Archive for July 2006

No triumph today

July 31, 2006

I got a spot of blood on my dress today. It happened as I was on my way out of the hospital and heard the code bells ring. I ran, cursing, past two women clutching each other in a hallway, into a room where a man was lying unconscious in a chair, blood trickling from his mouth. He was a pre-transplant patient–a man about to get a new liver. 

Ideally, a code is a carefully choreographed disaster. No one expects the outcome to be good, but everyone expects the process to be organized.

This code was a disastrous disaster. I didn’t participate this time–just tried to stay out of the way. The anesthesiologist shouted over and over again for suction, cursing as she pulled streams of clots out of the patient’s mouth. The respiratory therapist, who was ventilating the patient with an oxygen bag attached to a mask on the patient’s face, got himself and about 7 other people sprayed with a fine aerosol of digested blood. The transplant surgeon ran in a silent, heartbroken panic in and out of the room, his face twisted with worry. 

At fifteen minutes, the charge resident said, “Anyone opposed to ending this code?” and the patient suddenly developed a heartbeat. The surgeon finally spoke: “You want to call a code on a patient with a beating heart? Push bicarb! Push epi! What’s wrong with you people?” 

There was an exchange of meaningful looks: a code is supposed to be run by only one person at a time. Amid the carnage at the head of the bed, the anesthesiologist said, without much pride, “We have an airway.” There were a few more minutes of chest compressions, and then it was over.

I don’t usually cry after these things. But this time, I came home and sat on my sofa and sobbed. I can’t clear my head of the image of the two women standing in the hallway outside the unit, and I can’t clear my ears of the sounds of their terrified crying. There was no triumph today–just a sick man dying in a way he couldn’t have wanted to.

I doubt that in this case, the outcome would’ve been different if the code had gone more smoothly. But there would have been, as there usually is, something reassuring in the well-executed process. When that process breaks down, the thin membrane that contains all the physiological chaos of a resuscitation is torn, and the futility and ugliness of it all spills and is smeared all over the place.

I, for one, feel dirty.

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This is fraud

July 27, 2006

As a brittle, childless spinster, I don’t have child-rearing experiences of my own to draw on. Yet every day in clinic, I make reassuring eye contact with haggard looking, applesauce-spattered people, and explain to them how to raise their children. I have no data to back me up–only snippets I’ve overheard from people who actually know what they’re doing.

This is not evidence-based medicine. This is fraud. As someone who has never had the pleasure of ignoring a breath-holding spell or a tantrum, I feel like a total jackass telling parents to do it. But what’s odd is that when I speak as if I have a clue what I’m talking about, they obediently bob their heads at me and hang on every word that comes out of my mouth. It is completely absurd.

More on this at a later date.

Completely freaking irresponsible

July 21, 2006

This is why people who don’t know science shouldn’t write about it as if they do. I don’t care how much she’s “mulled it over”–the author of the recent New York Times opinion piece about compulsory vaccination of girls with the vaccine against HPV makes some dangerous assertions here based on totally unscientific thinking and some seriously lame perspective.

First of all, has this woman ever had an abnormal pap smear? A LEEP excision? No? Well, neither of them is much fun. Also? Cervical cancer may not be on the top 10 cancer list in the U.S., but it still exists, and it still kills 3,700 people each year. I haven’t done a statistical analysis, but I’d guess that the number of adverse events expected from the vaccine is outweighed by the number of cases of cervical cancer that would be prevented by the vaccine, even in our pristine American cervices.

And if this lady is SERIOUSLY going to suggest that in the face of other preventive options, we choose to rely on the often-imperfectly-used condom for prevention of STD’s, especially among adolescents whose access to them is determined by how much their school districts’ chieftains love Jesus, then she is just insane. 

There is at least one fact she got right: Cervical cancer causes far less death than it used to due to the early detection capabilities of the Pap smear. OK, and she’s also right that vaccines carry risks. But those risks are teensy tiny, and often exaggerated by media reports.

