My "Family Voice" has been getting a lot of practice these days.

The "Family Voice" is something that I think all doctors subconsciously develop somewhere along the way during residency. It's the tone, the inflection, the parsing of words we use when talking to the patient or their family. This is not to imply we treat people like they are stupid or uneducated, though that happens quite often as well. What I mean, however, is the way some residents will lower, or raise their tone the way you might change your inflection when talking to a dog or small child. Some slow their speech as if to make sure each fact gets through, while others speed up perhaps hoping to get all the worst info out in one go. Everyone has a different way of speaking and one we never seem to use when speaking to colleagues, calling consult, instructing nurses, or even chatting with the cafeteria staff. It's a special way of speaking used just for the patient and their families.

Most of the time, it is used to break bad news. "I'm sorry but you have cancer."

Other times it is used to force families to make hard decisions. "We need to know what your father/mother would have wanted-should we continue to leave them intubated?"

And these days, I find myself using it as a means of authority. "Miss, he's coding and you NEED to leave the room while we work."

At first, I felt like most of the authority came from the coat. It was my armor, my shield, and I could hide behind it and spout great pronouncements of fortune and favor or doom and despair. Later, I thought it came from the education. I knew the jargon, and I could rattle off big words and fancy phrases until the average person would agree just because they no longer knew how to disagree. Now I have learned that it comes simply from The Voice.

When I use The Voice, it's not about defending myself, or sounding smart. It's stating facts, what I think is best for the patient, or what information I need to be provided in a tone that brooks no argument. It is neither insulting nor cajoling, just a pure issuance of confidence that I have found people respond to. And because of that, it gets results. History that was previously hidden, difficult family stopping to listen, even if they disagree. 

And because I get such good results, I find myself using The Voice more and more often. In some ways, I am watching my future hospital me develop, one skill at a time. Right now, it is still Dr J using the voice as part of his work toolbox. But I can easily see it developing its own personality, and becoming the hospital Dr J, while regular Josh continues to develop in his own ways outside the work environment. 

And while you may disagree, I think it's a good thing. A way for me to separate my work and pleasure, my yin and yang, the two halves of my personality that just cant seem to reconcile with each other despite the things they have in common.

Or maybe I am still looking for any safety net I can grab as intern year draws to a close. 

So how did my vacation begin. 4 hours into an 11 hour flight...

"Attention all passengers, if there is a doctor on board please identify yourself"

Dr J's thoughts: "shit shit shit shit shit"

I'll admit, I seriously considered not saying anything, leaning back in my chair and trying to sleep. Call it a lack of compassion, call it a fear of litigation, but there was a strong urge to just let the announcement pass. After All, I'm on vacation...and not only that but I'm just a first year resident, what do I know?

And the answer is, probably more than the average person on the plane, meaning my stupid conscience wouldnt let me ignore it. So off I went to answer the medical emergency hoping to god it wasnt something serious.

A 34 year old man with no past medical history had been complaining of palpitations and chest pain to the stewardesses intermittently, initially refusing further aid then becoming worried and agreeing to have a doctor paged. Which is where I come in, to find this man sitting on the floor clutching at his chest, damn near giving me a heart attack. The first and most important thing was to triage him...he was young to be having a heart attack but without any lab equipment, diagnostics, or even a stethoscope (at least initially) all i had to go on was my history and physical diagnosis

After taking his pulse and checking his blood pressure, and learning that he had been seen three days earlier with a diagnosed panic attack and subsequently cleared to fly, I felt reasonably safe in diagnosing him with another panic attack and informing the captain that there was no need to land the flight in siberia to get him further medical attention. My reasons for this were as follows

A 34 year old with no family history, no obesity, and no risk factors other than smoking with a previously worked up similar complaints 3 days before. Oh yeah and one other doctor was also on the plane, but as soon as he got there and saw me talking to the guy he basically asked what year I was, and after hearing I was a first year internal medicine resident, he was like, okay all yours and disappeared into safety from liability land up in first class.

So I basically just sat and talked with the guy through his panic attack, gave him some oxygen, and retook his pulse. All without the aid of modern medical technology, and essentially doing nothing, he got better and was able to retake his seat and I mine. And for this doing nothing, AA gave me 25000 miles and a free bottle of red wine from first class. So this time, no harm, no foul. It was both a heady and terrifying feeling.

