On yet another day of continuity clinic, I was expecting more mundane blood pressure and diabetes follow ups, another visit from my fibromyalgia patient, and possibly some genital related question. All in all, pretty standard fare.

Hmmm…25 year old here for yearly physical, no past medical history. Oh good, I figured, this wouldnt take long…go in, listen to heart lungs poke around stomach and reflexes, send him on his way with a clean bill of health.

Pt: Oh doc, I had a couple questions while I am here, the last doctor wasnt really able to answer them to my satisfaction and just sort of brushed me off.

Dr J: alrighty, fire away…

Turns out that the patient had had a 15-20 pound weight loss in the last two years, most likely because everytime he ate anything, he would throw up about 20 minutes later. He said his previous physician 2 years earlier told him he was a healthy weight and not to worry about it. Now, he was still a healthy weight, but I asked him, if he threw everything up, was there any pain or difficulty with swallowing, and he denied any. Then I asked him what foods if any he was able to keep down…and he mentioned his diet consisted entirely of fruits and vegetables

At this point, the hamster wheel in my head began to spin…

Upon further review I learned that the foods which tended to make him sick following their consumption included spaghetti, rice, milk and cereal, and occasionally alcohol, specifically beer

Noticing a pattern? all grains. all gluten containing foods.

So I sent him off to GI after ordering a comprehensive celiac disease workup including an iron panel and IgA antiendomysiall antibody and Iga antitissue transglutaminae. In earlier times, an antigliadin antibody would have been ordered as well, however that has been found to have a lower sensitivity. It came back positive.

What makes this patients case so exciting (at least to me) is that he had no family history of any digestive diseases, and was from an ethnicity in which this particular disease is fairly rare and unlike the majority of my celiac patients who show up with the diagnosis already made, this was somebody who had absolutely no clue what was going on with him.

Sure it was a fairly textbook presentation in terms of symptoms, but had he not seen me, he could have gone on for who knows how many years with the same problem, just being brushed off until some other doctor picked it up on a whim.

My patient

My knowledge

My Diagnosis

It was one of those moments that helps to remind me why I went into the field.

I havent done anything educational here for a while. No, it has just been comics, and occasional mentions of my travels (still have a ton of australia posts to do) or my love life (spending time with girlfriend takes precendence over updating the intarwebs). Medicine works its way in every so often as well.

SO today, I am going to learn you all good about some handy dandy food products you can use for medical conditions. Please note, none of this constitutes actual medical advice, as for all you know I could be a cabbage farmer in Siberia (bUy our cabbage, it makes you strong like bull!)

Cranberry Juice:

This is the one you probably all know about already, but a recent review of the medical literature shows that cranberry juice may actually be helpful for preventing UTI’s in woman who expereince them recurrenctly

Coffee:

Caffeine is structurally remakrably similar to theophylline, an old-timey treatment for asthma little used today. Although we have access to beta blockers and inhaled corticosteroids, should you be on vacation and suffering from an asthma attack with no nearby hospital and no meds on hand, downing as much coffee as you can should help ease your breathing while en route to proper medical care

Honey (yes dear?):

Yet another cochrane study although of much lower quality showed that honey may be better than placebo in relieving the pain of partil or full thickness burns…so next time you have a sunburn, dribble some honey on it. Also effective? the tannic acid in lipton tea bags…slather yourself in a little english breakfast and watch as that burn fades away!

Vinegar:

In one that is close to my heart, especially during the summer season, vinegar should be liberally poured over any jellyfish stings, as it will prevent the undischarged stinging cells from firing. Contrary to popular belief, urinating on it will not work and will just embarass you and whoever you are urinating on…unless you are into that sort of thing, which is an entirely different problem.

