Let me tell you a story about 2 patients.

The first patient, a 70 year old gentleman who originally came in to have an electrical irregularity in his heart addressed. While undergoing the procedure, he proceeded to code and was successfully revived, though he required intubation. Several days later, his blood pressure dropped and he required another code. Over the month he has stayed in the hospital, he coded 6 times. Each time he was successfully revived within 15 minutes and in possesion of all his faculties. 6 times he was brought back from the brink of death and 6 times he appeared as though it would only be a few days until the drips could be turned off and the tube taken out of his throat.

The second patient, a 68 year old gentleman arrived earlier this week. Here for a routine heart attack originally, he went into the cath lab and received a stent. Shortly after returning to his room, he also required a code. His picture however was much more grim. One code during which he was successfully brought back, but requiring several pressors, intubation and appearing for all intents and purposes CTD (circling the drain). After the first code, his wife, 10 years his junior, made him Do Not Resuscitate status at the recommendation of the treating physician, who did not expect him to survive another such code.

Yesterday, I was responsible for covering both these patients while the other resident had the day off. The First patient appeared the same as always. motioning with his hands, nodding his head in response to questions no real changes. The second patient also appeared the same. His wife came in to visit and decided his chances of recovery were minimal, and he would not wish to live a prolonged existence in a vegetative state. She requested to change his code status to CMO, or comfort measures only. Meaning begin a morphine drip for pain, and then remove pressure support and mechanical ventilation allowing him to die a natural death.

This morning my fellow resident and I came in to discover the second gentleman sitting up in bed, conscious, and very much alive. When the tube was taken out, he continued breathing. When the pressors were stopped, his blood pressure stabilized. His wife, who last night prepared herself and made the decision to shuffle him off this mortal coil would be arriving to find her husband very much alive. And with no clue that his code status had been changed from full to dnr to cmo in the course of 4 days.

Talk about your awkward situations.

As the second gentleman was making his miraculous recovery, his next door neighbor, the first patient, began coding as he had so many times before. However, this time the man had reached the end of his 9 lives and did not survive the code, passing away on the trip his fellow patient had been expected to make only hours earlier.

Both these gentlemen shared the same last name.

As The Grim Reaper was wandering the halls last night how did he make his final decision? did he flip a coin? was he so determined to collect the one who had cheated him so many times that he left his fellow for another day? or did he accidentally step into the wrong room, confusing one man for another?

Or is a greater force at work?

An 86 year old woman comes to the cardiac unit because she experienced an episode of syncope (e.g. she fainted). An EKG done at the time of her admission showed she was in complete heart block, meaning her atria (the upper heart chambers) and her ventricles (the lower heart chambers) were all beating at complete different rates rather than in one organized cohesive fashion.

Initially, as part of the workup we check her meds, ask her about any history of irregular heart beats and do a ct to rule out a stroke. We also send her down to the cardiac cath lab to examine her coronary vessels for any blockages, MI or embolism being other possible causes of syncope.

And then the surprise.

Her heart vessels were completely clear. No blockages, decent ejection fraction, no apparently obvious reason for her to have suffered an arrythmia and syncopal event.

Until we learned that her husband and son had died one year previously on dec 22nd, the anniversary of which she had celebrated only a few days before her episode and subsequent admission.

Why would that matter? Because of Takotsubo Syndrome aka Stress Induced Cardiomyopathy aka Broken Heart Syndrome

Takotsubo is a sudden temporary weakening of the heart muscle that can often be triggered by severe emotional stress. EKG changes will often appear similar to an anterior heart attack, but on angiogram, vessels will be clear. However, further inspection of the heart anatomy will reveal a bulging apex with a hypercontractile base of the heart

This anatomy makes the heart look like an octopus stuck in a japanese octopus trap or a “tako tsubo”. It’s though that this is caused by high levels of circulating catecholamines (stress hormones like epinephrine) circulating at the microvesicular level, possibly causing vasospasm.

This condition is somewhat rare, and tends to affect mostly postmenopausal women. In those affected, heart function will actually improve to near normal levels within 2 months provided the individual survives their initial attack. While women are twice as likely to suffer from broken heart syndrome, men are 6 times more likely to die from it.

The good news for my patient is that she survived her attack and got an implanted cardiac defibrillator so if she should suffer another arrythmia she can be knocked out of it.

Bet you didnt know you really COULD die of a broken heart…so next time you see a friend who is down in the dumps, ask them if they need any help with fixing their octopus trap

-Dr J

2 fascinating patient encounters recently:

1)A 40 year old black gentleman, former (only by age) gangbanger and with a friendly but colorful dialect was in the hospital for reasons that are unimportant. However, while taking his social history, I happened to ask him if he had ever had any sexually transmitted infections

“ah shit n*gga, er I mean doc, you mean like that clap on clap off shit? Hell yeah, I had pus all comin out my junk like “blau blau” bu then they got some antibiotics up in this bitch and now it’s all good.

I should add that when he said blau blau, he also thrust his pelvis forward as if he was using his genitalia as a sidearm. It was one of the few moments in my professional career where I seriously doubted my ability to keep a straight face.

2) Another gentleman came in with severe burns on his arm. When asked how such a thing might have occured, he related that he had been in the midst of a domestic dispute with his baby mama. She became angry and hit him with the smoove. 

Dr J “What’s a smoove?”