Her great example of risky vaccines is RotaShield. Her proof of its riskiness? It was pulled from the shelves! Sorry, lady, but that is not data. RotaShield was, in fact, pulled from the shelves because eight of several thousand recipients developed intussusception, an involution of the bowel that can kill a child if it’s not caught in time. At the time, everyone panicked about the possible linkage between the cases of intussisception and RotaShield.

Now, intussusception happens in kids at a certain baseline rate. The question after the vaccine was pulled was, how many of the new cases of intussusception were due to the vaccine? Meaning, how many cases above the baseline rate occurred in kids who got the vaccine? The answer: not many. The estimated increased risk among kids getting the vaccine was 1 in 11,000-16,000 kids. (1)

(Slightly tangential, but good for completing the thought: the risk above is already a pretty low risk. It seems even lower when you consider that about 440,000 kids die each year worldwide from rotavirus diarrhea, the disease against which RotaShield was active.)

(Even more tangentially: the author conspicuously avoids naming one of the most popular “debates” about vaccine-associated morbidity. I’ll help her out: the mercury-containing vaccine preservative thimerosal does not cause autism. [2] Her entire article smacks of the same vague, clueless doubt that shapes the ethic of a lot of people who insist the above association exists.)

My point is that although most vaccines have some side effect–some more pronounced than others–those side effects are almost always greatly outweighed by the benefits. Although I appreciate the spirit of inquiry that provokes evaluation of risk-benefit ratios with respect to medical interventions, it is completely freaking irresponsible to suggest that we reconsider all vaccinations because “we don’t know what the long-term effects are.”

In most cases, we DO know what the long-term effects are: massive reductions in morbidity and mortality. The risks associated with the vaccines we routinely offer are so greatly outweighed by their benefits that they are not worth considering in deciding whether to vaccinate children. If she wants to argue otherwise, a weak “but” isn’t good enough–she needs to present some data. Otherwise, her New York Times essay is no better than an emailed chain letter.

And another thing. Has this author given any thought to the impact that HPV vaccination could have on countries outside the U.S.? Cervical cancer is the number one cause of cancer deaths in the developing world. Maybe, in between sips of her shade-grown, fair-traded, half-caf latte (on skim), she could consider that domestic vaccination might be the first step toward a global vaccination strategy.

It wouldn’t bother me so much if she’d have discussed vaccine risk-benefit from an informed perspective. What steams my rice is the nonchalance with which she makes sweeping statements, and the fact that it’s not even data she’s misinterpreting. This might be the way that your average schmuck on the street formulates an opinion, but it’s not the way an opinion should be presented in a major U.S. newspaper, where it could influence so many others. Vaccines, and the kids who need them, deserve better.

1. Simonsen L, et al. More on RotaShield and intussusception: the role of age at the time of vaccination. Journal of Infectious Diseases. 2005 Sep 1;192 Suppl 1:S36-43.

2. Hviid A, et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003 Oct 1;290(13):1763-6.

Marathon runner

July 17, 2006

As part of our resident education program, there is an hourlong noontime conference at the hospital five days a week. The subject is usually something medical, like “Diagnosis and treatment of urinary tract infection in the elderly.” Although you might expect us to resent these conferences, we usually don’t: for some of us, it’s the only didactic teaching we get during busy rotations, and when it’s good teaching, it’s really useful.

The other day, however, the subject was “Surviving Medical Residency.” Apparently, it featured some guy nattering about how in residency, you have to make time for hobbies and family and going to the bank. I don’t know for sure, because instead of going to some dumb lecture on surviving medical residency, I went to the freaking bank. And then I sat down among the birds and the trees, and I ate my freaking sandwich outside of the goddamn hospital.

