Death certificate

Today had to pronounce a patient dead. Quite an experience. This was a 47 year old african american male with a past medical history significant for hypertension and cardiovascular disease who had suffered a cardiac arrest. His heart had stopped for unknown reasons, he was resuscitated by EMS personnel, and brought to the hospital where he was started on Arctic protocol. This is a relatively new medical advance whereby we cool the blood of patients with recent cardiac arrest, bringing down their overall body temperature, with the intention of trying to save brain. In some patients it works, in this patient it did not. He likely had just suffered to much of an anoxic (no oxygen) brain injury from his arrest. So after rewarming him from the Arctic protocol, he was found by Neurologists to be brain dead. Still he remained on a ventilator, and we were keeping him "alive" with machines and fluids. Once we confirmed his brain death then the tough decision had to be made to take him off the ventilator. We discussed the medical course and the plan at length with his family. It was quite tough for them. This man was still relatively young, I think it was quite hard for them to let go, even with the knowledge that he was essentially already dead.

So with about a dozen family members around, we prepared to withdraw the ventilator support. We kept only IV fluids and medications to prevent him from having seizures or pain. Then we removed the breathing tube, and this young patient slipped away quietly into the day. Without the ventilator his brain did not tell the muscles of his diaphragm to keep breathing. He took no more breaths, so slowly his heart ran out of oxygen and it too stopped beating. I watched this process on the telemonitor, while trying simultaneously to be there in a caring way for the family. They cried, in fact they sobbed quite loudly. The emotion in the room was palpable. But in this scene I still had to do my job. I confirmed that he had in fact passed away, by feeling for pulses, examining his pupils for any response, and listening for any breathing.

He had passed away, and after consoling the family some more, I went to fill out the required paperwork, including the death certificate. Felt kind of weird, to have experienced as a 3rd year medical student the joy of helping to deliver babies. Now I had completed the other bookend, and had officially declared the end of life. Being a doctor really does mean being a part of the whole life process from beginning to end.

CICU

First day of Cardiac ICU. Wow. It's as intense as I thought it would be. Within hours of arriving I was helping with a "Code". That means cardiac arrest, the real deal with chest compressions, shocks, the whole nine yards. The rest of the day was House-style rapid-paced differential diagnosing on multiple patients at once. One thing about manning the CICU . . . you can never claim that it's boring. Hours today: awoke at 4:30 AM, shower/breakfast/headed to hospital, back by 9:30 PM. Not much time for much else besides eat and sleep now . . . back to work same time tomorrow morning.

Just beat it

I was really struck with a patient who I encountered while manning the Pulmonary clinics this week. This 65 year old gentleman had been hit by four separate cancers and had beat them all. Throat, Lung, Prostate, Colon. Definitive treatment completed, still going strong. He tells me, "If another one pops up, you cut it out and I'll beat it again." What gutsy determination! This guy credits the fact that he's still alive to his attitude and willpower. I think it's quite possible he's stumbled on the power of the mind . . .

Patent-able idea?

Today, on the spur of the moment, came up with a draft of an idea for a medical device / method for helping to cure patients with Bronchopulmonary Fistula (BPF). I've gotten some good feedback on the idea already and may move forward with testing / patenting / etc. It actually felt pretty neat to turn my creative side on today, even if this doesn't result in an actual patent or my name on a device . . . Cheers, Dr. Kowawa

So Much to Say

OK, so a lot has been happening. So chronologically and briefly . . .



"Pull" went well. Spent two days wearing the Inpatient Digestive health hat. I happened to have seen a boatload of patients with liver problems. Most frequent patient was a 60ish male with a history of alcohol abuse or hepatitis infection who presented with liver cirrhosis and the complications that accompany it -- for example ascites, or fluid in the belly. The liver produces proteins, and proteins such as albumin help keep the fluid part of blood (plasma) inside of the blood vessels. Low protein --> fluid seeps out of the vessels into the belly. One guy I saw had gained 19 lbs of fluid to his belly in 1 month. So we tap it . . . and drain it off. And replace the proteins via IV . . . and do lots of other stuff. The experience was incredibly fast paced, pager going off constantly, balancing several things at once, but it was a great learning experience. This kind of busy-ness is the quintessential intern experience . . .