And that's how I started my spring break. Let's hope the remainder of my trip is somewhat more uneventful

Dr J

Thanks to everyone who viewed and or commented on the post about my friends death. As long as his memory lives on, a part of him will always be with all his friends and family, and that's the only immortality any of us really need. One nice thing is the act of remembering him helped bring me back to xanga after what has felt like too long a hiatus. So let us now resume your regular musings, thoughts, complaints, and inappropriate comics.

Given the state of medicine today, and all its gagdets and electronics, doesn't the idea of a rectal exam seem a bit low tech? When I was a young lad, I heard the term digital rectal exam and thought it was something like a digital watch...you sit on some machine and a printout is ready to tell you if you have butt disease.

Who was the first guy to think of performing it. Like way back in ancient times someone looked at a sick person and thought to themselves...I bet if I stick a finger up his butt, I can figure out whats wrong with him!

In other news, while I love being back on wards, I really dislike social admits. They usually go something like this

marriedtothesea.com

It can get very frustrating when families have unrealistic expectations. Some people do not get better, some people can only be stabilized and returned to their daily life. And yet there seems to be an unspoken...heck often even a spoken expectation that not only will we as doctors return the person to normal, but to what they were in their youth. Fix them up to make them better stronger faster, etc. And I am sorry for the forthcoming cynicism, but as long as we continue in this culture of not taking responsibility for our own health and actions, medicine will really only serve for the most part to keep people alive who should have died long ago.

I realize the above is not an entirely fair statement, but in many cases it's all too accurate. And somehow I have turned depressing again. bleh. oh well next entry I'll try again to share some happier stories.

Am I keeping to my once a week posting, or have I already broken my resolution?

In either case, it has been a busy busy week. I have been fortunate enough to perform two lumbar punctures on patients and it wasnt anywhere near as scary as I thought it would be. I find that happens a lot in residency...I spent all medical school getting all psyched up about one thing or another that I thought would happen when I became a real doctor, and then it actually happens and it turns out not to be anything I can't handle.

But I digress. My very first lumbar puncture ever was on a elderly (surprise surprise) gentleman who was pretty much comatose by the time he came in. The ED doc had stopped by the workstation to talk with the attending and asked if there were any residents around who wanted to do a procedure. As part of residency, we have to do X number of procedures like paracentesis (draining belly fluid), lumbar punctures (spinal taps) and ABG (drawing blood from arteries) to ensure that we are capable to provide any kind of care at any time as part of the diagnostic workup. So off I went to do the procedure with the ED doc providing a watchful eye and a guiding voice as I did my very first solo spinal tap.

The gentleman was rolled on his side and placed with knees to chin, balled up in the fetal position as tight as the nurse could make him. This helps curve the spine and presents the maximum surface area available for me to slip a needle in between. This is good because the last thing you want to do is miss the spinal fluid and accidently stab the spinal cord. Then after feeling for the anatomical landmarks, the spot was marked and confirmed by the ED doc and I numbed the area and in I went. I'm told by friends who have had it done that it is a fairly painful procedure but this gentleman didnt even flinch, which told me just how sick he was. Fortune smiled upon me however and I got it on my very first try...a gentle popping sensation and sound as I passed through the vertebral colum, and when I withdrew the trocar (guideline inside the hollow needle) a clear fluid came dripping out. I collected in into 4 small vials and then sent them off for studies to find out if he had an infection in his spine.

Now quite often interns will cause a "traumatic tap". This means that they dont find the right space on the first try and the first vial will have a high degree of red blood cells, and thus be pretty much useless to the lab. High degree is 60rbc or higher. COnversely, there is also a "champagne tap" wherein no rbc's are seen, and the csf (cerebro-spinal fluid) collected is clear like champagne. It is also called that because if you actually achieve fewer than 10rbc's, or a totally clear tap, the attending who supervised you is supposed to buy you a bottle of champagne. So my very first one had 22rbcs in the field...too high for free alcohol, but a pretty respectable number for a first try by a rookie.

....

About three days later, I have an 80 year old woman with severe dementia who initially came in with a pneumonia, but has altered mental status a little more severe than could be explained by her dementia alone. So infectious disease specialist is consulted and recommends a lumbar puncture to rule out meningitis (inflammation of the spinal cord). No ED doc around this time to help, and my resident has clinic. She offers to find a third year to supervise me, but reassures me that, "you have already done one, you will be fine" The third year who is there to supervise has only done one in his three years of residency.

