Gifts From Patients

Last week, one of my patients gave me some elk jerky cured from a buck his 14 year old grandson shot last season. Read about my experience at the Medscape blog. Of course you'll need to use or sign up for a free login to read it.

Straight from the Medical Record

Sometimes information in medical records cracks me up. Take for example these excerpts from a note for a patient I helped care for:

Interval History:
Had a good day, with an especially lucid morning. Enjoyed throwing rubber chicken into sink. Family pleased with progress.

Exam:
NEURO: Continues tremulousness, is mostly non-verbal (per family, is exhausted and getting cranky after busy morning). Throws rubber chicken onto attending physician and into sink.

ATTENDING STATEMENT:
I personally saw and evaluated the patient. She did seem to enjoy throwing a rubber chicken at me and into the sink. I discussed the patient with Dr. XXX. I agree with the findings and plan as documented in his note.

The moral? Rubber chickens never fail to amuse.

Critical and identifying information has been changed to protect this patient's privacy.

Diagnose This!

You're a student on rotation at an academic medical center's walk-in clinic. A new patient presents with a one week history of pruritic 1-2 mm diameter vesicles and evidence of excoriation on the extensor surface of both hands that is most prominent between the metacarpophalangeal joint and the dorsal crease of the wrist. There are also some lesions at the proximal nail fold and distal phalanges. The interphalangeal skin and finger webbing is largely spared, except for the area surrounding the left 4th digit. There is no palmar rash. Upon closer inspection, the lesions have a diverse morphology, ranging from non-erythemetic fluid-filled indurated vesicles to bright red papules with a 3 mm diameter border to small salmon colored macules with crusted centers. A thorough skin inspection yields no other rashes. Complete physical exam is unremarkable except for dark circles under his eyes. The skin finding is shown below.

Further questioning reveals that this patient has developed irregular sleep habits over the past several months and has several other new stressors in his life, including physical relocation, new responsibilities at work, looming deadlines, personal grief, and a perception that his future depends on every daily task. He does report several adaptive behaviors to help manage this stress, including creative outlets that use all ten fingers... The rash has been refractory to cortisone and triamcinolone, and Actifed helps a little bit with the itching. He seems resigned to this condition, stating that his position will change in about a month.

After consulting your attending, you recommend which of the following therapies:
A) Bed Rest
B) Solar Therapy (Specifically In Zihuatanejo)
C) Desoximetasone Baths
D) Cutting Back On The Alcohol

Oh, I almost forgot: What's your diagnosis doctor?

Only A Medical Student

About the only thing a medical student doesn't duplicate on the hospital care team is time spent with patients. With their time, students contribute to care in a manner others cannot.

A thorough exam to assure nothing is overlooked. Tucking in the developmentally delayed adult with her stuffed animal. Listening to a hero's WWII stories.

This is the medicine no drug company will ever invent. It is the treatment Medicare will never reimburse.

Is this year the only period of my life when I dispense the prescription of time?

Floating An Idea

In between some pages for patients, I just finished watching snippets of Bush's SOTU and the Democratic response.

One of the calls was for a patient who developed severe tachycardia (his heart rate shot to 150-170) just as Bush began his speech. He assured me that it was not anxiety that caused the spike.

But I digress. If you are planning to vote for a Democrat in the fall, I need your advice. What do you think about the strategy of getting behind your candidate, but not so much that you are upset if she/he doesn't get the nomination? Or is this just a rationalization for me to justify not picking a horse in this race?

Insulated

Whatever goes on in the world, there will still be sick people.

Evidently, the world is on the brink of financial collapse. Somehow, I missed that. While folks from Wall St. to Main St. were freaking out about the economy, I was talking with a patient who had been largely unconscious since last Thursday. This is a Gram stain of a sample of that patient's cerebral spinal fluid:

What's your diagnosis, doctor?

I also understand that yesterday was a holiday. Of all the national holidays, Martin Luther King Jr. Day has always been the one with the most regimented for me. Sometimes I would fast on that day, I would always read some of King's writings, often I would participate in a community service project; yesterday I took call. The only nod to the holiday I experienced were some residents questioning whether it was actually a holiday, and a newspaper article about how (unlike 800 other cities) Spokane has no geographical reference to Martin Luther King Jr.

Metastatic Prostate Cancer

This one is heavy.

"You and I talked yesterday about the blood prostate test that came back with a very high value. That combined with your low blood counts is why we did the bone scan this morning. It looks like some prostate cancer has spread to your pelvis and tailbone."

It's taken a while for me to work this first experience delivering a cancer diagnosis into a cogent journal entry. When it comes to this blog, I have the most success transcribing ideas and feelings immediately. This one required more drafts; a whole folder of entries spanning several days sits tucked away on my hard drive. What I keep coming back to is that through my entire experience with this patient, I never felt uneasy.