On Friday got up at 5:15 AM, got ready, went to the hosptal, and didn't get home until 10:15 PM. On returning sweewawa and I had a late dinner, and then I got an email from my Mom. Turns out Dad had a freak fall -- ruptured both quadriceps tendons while doing his normal walk on the trail near the local high school. No trauma, just a sudden snap and then both legs were flexed as he fell to the ground. Without the balancing force of the quadriceps the muscles of flexion worked unopposed. To make matters worse as my poor dad struggled to get up a bunch of hornets stung him repeatedly. It must have been awful!! So he was taken by ambulance to the hospital where I was born, and by the next day (Saturday), after XRays and MRIs a orthopedic surgeon had gone in and re-attached the tendons to the patella using sutures and metal hooks. Quite an ordeal.

So during all this time I was doing my homework. It's exceedingly rare for someone to have bilateral rupture of the quadriceps tendons. Typically one of those rare individuals will have a underlying condition -- kidney failure, diabetes, prolonged steroid use, recent fluoroquinolone (an antibiotic) use, lupus . . . my dad had none of these things. But my Mom told me incidentally that he had recently been started on a Statin, the leading drug used to lower cholesterol. And I had an inkling in my mind that I had learned in med school or out in practice that there was this VERY rare side effect of tendon problems in Statin users . . . and looked it up. It's not an official adverse event listed on the drug info, but there have been case reports of people with tendonitis and tendon rupture on the drug. So I'm intrigued and have been learning all I can about this. I may write this up for publication.

My parents were just getting ready to leave for a trip to Europe, followed by a year of working in England. Now all the plans have to be postponed / modified as my Dad goes through rehab. It's all pretty hard on him -- he definitely isn't enjoying being pretty much totally confined to the bed for most of the day. Who would like that? I really hope the recovery is complete and as fast as can be -- and I'm trying to be supportive emotionally and from a physician standpoint . . .



So since that I've headed back to Pulmonary Consults at the Veterans hospital. Stayed late this evening. Got to do a lot of interesting stuff. Did my first ever emergent flexible bronchoscopy. Briefly, had a patient who had gunk (yes, that's a medical term) in his airways and couldn't breathe. The arterial blood gas numbers and portable chest radiographs were starting to look screwy. I used a long scope to traverse the tunnels of the bronchi (lung airways), then suctioned it out. Problem solved, very rewarding to practice that kind of medicine.

Dems health care plans

Pulled!

Got the page today, I got pulled! This means I'll be leaving Pulmonary Consults at the veterans hospital and heading back to the main campus for the Inpatient Gastrointestinal / Digestive Health service. One of my colleagues got sick and I've gotta cover. Which means much more work. Blah. At least it should be interesting. I'm probably going to be pulled for the next 4 days, which also means bye bye weekend . . .

Today I had a patient with Chronic Obstructive Pulmonary Disease (COPD). In the process of taking his medical history he starts to tell me about getting shot in the back of the thigh. Being a veterans hospital patient I assume he's going to tell me a war story . . . but it turns out he was at the receiving end of the bullet as he was climbing out of a second story window. His girlfriend's husband had come home a little earlier than expected . . . Bam! He told me that was their last "date". Love the stories you'll get at the V.A.

Cheers, Dr. K

Ayn Rand's Objectivism

"Pull"

Tomorrow I begin two weeks of "Pull". I'll continue with my normal duties as a Pulmonary Consult at the veterans hospital, but will be on call 24 hours a day 7 days a week if needed elsewhere at VCU or the VA. If another resident gets sick, I cover for them. This means that one day I could be in the Cardiac ICU, one day covering clinics, one day back at Pulmonary Consults, and one day on the Wards. Should be an interesting couple of weeks, filled with a variety of types of medical encounters. I look forward to the challenge.

Dr. Kowawa

Santa Barbara, CA

Another interesting youtube vid I found about SB:

Lung doc

I consulted on a 65 year old patient who came to the veterans hospital with longstanding cough but who had recently started coughing up blood. This nice gentleman had smoked for many years but had kicked the habit 10 years ago. We took Xrays and then CT scans and found tumor and lymph node involvement in his central chest and lung area which had spread around his main airways and around the pulmonary artery (the one that connects the heart & the lungs).