Let's pause there for a moment, shall we. The person supervising me during this procedure will have less experience than me by the end of the procedure. Ah, residency.

Carrying on. Unlike my first patient who was knocked out 6 ways from sunday, my current lady is demented, angry, fidgety, and has a mouth like a sailor. It takes 2 nurses to hold her in position and this time I am doing the whole procedure from memory, with minimal input from the supervising resident. (which I am okay with, i just didnt want to be alone to do this) I found the landmarks on my own, I cleaned and draped the patient and even had to use my "doctor voice" to quiet the lady down because all her moving only prolonged the pain and procedure for the both of us.

Unfortunately, the first attempt, I missed the landmark completely, placing the needle about 1inch too high...whether because of the difficult behavior of the patient or my own inexperience is anyones guess.

Rallying to the fight however, I knew my mistake, and just like in showbizness, you never let them smell the fear. I simply told the patient that I had to do the procedure again and she would have to stay still this time. I then re-anesthetized the same area 1 inch lower, and set back to work...and a short time later was rewarded with spinal fluid. I had guessed my mistake correctly and adjusted myself accordingly with no one other than myself (and the resident) the wiser. And for all that the rbc's in tube 1 was only 61, with the patient not suffering a post-lumbar puncture headached that commonly occurs after traumatic taps.

So while my second attempt did not warrant a bottle of champagne, I still celebrated with a glass of beer for a job well done. One of the procedures that had frightened me so much in medical school, the thought of putting a needle into someones spine, had succesfully been done by me twice in one week on an easy and a difficult patient and both times I had achieved success.

Looks like I'm starting to get the hang of this whole doctorin' thing after all

Sometimes I stop and think how strange it is to be a doctor

I see people when they are sleeping and totally vulnerable. They tell me things that they wouldnt tell their best friends, family, or even priests.

I alter their very body chemistry-Magnesium too low? give some IV! Now tell me, when was the last time you ever even thought about your magnesium level, or that you had one? And yet here I come to tell you that your current level is unacceptable, and I am going to "fix it". And this is a minor thing, which leads me to...

I tell people that they need to be cut open, or have tubes shoved through their groin to their heart, or that they have to start taking pills to thin their blood and/or make them pee for the rest of their lives, and THEY AGREE TO THIS. Now dont mistake me, it is important for them to do so, and I have justification for these pronouncements...but the fact that people take what I say at face value just because of an article of clothing I wear blows my mind.

and that's all for that.moving on to another fun er junkie story

"I was on my way to my girlfriend's place and did some meth in the car because if I waited till I got there she and her roommate might use it all. But there was something wrong with it and I began shaking, and got real dizzy, and then began puking all over the steering wheel. Then my vision got blurry and I couldn't see the road very well, and I was afraid to pull over cause then a cop might come try to help me, and I'd be in deep shit, so to be safe I started driving as fast as I could to get to the nearest emergency room"

and here is a fun little picture for no good reason

Currently I am rotating in the coronary/cardiac care unit, or ccu.

I dont like it.

I have been a doctor for almost half a year now, and this rotation is the first time that I have actually felt like what I do is "work". I dont remember being so unhappy even when I was doing my two months of night float, running to every code and socially isolated from everyone else.

Every single day on this rotation has taught me, but it has taught me in such a way that I go home feeling defeated, disappointed, and dumb. I look at an EKG and I have learned to recognize specific types of abnormal rhythms, but cant wrap my head around the spatial orientation of the leads that those rhythms represent. (by contrast: the fellow looks at a morning EKG and can say, oh the surgeons will probably find this vessel occluded because lead v2 has an inverted t wave-wtf?)

I come in earlier and earlier each day and still cant seem to stay on top of all my patients before we round. I know what happened during the night, I know what meds they are on, but I will forget bits and pieces of the their other problems or plan during my presentation because I will mix up details between the 6 people I had when I left, and the 3 new ones who came in this morning, all 9 of who I am apparently supposed to have memorized to the smallest detail by 8:30am.

The fellow subtly reminds me and the other two interns on an almost daily basis now that if we cant get all this done in a timely fashion, we might just have to come in earlier. I already get there at 6am, and that's after a 40 minute commute. Then he will tell us how back in his day, he used to be responsible for more people, earlier and it could always be worse.

Yes, but it could also be better. Isnt that why things like duty hours and other resident sparing measures were implemented to begin with?