Sitting on his bed, without my white coat, without my clipboard, and without a rehearsed statement, I was simply present with him. I still can't find the words to describe my feelings in that moment. Why can I not pin down my emotions? Was it confidence about a puzzle solved? Relief that the patient was finally given an answer? Surprise at how much the patient already knew (even without symptoms or knowledge of lab results)? Was I feeling an adrenaline rush due to an awareness that I was participating in an important point in this man's life?

In the end, the question I need guidance about is: Is it wrong to be comfortable delivering bad news?

This patient gave me permission to write about these experiences but asked me not to use his name.

Keeping Track

What a Day. Today in the ER, I diagnosed the following:

• New onset temporomandibular joint (TMJ) syndrome in a 29 year old woman.
• Phimosis and otitis externa in a 10 month old boy.
• Hip bursitis in a 72 year old man.

I participated in the care of:

• Man vs. table saw: the loser was a finger (unless the hand surgeons at Harborview can work a miracle).
• A young man with periodic familial hypokalemic paralysis.
• 51 year old man with suicide ideation and a plan. (See photo below.)

The currents are deadly enough without having to deal with the impact. I have first hand experience (with the current, not the impact). Let me tell you: going through at slack tide is a much better idea than trying any other time. The current gets up to 8+ knots at flood and ebb. My wife once diagnosed me with suicidal ideation for trying to take this tidal rapid in my now deceased aluminum Grumman canoe.

We admitted the the man with severe depression. Things are looking good for him. I am glad he came in today and decided to stay; he's also been an excellent teacher so far.

FAMILY Medicine

This is family medicine:

In the ER on Monday night, I injected a steroid/marcaine cocktail into a man's biceps tendon and referred him to an orthopedic surgeon. On Thursday, I saw his wife to renew her Vicodin prescriptions for rheumatoid arthritis. This afternoon, we deliver their 4th grandchild by C-section.

First Birth

Yesterday I witnessed my first birth. Not in recent memory have I experienced such rapid emotional cycling. I have a new understanding of the common parlance use of "emotional roller coaster," and have a new respect for the process by which human life begins. We hear in the lay press about the artificial intensiveness that hospital births impose on patients; my experience as a medical student sometimes confirms the believe that kids get put through more than they need to be. This episode pushed me in the other direction. There is a reason why certain procedures are necessary; when medicine occurs at the brink of life and death, I want life to prevail.

As part of my pediatrics core clerkship, I participate in care at the university hospital's newborn nursery. The team of medical residents I join is not the same as the doctors who take care of infants in the neonatal intensive care unit (NICU). The NICU cares for babies that have already been born and need additional care; the nursery team cares for babies immediately after birth. Those of you who have had kids, they are the folks who assign Apgar scores, conduct the baby's first physical exam and look after the babies in the newborn nursery while mom is resting in the wake of her birth. Whenever there is the possibility that the baby will not do well in the minutes after delivery, this team in on hand to revive and restore the infant's vital signs.

Our first call came in the afternoon - about 20 minutes after the other team passed the pager to us. A normal vaginal delivery had failed to progress, so the doctors decided to do an emergency Caesarian section. This was a good choice, because the baby's skull probably would not have fit through the mother's pelvis. When we entered the room, the only sounds I noticed were the beep beep of mom's heartbeat and the constant calm voice of the baby's father. Dad's retelling of their shared memories was a distraction for mom; for me it put into context the significance of what was happening. An epidural anesthetic kept mom from feeling anything but pressure below her belly button. This was important, because a few minutes after our team entered the room, two different doctors were up to their elbows (literally) trying to extract the baby. A normal C-section looks like the picture at right. The baby is removed from a horizontal cut about 8 inches long at the mom's waist. That's not what I saw.

As Dad relayed stories from their honeymoon and spoke of a recent family gathering, I provided a foot-stop so the ob-gyn resident could push the baby back up through the vaginal birth canal. Her body was at about the angle you want to see a second row lock at in a rugby scrum; 30 degrees to the ground is how you get the best forward push without falling on your face. At this point, you can expect there were more sounds in the delivery operating room than the heart rate metronome accompanied nostalgia. I was surprised about the C-section incision, disgusted by the amount of blood and fluids being schlepped about, fascinated by the procedure, and incredulous that mom was not screaming through it all.

Finally, after the longest 6 minutes I can recall, I glimpsed the baby's head and snapped back into my role. In the midst of the joy associated with seeing a new baby, my job was to provide the team with fresh warm towels to clean and stimulate the baby. The cleaning part should be obvious; the neonatal team also uses warm dry towels to stimulate the newborn. Maybe you have heard about smacking the baby to make it cry? I am not aware that this is still done, but there is still plenty of jostling that is done to help the infant take its first breath. Repeated rubdowns with a warm towel is also useful for this purpose.

When the baby was removed, there was no cry, there was no gasp for air, he wasn't even moving his limbs. Furthermore, since mom was under local anesthetic, she didn't know the baby was out until the obstetrical surgeons told her. The parents had decided not to know the gender. This was good, it was about the only positive finding we could report about his first minute of life.

