friend just sent me this link, which lists 10 things that should make you think "hey, my personality fits ER!" To steal an excerpt from Dr. Hayward's article (originally h/t Desperado on the EM forum):

1. The Emergency Physician (EP) sees his profession as a job, not a calling. You will notice in your medical school class that there are those who live, eat, and sleep medicine. Those people typically do not go into EM. EPs typically have many outside interests, and are interested in a job that allows them to pursue those interests as well as medicine.

2. EPs love working up undifferentiated complaints. They got upset in their third year medicine rotations when they were told to go down to the ED and work up the guy with the COPD exacerbation. They wondered, “If I already know he has a COPD exacerbation, what’s left to work up?”

3. EPs think a doctor-patient relationship is what you have when someone gives you a chart with a patient’s name on it, not what happens after following someone’s hypertension for 10 years.

4. EPs like to do procedures. They think sticking people with needles is fun.

5. EPs aren’t afraid to make a decision on limited information.

6. EPs like to work as a team. They know what their nurses do outside of the hospital, and nurses call them by their first names.

7. EPs like to multi-task. EPs prefer to work while they’re at work.

8. EPs prefer a specialty of breadth to a specialty of depth. They enjoy learning practical information, and using common sense.

9. EPs enjoy being able to take care of people from all walks of life, rich, poor, old, young, smart, stupid, etc., without having to worry about whether they can pay you.

10. EPs typically enjoy a large percentage of their medical school rotations. They often think psychiatry is interesting, just not necessarily something they’d like to do all day. They enjoyed surgery, they enjoyed ICU, they may even have liked OB/GYN. They usually liked internal medicine, but detested rounding for hours and writing 10-page-long notes.

Interestingly enough, I have verbatim spoken the words in #2, #4, and #10... and paraphrased every other one at some point in my career. If you're considering Emergency Medicine and want to read more, I suggest reading the rest of the article.

Awesome! I'm off to go put in a 2 hour 'shift' on the bike... later gators.

Can’t hack it, Sparky.

Alright, I'm going absolutely batshit stir-crazy† on radiology. Yeah, it's interesting. Yeah, it's fascinating. But seriously, they just sit down in that dark room, isolated from mostly all human contact, and read films all day. Good lord, I'm about to lose it. Also, sciatic pain is resurfacing from sitting all day.

ED starts in 2 weeks. Woo!

†Welcome to the roller-coaster ride that is Zac's emotional state. Some of you are more familiar with it than others

You hate to see that happen…

A 40-something female presented to the ED a few days after having her gallbladder taken out for infected stones. Keep in mind, this is a teaching hospital in July, so the surgeons are pretty new at this. Hopefully there's an attending helping them out, but you never can be too sure.

Of course this woman gets admitted to the hospital, because now she's got a post-operative fever, high white blood cell count, tender abdomen, etc. etc. etc. Naturally they get a CT to see what's going on...

The surgeons had accidentally cut through the gallbladder, releasing all of her infected stones into her abdomen†. And then for some reason, they just left them in there. Maybe it added to the feng shui of the abdominal walls, I don't know††. I imagine it went a little something like this:

Intern: Making the first incision now... I'm grabbing the gallbladder.. annndd.... oops.
Attending (turning around): Was that an oops I just heard?
Intern: Uhh, it was nothing, sir. I just jiggled the camera a bit.
Attending: Very well, carry on.

†BTW, when I'm a resident I'll start carrying a USB drive with me so I can start posting images to go along with the stories... I've been trying to figure out how to keep this blog going if I end up doing rads.

††Zing! Puns just never get old.

Goin’ for it

Well, folks, I've made up my mind (mostly). It's either Radiology or ER at this point; I've found Rads so interesting that I'm actually *gasp* inspired to write a personal statement about it. Shocking, I know!

We'll still have to see if the aforementioned pandemonium of the ER gets me going... but honestly I find the visual aspect and the breadth of Radiology really works for me. Our program is a bit... quiet for me (I'm a fairly loud person, as most of you know) but the residents are really chill and it's undeniably cool stuff.

More to come!

Edit (9:45PM): Well, that was fast... done already! I gotta be honest, personal statements for residency are a whole lot easier to write than medical school... you've actually DONE the thing you're applying for

Mayhaps I have been too hasty

Well, I gotta be honest, I'm really enjoying Rads at this point. Maybe not enough to actually do Radiology, but it's certainly one of the more interesting fields I've seen so far. There are a couple things so far that have made me reconsider my last post.