I feel like I am a constant disappointment to the attendings when I am pimped and even when I come up with the correct answer its not fast enough to suit them. Now, to be clear, neither the fellow or the attendings are in any way mean or belittling. Quite the contrary. All the suggestions they make are legitimate, and necessary and really will make me a better doctor...it just would be nice if every once in a while I could hear that I did something well rather than that I could do something better.

Or maybe I really am just a terrible doctor.

It's the constant doubting of myself that this rotation is causing that is really taking it out of me. Now I have a habit of becoming a little bit more easily depressed during the winter months (as do many people) and I was hoping that being in california with more sun, among friends, and enjoying what I do would help with all that.

But I dont see the sun...I get to work and leave work when its dark. I am friendly with all my coworkers, but have really only one or two I trust enough to call friends and complain to without having to worry about who might say what to whom. And I dont have an academic interest in the heart to begin with and this rotation certainly isnt going to improve it.

I am a categorical intern for internal medicine. And I need to know this stuff. But learning it like this is slowly killing my spirit. And I dont know how much more I can take and still put on the "thank you sir may I have another" act.

I know I chose a hard profession, and it wont always be fun and games. I just didnt think it would get to me this early. and take away so many of the simple joys, like having time to myself, or cooking dinner, or stopping to watch the sun out the window.

I guess I just wish there was someone else who understood. and who I could trust enough to confide in.

Oh well. Happy Holidays.

*insert standard excuse about lack of consistent posting here-make it like mad libs!- Dr J could not post because he was busy (adj) his (noun) for (length of time) and is very (emotion) and promises to (excuse that will not be followed through on)*

How many of you are familiar with the pain scale when you go to the hospital. You know the one...on a scale of 1-10, 1 being no pain and 10 being the greatest pain you have ever felt in your life, such as rabid dogs gnawing off your face while your legs are on fire and jason and freddy are alternating stabbing you?

I see lots of people ever day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale.. But pain is subjective, so who is to say a mildly sprained ankle or an upset stomach isn't more horrific to this individual than the fires of Hell?

Anyone who says 10 (everybody), who doctors don't think looks like a 10 (90% of people), is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.

In Other news, GE made a pretty neat graphical representation of healthcare costs of various common problems for people at various ages. Looking at it helps to understand a lot of the problem we have as a country with healthcare-if your high blood pressure costs the insurance company 7000 dollars a year, but you only pay 1300 a year, there is a pretty big disconnect from your understanding of WHY you need to take your meds, not to mention a growing sense of entitlement that everything should be free free free. Update on that later.

Check it out!

Oh Cyanide and Happiness, how i have missed your carefree medical comics.

I'm still plugging away in the ccu

I think there is an unspoken expectation that people at the time of their death will have last words. Some final message they have been waiting to impart, whether it be words of reconciliation for long estranged relatives, or a simple goodbye to those they love. In this archetypal deathbed image, family members are gathered around the bed of the dying, who is clear, lucid, and distills a lifetime of experience into a few words of wisdom before sighing once, and passing on.

The sad reality is that most people never get a chance to say anything before they die, because they have long since lost the power of speech.

I recently sent a man home to die. A man who, a mere month ago, I had treated for a relatively straightforward pneumonia. Unfortunately, old age is insidious, and at a certain point, it can become quite hard for individuals to recover even from straightforward diseases. On his readmission, this elderly gentleman stated his pneumonia had resolved, but he still had fatigue. So we admitted him, and began working him up to locate other possible sources of the infection his labs indicated he still had.

And I spent the next 2 weeks watching him slowly but gradually decline from an interactive, lively, hard of hearing old gentleman breathing on his own to a nonverbal, nonambulating, shell of his former self, lying in bed on oxygen, while the family met with the palliative care team. A thorough inspection had revealed no infectious source, his cardiovascular status had gone from poor to practically nonexsitent, and finally I had the dubious responsibility of telling his family, "I'm sorry, there's nothing more we can do. Perhaps it's time you think about taking him home."

The family, while saddended by the news (understatement though THAT be) understood, and we discussed the options available before they decided they were in agreement with comfort measures only, a do not resucitate order, and bringing the patient home to die in a familiar setting.

I signed the discharge orders, knowing I would never see this patient again. I tried harder than I could say to recall when the last conversation I had with him was, reaching to find anything at all that could be construed as last words and not just my one sided questioning of daily symptoms to which he could only respond with nods. I came up with nothing.