My program is not that bad. Our graduate medical education office is so on board with the work hours thing that it’s a little embarrassing. Still, it’s a little bit funny, and not in the ha-ha way, to sit among a group of stressed-out people listening to someone tell you how to function as an adult, when you all know that if you just had the hour off, you wouldn’t seem so dysfunctional in the first place.

********************

When I first met my fellow interns at the beginning of the academic year, I was struck by how many of them had run marathons. A full 3/4 of my class had trained for or run at least a half-marathon, and it was not just coincidence–the proportion was similar in classes ahead of us.

I guess it shouldn’t have surprised me so much. The kind of people who run marathons are the kind of people who are completely OK with being told to work 27 hours in a row without sleep. And it’s odd–most of us really are OK with it, even though we can give only weak reasons (“It promotes continuity of care/provides a view of acute disease evolution/builds character”) why.

Lawyers, software engineers, and beat journalists all over the country pull all-nighters all the time, both in training and on the job. It’s almost a point of pride to work so hard every now and then that you don’t sleep, because it’s fun to have a war story to tell, and it’s pretty satisfying to lay your head on a pillow after having pushed through fatigue to complete a job.

But how many of these professionals have all-nighters every three nights for a month built into their apprenticeships? How many consider thinking while tired to be a critical skill of the job? How many have to put systems into place to prevent the errors that occur as a result of the routine fatigue of its trainees?

Theoretically, the point of working so hard during internship is to make sure we’re able to handle the demands of the rest of residency. And the point of working hard during the rest of residency is to make sure we’re able to handle the demands of functioning as an independent physician in the most understaffed, underresourced hospitals.

What if we were to instead hire more doctors, and pay them less? What if you didn’t ever need the skill of thinking while tired, because instead of working until the work was done, you worked until the end of your shift?

Demonstrating, perhaps, a touch of Stockholm syndrome, I feel that a little something might be lost. Maybe I’ve just let The Man convince me that the way things are are the truth and the light. After all, I plan to use my skills in understaffed, underresourced places, and I’ve already translated those thinking-while-tired skills into terrific midnight tuna sandwiches.

Or maybe I just like having good war stories. I guess I’m a marathon runner, too.

The way of all flesh

July 10, 2006

You’ll hear residents everywhere refer to “codes” as both the most terrifying and the most exhilarating experiences they have during training. “Code” is short for “code blue,” or “code red,” or whatever term each hospital applies to situations wherein help is needed in resuscitating a patient. It’s used as a noun (“I wet my pants during the code today”) and a verb, both transitive (“Rounds were so boring today, I nearly had to code my attending”) and intransitive (“Your patient probably coded because of the Tylenol you wrote for”). Codes are often chaotic, and, I won’t hesitate to tell you, often kind of fun.

Let me tell you what a code is like. It starts with five bell tones sounding overhead. At this sound, residents all over the hospital put their coffee down, lift their heads up from tables, and shush their interns. After the bells comes an announcement about the type and the location of the resuscitation, by which time the hallways and stairwells are already filled with residents in long white coats, all of them running in the same direction.

When residents run to a code, it is only partly because the patient’s life depends on it. The reality is, only about 1 of every 5 adult patients who get CPR in the hospital will live to leave the hospital, even if they are successfully resuscitated (1, 2). The more compelling motivation to run to codes is the desire to be involved.

If you are not among the first ten people to arrive at a code, you spectate from the doorway, craning your neck around the wide hips of the anesthesiologists and over the skinny shoulders of the neurologists. But if you arrive early enough, you have a shot at actually being involved in the code. It’s like playing a game of pickup basketball in front of an NBA playoffs crowd. If you succeed, it is before an audience that matters. And if you fail–well, it was like that when you got there.

Cardiopulmonary resuscitation is directed toward two big goals: restoring breathing and restoring circulation. The chest compressions and mouth-to-mouth that you’ve seen on Baywatch (admit it!) are only part of the complicated algorithms that guide resuscitative efforts in the hospital. Tracheal intubation, electrocardioversion–applying shocks to the chest–and rapid infusion of medicine and fluids also play a large role in in-hospital CPR.