I thought radiologists never saw patients. While this is mostly true, there are a lot of procedures you can do, especially in the field of interventional radiology. On top of that, on chest Xray (which I'm on this week), the radiologists review all the ICU radiographs from the previous day, so they are very familiar with every patient in the ICU. There is also a lot of cross-talk between the radiologists and the other docs (pull this tube out, decrease the fluids because he's getting edematous, we suggest getting a CT scan, you gave him a pnemothorax, etc).

The field is also INCREDIBLY broad. Even a simple chest x-ray holds a massive amount of information, so you never see the same thing twice. You go at your own pace†, and they get really, really good at this stuff. The difference between a radiologist looking at a film and an internist is crazy.

So here's the other thing: the geek factor. Listen, I grew up playing video games, tweaking computers, and spending inordinate amounts of time on the internet. Oh, wait, I still do that. Radiology is one of those fields where technology is growing at an exponential rate, and that suits me just fine.

Obviously there's a few problems, like the fact that it's a fairly solitary field and you become a vampire. We'll see once I get on Emergency if the bright lights and the pandemonium are what do it for me... I have an overdeveloped sense of schadenfreude which fits in just delightfully with the ER. So, we'll see. I'm keeping my options open.

†bonus for me, who hates the structured 8-5 workday of clinic.

A Strange Craving… For BLOOD!

Well, I started my radiology rotation today, and much like my immediate, vehement feelings about ophthalmology, I can quite honestly say that I'll never, ever be a radiologist†.

It's really interesting, and really, really cool, and I know I'm going to learn a lot... but I swear to god, if I sit in a dark room for one more day staring at a black and white screen (with infinite shades of gray, of course) I might just go postal. Oh, wait. It's only my first day of the rotation.

By the end of the month I swear I'll be feeding off unsuspecting humans, cackling with my paper-white skin, slicked back hair, and long, well-groomed fingernails. Bonus: if Interview With The Vampire has anything to say about it, maybe I'll end up looking badass like Brad Pitt.

Aside from sitting in a dark room the other thing that gets to me is that all these guys are really low-key. And not in a "laid-back" sort of way. More a "I talk very quietly into my dictaphone for 8 hours every day" sort of way.

I'm going to lose it.

†Sorry Uncle John, it's just not in the cards.

Blaming the wrong people

I read an article on CNN today about a woman who was shockingly left to die on the floor of a hospital waiting room. She was waiting for admission to the inpatient psych ward.

There are several things I find wrong with this story.

1) Inpatient psych patients are not typically ill, so psych nurses/docs don't expect people to die on their floor.

2) She had been waiting for 24 hours. They probably thought she was sleeping.

3) A security guard rolled his chair over and looked at her, then left. I find it hard to believe he's cold hearted enough to leave a dead woman on the floor, so I'll bet he thought she was sleeping.

4) Other patients "didn't react"... so they probably didn't think she was dead either. They probably thought she was sleeping. Or crazy. Or both. But if they thought she was dead, I'll bet someone would have called for help.

5) She was being committed, which means she's crazy. Crazy people do wierd things, like lie prone on the floor. I'd like to see how she was acting before she died, but we don't have that footage.

6) It is the fault of how we currently treat psychiatric disorders - not the individual hospital - that there are never any inpatient psych beds.

7) Mis-documentation usually means "lazy" or "didn't check". Doesn't mean it's acceptable, but it doesn't necessarily mean it's a coverup. See (1).

Now, I'm not trying to say that it's not a travesty that this poor woman died waiting for a hospital bed, but there are a few points to make. Most importantly, an inpatient psych bed is a very, very different beast from an inpatient hospital bed. In fact, psychiatrists as a general rule are terrified of "sick people" and will call in consults from other doctors simply to see if it's ok to give tylenol. Patients are not treated for medical conditions on a psych ward.

For that matter, patients are often left alone on a psych ward... because the purpose of being a psych inpatient is simply to do behavioral therapy and give antipsychotic drugs on a scheduled basis and wait for them to take effect... which can take months. If someone ever gets sick, they are shipped as fast as possible off to the Medicine ward, because (again) shrinks don't take care of medical conditions.

Because of the way we currently treat psych disorders, it's also not the fault of the hospital that there are never any beds on the psych ward. The ER would have called around every hospital in town to find out who had the shortest waiting list, and then sent her to wherever could fit her in.

Also, only certain hospitals accept the responsibility of "involuntary committment"... the VA, for example, is voluntary stay only. They can only fit so many patients into a psych ward, and they are always at capacity. You wait to be admitted until someone else is discharged, which is wholly dependant on how long it takes their drugs to kick in.

I find it frustrating, because the easy thing to do is to point the finger, especially because this woman was only 49. But without more information, I'm just not sure there is blame to be placed, aside from the misplaced, abject anger at the system itself.