Bacon!:

Myiasis is tissue infestation by fly larvae (Order Diptera). There are different types of cutaneous myiasis, including wound-infestation, migratory and furuncular. Furuncular myiasis results from the fly larvae penetrating the skin where they feed in the subcutaneous tissue. The larvae still need to pop up for air now and then, so seeing a wriggling white thing with black “eyes” (respiratory spiracles) poking out of a skin lump is a dead give away. There are two important types of fly that cause furuncular myiasis. The human Bot fly (Dermatobia hominis), found in Central and South America, and the Tumbu or Putsi fly (Cordylobia anthropophagia) from Central and Southern Africa (plus at least one case from Portugal!).

The furuncles are left covered with bacon fat. This encourages the larvae to exit the skin, either due to suffocation or an attraction to bacon. After about 3 hours the bacon fat is carefully removed with forceps at the ready to help fully extricate the larvae

So if any of you were planning a trip to central america, or africa, keep some bacon handy, it might just prevent some uncomfortable furuncles…plus you will be able to eat bacon!

So there you have it, dont say I never taught you anything

-Dr J

I’m counseling a clinic patient this afternoon about obesity and her high cholesterol, and as we’re talking she reaches into her purse…

And pulls out a hot dog. Wrapped in foil, but still… a hot dog. And she unwraps it and starts eating. While we are talking. About her eating habits.
I am literally dumbstruck. This does not happen often. I inform her that she can not have a hot dog in the middle of clinic. Doubly so while I am telling her to lose weight.

“I didn’t get a chance to eat lunch.”

That is entirely beside the point. you can eat before or after your appointment but not during.

“I didn’t get the french fries. I’m trying.”

There is a fundamental connection here being missed. I tell her again she will have to put it away, or throw it out.
And then she stuffed the entire thing into her mouth, chewed it up, and swallowed.

“You didn’t give me much of a choice.”

Ah, clinic.

“Of all the patients in all the clinics in all the world, she had to walk into mine”

During my intern year oh so long ago (over a year! ) I recall seeing an elderly lady who was visiting me for high blood pressure. She mentioned that she wanted to start taking cozaar, a specific anti-hypertensive drug to control her blood pressure. Scrolling through her medications, I saw that she was already on an ACE inhibitor, a similar class of drug and so asked her why she wanted to switch. Was she having side effects? did she feel her bp wasnt controlled?

It turns out all her friends were taking the same drug for their hypertension so she thought she should be on it as well. I explained to her that just because all your friends are doing something is not a good enough reason for me to change your medications. Then, because I was an intern and had to run all my cases by the clinic attending physician, I left the room to go present the case, explaining my absence with a simple “I am going to confer with another doctor and return to let you know the plan.” The plan was exactly what I had told her to continue her regular medication but it still had to be presented.

And that was the end of it.

Until about a week ago, when I learned that that patient had gone home and googled me, found out I was a freshly graduated intern (not that I was trying to keep it a secret) and felt that I handled the situation inappropriately, both in my flippant response and my apparent self doubt, as I told her the plan then said I had to check with another doctor for something as simple as a prescription question. She then lost all faith in my diagnostic abilities and decided to go see another physician at a later point to follow up.

How did I learn all this?

The patient is the grandmother of my current girlfriend

Talk about your chance encounters.

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?

*Hello* *hello* *hello* *hello*

Anyone still out there? If you are consider me impressed. I am clearly going through a “meh” writing phase, mostly because I am out doing things. But every now and again it’s nice to come back to see how everyone is doing and write myself these little reminders of what it is like going through residency.

So what is it like? I am now a second year resident. I have been keeping this particular iteration of the blog going since my third year of college and for the last 5 years it has been primarily related to my experiences as a burgeoning medical professional. 

As I have mentioned before, being a resident is a LOT better than being an intern. The general hospital staff have a lot more confidence in you, you have a lot more confidence in yourself and it’s when you finally start to feel just a little like the doctor everyone you know assumed you were from the day you got your acceptance letter to med school. I make decisions about patient care. Yes I have an attending to oversee and discuss those decisions with, but ultimately, the attending is there as my safety net. I am the one seeing the patient every day, writing orders, calling consultants and in general dictating the plan of care. As an intern I was doing a lot of these things as well, but there was almost the feeling at times that I was mostly there to write notes and follow orders. If I didnt know something, I could ask my senior, or my attending, or just assume someone higher than me would have the answer.