In most hospitals, anesthesiologists or emergency medicine doctors are responsible for intubation and ventilation during codes. The responsibility for restoring circulation falls to the medicine people, which means that we do the chest compressions and the electrocardioversion, and we put in the central access lines, which are essentially really large IV’s.

The other night, my senior resident and I were the first to show up at a code. The patient was a 92-year old man with several end-stage diseases, and his heart had stopped beating. 

Now, my medical school was very heavily invested in teaching a holistic approach to the patient. We spent more time than I care to quantify learning about the impact of social, cultural, religious, and familial environments on health. Despite the occasional mawkishness of it all, I bought it, and I feel that modern medicine is an incredibly engaging profession precisely because of its extracorporeal dimensions.

Still, the second I walked into the room, this guy was, to me, a container. He had gone the way of all flesh, but for the next twenty minutes, his body would be close enough to living to function as an experimental field. At the urging of my resident, I opened a central line kit, and began digging around for a femoral vein. I was not alone; within minutes, three other residents were lancing in and out of his wrists and his groin as voices shouted for atropine, epinephrine, chest compressions, oxygen.

Three minutes passed, then seven minutes, and I had not found the vein. I took over chest compressions, kneeling on the bed next to the man’s head. I was smiling, a little embarrassed, in the same way children are when they are caught playing with imaginary friends. This was not for real, and we all knew it.

When we paused to reevaluate for a heart rhythm, I nearly fell off the bed in shock: he had one. The residents poking at the large veins in his groin poked with greater urgency. Although he still didn’t have a central line, the drugs came now in rapid succession. But at thirteen minutes, his rhythm was slowing. At fifteen minutes, it was gone for good.

Not many codes last longer than twenty minutes. My resident looked at me and whispered, “It’s over.” And then, “Do you want to try for the line again?” I exchanged looks with the charge resident running the code. “You can try,” he said, “but fast.”

I didn’t change into sterile gloves. With my right hand, I stretched the loose skin on his inner thigh, and with my left, I pushed a needle deep into his groin. “Seventeen minutes,” said the charge. On my second try, there was a flash of blood in the chamber of the syringe, and a hoot from the foot of the bed. I unscrewed, threaded, introduced, nicked, rethreaded, and drew back on one of the line ports. As I watched dark venous blood flood the syringe, I heard the charge shout again, “Twenty minutes. Let’s stop resuscitation.”

The room deflated, with people dispersing to make calls, write death notes, and get back to saving lives, or whatever it is they do. I stayed behind to clean up used needles and other debris, and as they passed me, several residents said, “Nice job with the line.” I glowed.

If I were a better person, I’d be getting very metaphysical at this point, musing over the conflicts inherent in having obligations both to care for people and to learn to care for people. I would probably feel a little guilty about so easily abstracting my own goals from this rather undignified end of an entire person’s entire life.

But I won’t, and I don’t, because this is what we do. We learn by practicing on patients, whether living, dead, or somewhere in between. The learning is fun. And although patients might not want to know it, and doctors might not want to admit it, the joy of discovery is there even when the outcome for the patient is bad.

It was fun to put in a central line, even in a dying man. It was fun to do it again, shortly thereafter, in a living woman. Even if it is not fun, it is somehow satisfying to diagnose a coagulopathy; a rare, genetic lung disorder; a stroke. If it weren’t, many of us wouldn’t come in to work in the morning. And none of us would run to codes.

1. de Vos R, et al. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Archives of Internal Medicine. 1999 Apr 26; 159(8): 845-50.

2. Nadkarni VM, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006 Jan 4;295(1):50-7.

White cloud

July 8, 2006

When I was a little kid, we had a yearly raffle at my elementary school that I won every year with such weird regularity that I started to think of myself as lucky. It’s been a long, downhill slide ever since, but when I started residency a couple of weeks ago, it seemed I might have gotten my game back: against all odds, I was a white cloud.  