So I sent the family home with last words of my own: Whatever your beliefs are, I sincerely hope that your loved one finds peace and happiness in accordance with them. Then I stepped over to the computer, clicked the order to discharge, and watched as they disappeared forever.

The numbers on the clock read 3:30. 30 minutes until I am protected from admissions, 90 minutes until I get to go home. I spend my time idly performing chart review for my research project, digging through months of notes to grab minor details for the statisticians. Suddenly the pager goes off.

"Oh no oh no oh monkeyfeathers!"

"Hi Dr J, we have a patient for you to admit, and this is a good one for the subintern, so have him do the H&P."

I inwardly cringe. The sub-intern on my team is a nice guy, but like all students cant help but slow me down when I was hoping to knock this out and be out by 5. Nonetheless, I agree, the sub-I and I briefly review the pts chart and down we go to visit him.

The pt is a 55 yr old gentleman with a past history of high blood pressure, high cholesterol, and recurrent urinary tract infections here with another urinary tract infection and some shortness of breath. I let the student take the lead in questioning while I scribe notes. After 10 minutes (my patience threshold when I am trying to go home) I subtly begin to help direct the students questions to the pertinent information.

The biggest concern with our gentleman is his low blood pressure. Someone who reports a history of high blood pressure coming in to the ED with 74/61 is worrisome. More so when that blood pressure barely corrects after 4 liters of fluid. To clarify, I want you to imagine you have just drunk 2 of those giant soda bottles.

Despite the fact that this man is sitting up and talking to me, that he appears relatively healthy, he is in septic shock. Lab tests revealed more disturbing values. A creatinine (kidney function measurement) of 5.4, where a normal level is 1.0 So on top of his sepsis, he had acute renal failure. Oh yeah and troponins were elevated as well (heart injury lab) meaning he had some demand ischemia (almost, but not quite heart attack) also likely due to his sepsis.

So it was off to the ICU with him. I called up the admitting fellow and informed him of our plan.

"Yeah that sounds fine, but drop a central line in him so we can give pressors and antibiotics"

No problem, except I had never done one of those before. Looked at my watch. 5:30pm. Duty Hours and my internal devil are telling me to sign it out and call it a night. But how in good conscience am I just supposed to walk away? Do I tell the family, sorry, residents have an 80 hour cap, some other doc will come in and jab a needle into a major vessel.

So I sighed once for my lost evening, and went to track down an attending to supervise me while I placed a central line. A central line is a large bore catheter placed in either the neck, chest, or groin. Most interns/residents tend to opt for the femoral option as it is 1)slightly easier to place a line and 2) does not carry the risk of puncturing the carotid artery or causing a pneumothorax among the more traditional complications of the procedure

I, however, am not most residents.

I explained all the risks of the procedure to the patient, and then the benefits and why I thought he needed this and should consent. I clearly managed to convey the appropriate authoritative and experienced image because rather than saying "YOU ARE GOING TO JAB A HUGE NEEDLE INTO MY JUGULAR VEIN? ARE YOU EFFING CRAZY?" instead he went with the more traditional-"whatever you think best doctor."

Perhaps he may not have had the same level of confidence if he knew this was going to be my first one ever. But hey, that's the price of going to a teaching hospital, right? The secret to success is sincerity-once you can fake that, you've got it made.

Gowned and gloved in sterile attire, I palpated the gap between the two heads of the sternocleidomastoid, finding that magic triangle, in which the ultrasound tech located the compressible vein. Then, after cleaning the site, and injecting lidocaine to numb away the sensation of having a rookie poke around in your jugular area, in I went!

I wish I could tell you I was insanely talented and got it on my first try. However it took about 3-4 times of advancing and retracting the needle, and finally moving more lateral away from my initial puncture wound before I finally saw the inrush of venous blood. I maintained my serious doctor face the whole time while my internal monologue was screaming "YOU HAVE A NEEDLE THE LENGTH OF YOUR HAND IN THIS MANS NECK, QUIT MUCKING ABOUT!" and successfully inserted the catheter with only a modicum of blood spilling onto my gloves, and no complaints of pain from the patient.

I had successfully inserted my first central catheter, with no complications, and in a more challenging location. I ordered a chest xray to check the placement, and sent him off to the ICU. The time was 8pm, 3 hours after I was supposed to be off, but totally worth the experience. Next time, I will be much less hesitant and once again, I will go for the throat!

Dr J