Now, I cant afford to take the luxury of hoping someone else will fix it, when it comes to my patients. In the last year alone, I have diagnosed several people with cancer, others with AIDS, and convinced more families than I care to think about changing their code status. Some of these things would have happened regardless of whether or not I took a leading role. Others only happened because I decided to follow up on something that just didnt feel right. A couple were just dumb luck. But each of those decisions rested solely with me.

It’s not something you think about at the hospital. You are too busy with writing notes, or catching up with coworkers at lunch, or attending conferences, or working on research. Every moment, even the idle ones are filled with something. It’s not even something you think about that often at home. You are too exhausted and have to do the chores, socialize, make dinner, take care of family if you have them. But every now and again it still hits me how much total strangers place unquestioning faith in my decisions

And those few quiet moments are the reason that you stay past the work hour restrictions, writing notes 2 hours after you finish. why you come in with pneumonia even though everyone in clinic seems to have taken several days off their jobs for a case of the sniffles. why even in your downtime, you end up discussing journal articles or patients. Because no matter how I claim to be more than just my job, it will still be a large part of my past, and what has shaped my ways of thinking and behavior. 

In the end, no matter what specialty you have chosen to go into, the truth is that we are always learning, always thinking, always on call, even if it is only to ourselves for the sake of patients we may not even have met yet. Regardless of when the shift ends, we are all still 24-hour people.

I walk into the patients room, a young to middle aged black female with a pleasant smile on her face

Dr J:”How are you feeling today Mrs X?”

X: “Oh I’m just fine but betty isn’t doing too well”

I think to myself what? who is betty? that’s not her name. is this a psych patient?

Dr J: “What’s wrong with Betty?”

X: “She’s just not putting out. She does that from time to time no matter how much I yell at her, and when Betty doesnt put out, I end up in the hospital”

At this point I am thoroughly confused with perhaps the occasional rascist stereotype trying to edge it’s way in to my head.

Dr J: I see. well, erm, where is betty right now?

Patient lifts up her shirt and points to her colostomy. “Right here, doc. Where else would she be? That would be weird.”

Yes Mrs X that would be weird indeed.

I have been MIA for quite a while. Chalk that up to finishing almost 3 months straight of ICU care, with the last two weeks being night float. As a second year resident, every one of my non-ward service calls is as the overnight doc in charge for the ICU.

36 patients, every one of them in critical/intensive conditions, plus whoever is hanging out in the ER, and any issue that comes up, be it for renewal of restraints to sudden desaturation requiring intubation and a breathing machine is dealth with first by me. Later by the fellow, if I call and cant handle it. But the buck initially stops with Dr J. 

For added fun, I now get to run codes. That means when someone’s heart stops beating, or they stop breathing and a code blue is called, the one doc expected to head up the team and tell everyone what to do, and for how long. Now of course everyone knows their job and it’s not like I have never been at a code before…it’s just a little intimidating to realize that the big decisions are now in my hands.

On the plus side after a month of ICU, a month of Pulmonary consult (most doctors who run hospital ICUs are pulmonary/critical care specialists) and two weeks straight of nights being on call for the ICU, I feel pretty comfortable handling almost any kind of critically ill patient. I also got some of the hardest months out of the way early on, so I will be well prepared by the time I go to wards service.

In the meantime, I am kicking back with a little bit of research/hospitalist elective for the next two weeks while I continue to decide about applying for fellowship this year. Start my gastroenterology (GI/digestive system) elective later this month, and should have some more stories to share at that point.

In the meantime, I guess I can take a step back and say I have continued to grow as a physician. So hey, good for me!

-Dr J

On several occasions I have written about making a patient DNR (do not resuscitate); about the difficulty, the responsibility, the power of convincing someone to just let their loved one go, to not force them past their allotted time on earth. I have written about how I have helped others deal with this all too common modern medical situation. I have written about why I think it’s a good idea that everyone have an advance directive. 

