Success

We all measure the success of our days in different ways.  I wonder how aware we are of those unspoken measurements we place on ourselves?  It's different depending on what we do, or what we are after.  In pursuit of someone's affection, our success may be if we spoke to that person during the day.  If there is some behavior we are trying to change, our success may easily be, did we have that forbidden food or smoke that cigarette we swore we wouldn't?  If in school, did we actually get the work done on time?  Everyday, thousands of chances to give ourselves value by "succeeding" or devalue ourselves by "failing". 

It's good to find what we use as a ruler - because it may be completely unreasonable and need changing!  If for instance I made "success" pleasing every person I saw in the day, I'd be a big 'ol failure.  I was thinking of this today because I identified one of those subconscious measurements I've set for myself.  I realized that when I have my own clinic, with my own patients, I gauge my performance on how many times I had to ask a preceptor/staff doctor for input.  If I am autonomous, I give myself esteem.   However, asking another doctor's opinion shouldn't be deemed a failure- in fact, it's probably healthy to ask others for input.  Looks like this is one measurement of success that needs tweaking.

C-section vs vaginal birth

The newest stats on c-sections for 2004 are out at 29%.  That's almost 1 in every 3 babies now born surgically. This is a marked increase if you consider in 1996 the rate was 20%.  One component is the turn to elective c-sections.  While not an option in most of the Midwest - I can see the temptation.   As we American's grow ever time conscious and efficient - being able to schedule the birth of children down to the half hour seems ideal.  Everyone can come into town, the nursery ready, even pre-printed birth announcements-  like the "save the date" cards for weddings.  I could send people "save the birth date - Dec. 11th at 2 pm" 

As C-sections become more and more safe- it's hard from a legal perspective for doctors to deny elective c-section requests from patients. That leaves the ethical considerations.  As alluded to above, if given the option, when my time comes I would likely choose a c-section.  BUT the ramifications of everyone beginning to do this begins to trouble my brain.  Play it out in your mind - in 20 years from now, will our children learn of vaginal births from a historical perspective only? Could it become an extinct behavior of humans?  Does that seem wrong or just a social adaptation?  I'd love some discussion on this ...anyone?

First Semi-Code

Back from a little trip to phoenix. The night before I flew out was my last shift working nights. Of course, I should have known something would go wrong. I had my first solo code like situation. Throughout training I think it's the thing you dread most. Unlike most situations in medicine, your processes are catapulted into mach speed. There is no time to dwindle, pondering the effects of your decision. It's now or never.

The situation was a young sickle cell guy. I'd been the one to admit him 5 days earlier when his Hemoglobin was down to 3.9 (recall normal is 13-15). I hadn't heard much about him on my night time calls. The call came at 12:07 from someone on the floor "the nurse needs you up here quickly, something is wrong with Mr. R -he's just not acting right" I noted vitals and rushed up. What could be wrong- the guy is 27 - surely not a heart attack. Blood clot? Too much pain meds? Stroke? Seizure? I was silently pleading for God to grant me wisdom.

It always produces anxiety when there are groups of people around your patient's bed- the room was full already with nurses and respiratory therapists- I felt their tension lift as I entered. AS if, 'whew the doctor's here we can relax.' BUT my tension had hit the roof. Okay, start with information and assessment. He was obtunded, breathing hard, but if you squeezed his hand he'd respond. GOOD. Glance to the tele' monitor with the vitals- BP 250/120 UH, not good. Pulse 130's, not good. Oxygen 99% on the 2 liters they had strapped on his nose. That was good. Now I realize they( being everyone in the room) are looking at me -directly into my eyes. Can they see my fear? Can they see I am child, that I'm just dressed up in my dad's doctor coat and stethoscope, not really a doctor?

I push out my calm in control voice- "let's order some things- CBC, CHem 12, mag, phos, d-dimer, Abg, Chest xray" next "Let's do something about that blood pressure" And I order some quick IV meds. All this is intermixed with questions "what happened today?, anything new? what meds did he last have? Any changes? What were this morning's labs?" All the nurse knew was that he was okay when she came to work at 7pm- he was alert, not in pain, even refused his pain meds. All was okay until his alarm went off that monitors heart rate and blood pressure. He was FINE- and now all had changed. I was encouraged that he was awake enough to move all hands and legs- but something was definitely wrong.