Pt “You know, a smoove, that thing you use to smoove out your clothes”

Dr J *facepalm*

1 week left until I return to the ccu.

As you may remember, I was also in the cardiac care unit last year at this time as well. And if you recall that, you probably also recall that I didnt like it. See related posts for details, anything from dec 2009 will do.

And now I am going back into it with less help, more responsibility, and for a longer time. Once again working on both xmas and new years, and thanks to last minute scheduling issues, somehow I ended up on call on New Years Eve. Oh well.

At least this time around, I wont be seond guessing myself quite as much, and I can continue to become more proficient in an area of medicine where I acknowledge I am particularly weak.

After a fairly intense ward service, I have been back on consult for a relaxing few weeks.

Final thoughts on my first month of wards?

*Holy jeebus, I learned a lot in the space of one year-did I really used to know this little?

*It is way easier to do the work yourself than to have to constantly check up on others people’s orders; conversely, if you can trust those below you, life is pretty easy

*I cant believe I am the deciding factor in somebody’s grades now.

I mean, the med student still has to take the shelf exam, but at least 30% of grades come from evaluations and 100% of evaluations come from me, as I am the only spending any significant time with the med student. Now I understand why sometimes I just got straight B’s or satisfactories down the line…I may not have been outstanding or terrible, but you dont want to lie, nor do you want to destroy someone’s chances to apply for their field in the future. Apparently I developed a reputation as being a tough resident for constantly “pimping” my student with medical questions. Or at least asking him things to the point where he felt the need to complain to other students I was being hard on him, and they mentioned it to their residents just in normal conversation and those residents mentioned it to me. I figured I was just trying to prepare him for his exam, and never pimped in front of an attending, only gave reading recommendations rather than presentations and tried to teach everyday, but oh well, if thats being hard, then I feel bad for the next student I get.

I got feedback of my own of course as well from my interns in a one on one session who if they were lying to my face, at least told me pleasant lies that I was helpful, low key, and good. And I got a very nice compliment from my attending on the service, who told me I was operating at the level of a 3rd year resident (I am a 2nd year) and he trusted whatever my plan for the patients was and would basically sign off on whatever I did. Given that my last wards service before this was as an intern, and one who failed the rotation due to a particulalry strict attending, this was great validation of all the things I had been second guessing myself on since that time. If one attending can give me straight 3′s (out of 9) and a mere few months later another attending with whom I have more responsibilites gives me straight 9′s, either i made a miraculous improvement, or I was not as bad that month as I had been led to believe.

The last few weeks have otherwise been pretty eventful, although not in ways I can really come up with an engaging way to tell. Most exciting, I finally got my license in the mail.

That’s right, I am now officially a LICENSED PHYSICIAN AND SURGEON. No more calling myself “almost Dr J” even in my head anymore. I shall not be performing any surgeries, but it is nice to know I am licensed to do so.

I have been back on consult service this month, nephrology in particular where most of my patients are on dialysis and I have not been able to think of cool ways to present them on here. Maybe in time.

I also have two grand rounds to present which are basically big hour long presentations to an associated specialty. This week is to the GI department (who I want to join) on applications of probiotics in GI. Next week is to the renal department (my current service) on papillary necrosis. Doing these presentations is a good learning experience and actually not as bad as I was worried it would be although coming up with an academic lecture for an hour is a significant amount of work.

Oh yes, and for those of you following along with my relationship history (or until recent lack thereof) I have broken my gypsy curse and have now been dating the same girl for over a month. She is a PA student who I know from college, and of course there is more to the story, but I will leave that for another time. Suffice to say it is nice to be dating someone who understands my schedule as I am sure my fellow healthcare folks out there can attest to.

So that is the update for the last month. More patient stories to come beginning next week, as I finish up renal and move on to my research elective (aka 2 weeks call of duty time)

-Dr J

One week remaining until I submit my fellowship application. You may remember I was undergoing a crisis of the faith for a while as to whether or not pursue fellowship at all. I then completed a month of elective in GI and Hepatology which thankfully reaffirmed my desire that even though I detest research, it is something I am willing to suffer through for the greater ultimate goal.

On Nov 15 the ERAS website opens for submission of applications. I will be applying to approximately 10-15 programs located in souther california, chicago, miami, and a few scattered other locations. I have obtained my letters of recommendation from my program director, a gastroenterologist, and a hepatologist. I have almost completed my personal statement, meaning the one thing lacking from my application is research.

But guess what!

I finally published! The research project I have been working on since intern year was recently accepted and will be appearing in an upcoming issue of Clinical Gastroenterology. The project itself deals with treatment of hepatitis C in liver transplant patients, and most of the projects I am involved in relate in one way or another to treatment of chronic liver diseases.

So, my application can now be presented in full with proof of a dedication to scholarly pursuits and the all powerful publication to put on my CV.

In one week, I can submit my application.

And then we wait.

I was browsing through my old livejournal the other day (same name if you are that curious) and ended up reading a number of my old posts from when I was a first and second year med student just learning about the physical exam, and super excited to be allowed anywhere near patients.

I am glad to see that 5 years later, not that much has changed. Sure I am still a bit cynical, but on the whole, I have remained happy to be on the path i chose, and I am excited about what I do, although now for different reasons.

I think I will try going back to short posts for a while, just to get back in the habit of writing. After all, novermber is coming up, and it’s as good an excuse to resume posting as any.

Haven’t posted any comics in a while. Dont forget to laugh!