In hospital slang, white clouds are people who, through good luck alone, have fewer difficult patients on their services and fewer unpleasant call nights. As one of them, my call nights had been easy. I’d been getting more sleep than any person reasonably should on a MICU rotation. I woke up only to tweak antihypertensives or prescribe Benadryl. The code bells, which signify a patient’s need for cardiopulmonary resuscitation (CPR), never rang. Whereas other teams admitted 4 to 5 patients to the MICU each night, the most we ever admitted was one.  

In some ways, this was a good thing. I mean, I like to sleep. But when bad things happen at night, opportunities for learning and doing open up in places where they don’t during the well-staffed days. Being a white cloud gets me better rest, but it does not get me experience. Even as I stumbled sleep-headed out of the call room on mornings after my quiet calls, I knew this, and it gave me a little twinge of regret.

A few nights ago, things changed. In the space of two hours, three patients crashed elsewhere in the hospital. We admitted one of them, along with three patients who came in through the emergency department. I learned to put in a central venous line on a dying man, and thirty minutes later, I put in another one on a woman who’s probably going to make it. I put in an arterial line–my second–and I did chest compressions that actually worked. I didn’t get much sleep. But as I rubbed my eyes the next morning on the way to rounds, it felt like my luck had taken a turn for the better.

Avoid peoples’ stories

July 1, 2006

My parents call me every few days and ask to hear stories. Sometimes I’m contrary about it, and just rattle off a list of diagnoses and interventions. But I know that’s not what they want. They want a heroic ideal. They want a dramatic arc. They want a story.

To get to the ICU, you have to be unable to either breathe or maintain a blood pressure on your own. Most of our patients are mechanically ventilated and quite heavily sedated, and all require careful attention to the tiniest minutiae of their conditions. We rarely know what our patients were like before getting, as one of my residents says, “shlogged.”  I suppose this makes it easier to focus on the doings of their protoplasm instead of the drama of their survivals–or of their deaths.

I guess what I’m trying to say is that the ICU is a place where it’s easy–and maybe even beneficial–to avoid peoples’ stories. Even when a patient’s chart suggests good buildup or interesting characters, those things easily get lost in the thicket of tasks surrounding the gathering and management of their medical information. Maybe that’s why I don’t love the ICU: although my colleagues are quick-witted and entertaining, I only get the faintest outlines of what, other than physiological parameters, defines my patients.

On call nights in the ICU, I’m responsible for covering not only patients in the unit, but also “weaners”–patients elsewhere in the hospital who are slowly coming off mechanical ventilation. At about midnight last night, I was called to see a weaner for “poor toleration of feeds.” I did, and then sat down to order some tests and write my note.

Here is how I started: “Called to see patient to evaluate for poor toleration of tube feeds.” What I meant was: This man, who breathes with the aid of a machine through a surgically created hole in his neck and eats 70 milliliters an hour of a light brown solution through a different, also surgically created hole in his abdominal wall, just vomited out of the surgically created hole in his neck.

The next sentence: “Patient is an 85-year old man with quadriplegia and global cognitive impairment following a motor vehicle accident one year ago.” What really happened: An old man drove his car into a building and nearly killed himself, but someone was able to keep his organs perfused and his lungs inflated. Although he can’t move or think or speak or understand, he can blink, and because of that, his wife can’t let him die.

And the punchline, my assessment and plan: “Flat plate abdominal film shows evidence for abdominal ileus. Recommend holding tube feeds, continuing insulin coverage as necessary. Reassessment in a.m.” Translation: I hereby pretend to subscribe to whatever logic has made it possible for this man’s existence to get to this point, and tomorrow morning, you should, too.

It sometimes seems that the sicker patients get, the more their real stories reflect doctors as villains. I’m not sure how much people want to hear about who we really are.