Although things were serious, they were stable enough to keep gathering info - the nurses were helping sit him up a bit when one of them let out a loud shock like gasp. I glanced over. She was carrying something she'd found by his neck. There in her hand were about 3 teeth from a set of dentures- obviously broken, chomped right a part. Light bulb goes off in my head- "He had a seizure" I shout- "let's get some ativan on board." As the nurse went to get it- it happened- another seizure. His whole body started to convulse, as saliva and froth spewed from his mouth- she gave the push of ativan as his body, a minute later relaxed. During the seizure I was watching his oxygen rate- they suctioned, he seized and his 02 dropped to 50% - His seizure over, I stood saying out loud "go up, go up" The numbers crept -55, 60, 65, 70, 80" Then stopped- 80%. Not good enough- he wasn't maintaining his airway.

Game up. That's what I thought- no more playing for me -time for help. I gave the order that everyone had been waiting for, wondering when I'd say it - "let's call rapid response, get him up to the ICU" The ICU team swept in, didn't need to intubate, or put a tube in, but wanted to watch him upstairs in the ICU. In minutes he was gone. Now the empty room, and all the extra nurses and people who had stepped in to help. Suddenly it really did feel like some sporting game- nurses coming up patting me "great job" "way to go" "that was good" And i doing the same "you all were wonderful". "Good thing you found those teeth!"

So, another first. Not too many big 1st's left in medicine. But the "first crashing patient in the middle of the night" can be crossed off the list.

Tumors in the Bible

I am working nights these 2 weeks.  It's been tough adjusting to living at night and sleeping in the day.  BUT the good thing is that there is more free time in the wee hours of the night.  Time to read and watch movies sometimes.

I'm always surprised, when I pick up the bible and start reading it like a novel; what stories i find!  There are some really funny and dramatic things in there that have no profound spiritual insight AT ALL.  I thought I'd share this one story that pertains to medicine. 

So in Samuel, there's this big fight between the philistines (bad guys) and Israelites. This is when God lived in and around the famous ARK of the covenant.  You can guess- the philistines win and steal GOD (well, the ark).  What happens next is predictable- wherever the ark is- people get sick- they get tumors.  Towns keep passing the ark to other philistine towns- which get the tumors too.  Now the weird part:  They finally GET it, that the ark is GOD and GOD is cursing them- so they decide to send the ark back to the Israelites.  BUT they want to include a guilt offering with it.  Guess what they make?!  Golden rats.  Okay, strange, but still believable. BUT they also make golden tumors...  I laughed out loud reading this.  Golden Tumors?  Blobs of Gold like marshmallows packed together? I'm sure GOD loved that...what combined with golden rats- it's what all Gods want as a gift.

Secret Ballot

Families handle dying in such different ways. Our family hasn't had to deal with end of life decisions, so I can't say how we'd do it.  Throughout residency, these family meetings deciding the future of the life of a loved one, have been the most fascinating. The intense emotions, the passionate pleas... I wish I could have a sound recording of them.  This always occurs when there is conflict. It's the same thing every time- 80 something year old mom is in a coma, or has such severe Alzheimers she doesn't communicate anymore.  There are options to be aggressive and prolong life with medicines and machines- or we can let nature take its course.  Ultimately, there seems to always be arguments.  1 sister wants aggressive things, the other wants to let mom go. If only there were written living wills, or something. 

One patient's family this week had an unusual solution.  Their mother- in her 80's, has not been communicative for years.  She's got vitiligo- a condition that makes your skin white.  She's black- so her appearance is startling- like a calico cat- half white, half black - all in spots.  Her mouth is always open- giving her the appearance of a skeleton with it's jaw unhinged. Her eyes are never open. This poor woman needs to die. I can say that easily as a doctor. However, the family wants to keep her alive by any means- well, most of the family.  The arguments have been loud and noticeable by all in unit 43.  The eldest  daughter who's a preacher, is in charge.  She finally decided, enough arguing.  They got the whole family assembled 2 nights ago.  There were 35 people there!  They talked and gave arguments for their positions...and then... they took a secret ballot.  Honestly, they wrote down on pieces of paper wether they thought "mom" should live or die.  No raising hands- you'd be holding grudges with each other for years-  it was all secret.  And the tally-  she lives.