And yet, I realized I have never written about how I actually go about it myself. You know my basic formula based off Dr Folkmans advice, but how does one go about convincing a patient or family to change from “do everything humanly possible to keep my loved one alive” to “I dont want them to suffer anymore, if anything happens let them go.”

Well the first thing I always do is introduce myself. Nobody wants to be having life and death discussions with a stranger. So my goal from the get go is to build trust and rapport, to convince the family I am on their side, that I am using my education and experience to do what is best for everyone. Next I ask what the family understands of their loved one’s condition thus far. Oftentime people may be unaware of just how sick their loved ones are. They see someone come in with a minor infection or some mild chest pain, and not understanding the disease process, become frustrated or surprised when people appear to get worse in the hospital, a place they brought them too for healing. When the family explains how much they know, it gives me a better idea of how much further I have to take them.

I repeat myself. Often. I use a lot of stock phrases such as “his condition is very serious” or “she hasnt been doing well” peppered liberally throughout my talk. If anything I sometimes use my authority to overestimate slightly how close a person may be to death, so the family has no choice but to confront the issue now rather than a last minute phone call in the middle of a code by a covering doctor or someone from the crash team.

And after I have explained what is going on, after I have told them what critical interventions we have been doing to simply maintain the current level of awareness/health however dubious it may be, I start rolling out the big guns, and just like on Jeopardy I do so in the form of a question.

“Now have you and the patient ever discussed what treatments they would like if they were in this condition?” 

Unfortunately, in many people the answer is no. So I take two steps forward and one step back. I try first to personalize the issue for them, reminding the family that they know the patient better than I do, and ask them about their quality of life before hospitalization compared to know with whatever hospital needs they may require. I ask them if the person was standing there with them able to see themselves lying in a hospital bed, what would they want done. Would they want to continue in this way.

This may all sound very manipulative, and I cant deny that on some levels it certainly is. But I am not just running willy-nilly through the hospital trying to off people left and right. The people I take this approach with often have been unable to confront this on their own, have been in a state of denial and even if they decide they still want everything done, futile care though it may be, even the discussion gets them started with the process of preparedness, of acceptance, of realistic expectations.

That said, I dont leave people all open ended with a simple here are your options, full code, dnr, or cmo. That would be failing both myself and them. Most people are rarely confronted with the complexities of death on a daily basis and may not know when treatment is futile. For a doctor to tell them all this and then walk away saying what would you like is as useless as not discussing the subject at all. After the discussion noted above, I offer my recommendations. I tell them, if it were my family member, I would make them DNR, or cmo if the case warrants it.

And then I emphasize that do not resuscitate does not mean do not treat. Just because I dont think someone should undergo the suffering of rib fractures from compression, or electrical burns from defibrillation, should not be subjected to weeks on end of mechanical assisted breathing, should not lie in a bed full of tubes pouring out of every orifice does not mean I instantly leap to withdrawing care and starting the morphine drip. I start back at square one reminding the family how serious the condition of their loved one is, and ask them to consider allowing a natural death, or a death with dignity to occur if the body simply cant take anymore rather than forcing them back into life repeatedly.

I carefully avoid any reference to my own religious beliefs unless directly questioned. They have no place in this discussion, although respect for the families beliefs does. I repeat these conversational tidbits until the family gives me a clear reasoned response. Either they agree with my recommendations and change the order, or they tell me they still want everything done. And regardless of my own feelings, I accept that clear answer when given. If I disagree, I wait until another day and bring the issue up again. Sometimes it takes a few days for the veil to lift from someones eyes.

After having just one of these discussions this morning, one of the fellows relayed back to me that the nurses had spoken with him and told him I had done a great job of handling the family and discussing one of the harder topics in medicine. While nice to hear that I am deemed by my peers to be performing so well, I wish I hadnt become so proficient at this talk so quickly.

-Dr J