They say the Apgar score at 1 minute describes how well the baby did during delivery, while the Apgar at 5 minutes tells how well the neonatal team did. When he came out, this baby's face, arms and legs were blue, he had a pulse less than 100, he didn't respond to stimulation (with a grimace or cry), there was hardly any muscle tone, and he wasn't breathing. That makes for a score of 2/10. Most births score from 7 to 9 in the first minute. Our baby had a way to go and I was scared.

Every 30 seconds I retrieved a new warm towel from the oven. In between, I watched the team slap the soles of baby's feet, rub his head, belly and flank, suction his lungs, and apply positive pressure ventilation by mask. It looked a lot like the picture at left. We were patting and rubbing him, sticking tubes down his throat, and forcing air into his lungs. All we wanted in return was for him to scream at us. After 4 minutes, he took a breath; 30 seconds later we heard a weak cry. The intern kept imploring him to tell us how angry he was. When he did, I wasn't the only person in the room with wells for eyes. We invited dad to come look. I saw immense relief behind the ob/gyn resident's face mask and noticed blood on her arm above the glove. By the time 10 minutes had come along, Seattle's newest baby boy was screaming his displeasure at us. Being stuck in the birth canal left him with some superficial head injuries, so we ordered some head x-rays just to check in on him.

Usually the pediatrics team is the first to leave the delivery room; later, after showing mom and dad the baby, a nurse transports the high risk kids to the nursery for attentive care. In this case, we were the last to leave. Our team waited for the attending physician to come and examine the baby's skull, and conducted his first physical exam. By then he had a good suck reflex, was pink and screaming and had a heart rate of about 150; his hips were healthy and he even opened his eyes. Before we left the ob/gyn attending came back to tell us this delivery was the most difficult she could remember.

Body fluids and betadine were being mopped from the floor as we carried the babe down the hall to the nursery. In my emotional state, it was all I could do to open the doors for the team. Just as I sat to collect my thoughts in the residents' lounge, the pager rang with its distinctive sing-song. I was on my way to my second birth.

Images from Wikipedia.

My First Portrait

Over the past week, I have had the privilege to care for an amazing patient. He is a 5-year-old with inflammatory bowel disease. If you haven't heard of IBD, it's not a very nice disease. Flare ups feature bloody diarrhea, intense abdominal pain, vomiting, weight loss and a number of other things that go along with not having a functional gut. In most cases, the clinical course includes surgical removal of the diseased sections of intestine. It is rare to develop IBD at such a young age as 5.

What made it a privilege to care for this patient was that he permitted me to experience both his lows of pain and the joys of recovery. I checked out what his poop looked like, watched the colonoscopy, examined the histology slides, chatted with him and his parents every day, and conducted a physical exam each morning. He was particularly interested in my reflex hammer.

I almost cried when he gave me this finger-painted portrait the day before he went home.

It kindof makes me want to dye my hair pink and wear green lipstick.

My patient and his family approved my posting this story. The little guy wanted to know if the picture would be on the TV!

Y'all Just Want Your Hugs!

As I read Kate's digest of a study about the value of hugging among female spider monkeys over at The Anterior Commissure, I couldn't help but remember an incident that occurred a little while back on the wards. I was part of a team taking care of an older arthritic woman who had severe vertigo. She grew up in Alabama and frequently would share with us various stories about Southern tradition.

Anyway, soon after she was admitted, the team went about identifying the cause of her dizziness. One common cause of vertigo is the presence of a little stone in the semicircular canals of the ears. A stone, called an canalith (latin for 'canal stone') can impede fluid movement and interfere with your sense of balance. To see if a stone is the cause, physicians can do what is called the Dix-Hallpike maneuver. This maneuver tests for canalithiasis of the posterior semicircular canal, which is the most common cause of vertigo. The general idea of the Dix-Hallpike is shown in the picture below:If a canalith is present, the patient will get dizzy and his eyes will mover rapidly from side to side. This rhythmic regular oscillation of the eyes has a special medical name: nystagmus. Apart from invoking the emergency evacuation procedure cards on airlines, this image shows how our friendly frail old patient might have trouble completing the maneuver on her own. A good amount of core muscle strength is needed to extend and flex the trunk while the care provider gently twists the head. This is the part of the story that Kate's post reminded me of:

In order to properly conduct this test with the patient, the medical resident sat on the bed to support the patient's body while the attending physician turned her head appropriately. In the process of doing this, the charming, aged, once-southern belle announced, "Now Ah know why y'all er doin' this test. Y'all just want your hugs! If ya'd just sed so in the first place, Ah'd be happy t'oblige y'all."

I suppose that's one way for medical students to get their endorphins on the wards!

Parts of this story have been fictionalized to protect the privacy of persons involved. The elements pertinent for the 'teaching moment' remain. The image is from UpToDate.