When you step back it's eerie- a secret ballot to decide her fate. Moral of the story-  make sure you know what your loved ones wish for near the end; or you may be the one scribbling "live" or "die" on a piece of paper someday.

Dementia

Have you ever wondered what it really must be like to loose your mind?  To open your eyes and look around, and it all be unfamiliar and new?  I was thinking about that today when we went to see one of our patients with Alzheimer’s. There she sat with her pearls around her neck, and a long gold chain medallion and locket adorning her hospital gown. She was looking at her 2 watches both on her left arm next to her ID bracelet. When we entered she said cheerfully, "I hope you can help me... it seems I don't remember where I'm at or how I got here, but I sure hope I can get home soon." I was surprised she was so up beat, even though she knew her mind was in trouble.  "I'm having a problem with my memory, I just can't understand things" she said, smiling, her glasses half way down her nose like a librarian. She had learned to be clever, adapting to her loss.  When asked "Do you know where you are?" She'd quip, "sure I do, I'm where you are" Is that the grace that accompanies the loss of awareness?  That you also don't know enough to be scared?  I'd think it terrifying, if tomorrow I woke up and didn't know where I was... nothing familiar- the walls, the bed, the people...my mind would whirl trying to recount the last possible memory I DID have.  If it searched and found nothing...what then? Panic? Despair? Yet how happy and childlike Ms. H was.  Unconcerned, if not a bit entertained by all of us.  Although in 5 minutes time, Ms. H will have forgotten me, I don't want to forget her, and her pleasant dementia.  Since I didn't have any camera, I decided to sketch her and those crazy pearls… not as art, but as a reminder.

Puzzle solver

I am back on the hospital side again for work.  This change really only amounts to longer hours and sicker patients. 

It is rare in my job to really come across patients with mystery problems. I'd say 90% of the people who come into the hospital or clinic have names for their problems- they have heart failure, or pneumonia. They know they have gout, or liver failure.  If there is any doubt, usually the ER docs label the patients for us.  It's a shame, because I love solving mysteries.  I think a reason I went into medicine was because I thought I would be putting complex puzzle pieces together to figure stuff out.  This, again, doesn't happen that often.

Yesterday I had such a "puzzle".  This pale 50 year old woman hadn't been to a doctor in years. She was admitted for anemia, with a HGb of 5.5 (VERY LOW).  The work up began, as I thought through reasons and ordered tests.  All day I was absorbed, as tests started coming back very unusual.  I was investigating, and solving riddles, and I was loving it.  One of the abnormalities was gross blood in this patients urine.  Tho she hadn't noticed anything, this was an ominous sign.  Immediately, I ordered a CT scan, to look at her bladder and kidneys. While other tests were indicating she was hemolyzing her blood (chewing up the cells) AS well as having trouble making cells with a bone marrow problem, this blood in the urine couldn't be good.  The CT scan came back late last night.  With no radiologist around to officially read the scan, I took a preliminary read.  I was shocked as I saw what used to be a kidney, now 4 times normal with definite tumor.  Then the liver, studded with cancer, and the lungs full as well. 

My game, of solving puzzles, suddenly wasn't as exciting anymore. I think I had expected discovering the cause of her problems and fixing her; feeling delight in the fact that all the hours spent studying and learning would pay off in helping someone.  It was as if my treasure hunt had turned up, not a treasure, but a trap or a dreadful poison or something harmful.  Yes, I got an answer, but now I had to go sit with this woman, who had assumed she came in to get some transfusions, and tell her that she had a very bad cancer that had already ravaged her whole self. 

I guess, being someone who likes to discover new things, I must be prepared for these situations. If you go turning over stones, you must realize that there are very bad things that live there.  

Following is my patient's actual CT showing the tumor, quite impressive!