Cancer. In a guy who had tried to do the right thing, had kicked the habit. In a guy who at 65 years old still had a lot of life ahead of him. It was tough talking to him and his wife about his likely diagnosis, and the tests we needed to do to confirm it. He and his wife asked a lot of questions about prognosis, how tough the treatment would be, what were his options. I really felt for them during our discussions. They were searching for something to hold onto, something to help them make sense of the mystery, a life raft to guide them off the sinking ship, but there wasn't much to do but wait. I tried to be clear and realistic, empathic and patient. I think it helped a little.

The next day we did a bronchoscopy, the procedure whereby using a long-tubed camera we could look directly at the tumor and take biopsies. The visual evidence confirmed cancer, and a short while later the Pathologist sent the report: Squamous Cell cancer of the lungs. At this stage in my career I haven't yet become desensitized, so the news did affect me. I am going to strive to do my best to be there for this patient and his wife and to help them through this tough time of turmoil and turbulance.

Dr. K

Global Warming bill must be stopped

Click below for an excellent read on the Global Warming bill aka Cap-and-trade:

David Limbaugh : Cap-and-Tax: Government vs. America - Townhall.com

Week 2 begins

My second week of internship began today. I am really enjoying Pulmonary Consults so far -- quite a fun and relaxing way to begin the year. Today I just had one patient, and the rest of the day I spent researching pleural effusions and practicing reading / interpreting pulmonary function tests. I've heard it described before that Ward and ICU months are analogous to "systole", or the contraction phase of the heart cycle, while electives are "diastole", or the relaxation phase. My heart beats a little slower and I'm a lot calmer when I'm on "diastole". Great way to begin the year. With all this extra time and minimal stress I'm making sure to fit exercise and extra studying into each day. Looking forward to the rest of this week . . .

Independence Day

One last song of the day to end about a year-long tradition

Song of the Day: Hallelujah - Jeff Buckley

Just woke up from a 5 hour nap. Spent the weekend (Fri eve --> Sun morning) doing two night shifts at the Veterans hospital. While I wished I had had this time off to do fun things with my July 4th weekend, on the other hand it did feel kind of good to be working for our veterans on the Independence Day. After all, our veterans have sacrificed so much to keep our freedom and independence from tyranny a reality.

Each night the entire inpatient medicine ward was covered by two housestaff -- myself and a resident. The way we split up the duties, I did "cross-cover" (managing all the patients on the floor) while the more experienced resident handled new patients that came in during the night. This meant that I was managing up to 28 patients at once -- quite the challenge! I put my best effort forth and am very proud to say that everything went very well. Most times getting paged means making small changes to medication orders or adjusting fluids / electrolytes / or oxygen requirements. I felt I could handle 80-90% of the issues on my own with my knowledge gained to date in medical school and beyond. For a couple of the more complicated issues -- for example when a patient who recently had a liver transplant and was on immunosuppressants suddenly developed fever / chills -- I rapidly formed my own opinion of what I _should_ do but called the more experienced resident to make sure. The nurses are also often an excellent source of info, as they see the same patterns day in / day out.

Last night I only got about 1/2 hour of sleep, curled up in my green-blue scrubs in the intern call room, clinging to a pager on vibrate mode to wake me up at a moment's notice if a patient should suddenly "go south". While the lack of sleep was a little painful, it did feel really special to be awake and ordering lab tests, drugs, therapies, checking up on my patients, taking a focused history, doing portions of the physical exam -- all these things on my own in the middle of the night in a large hospital -- with the simple purpose of guarding the health of these veterans until the day shift team arrives. It was the least I could do on Independence Day weekend for those who guarded the country in Vietnam, Korea, and beyond.

Day 1 complete

I survived my first day of internship, and thankfully so did all my patients . . . all 1 of them. Turns out that Pulmonary Consults at the VAMC is going to be a pretty easy way to begin what will be otherwise a very challenging year. I kind of wish I had this "vacation" rotation a little later in the year once I'm more burned out, but that's OK. I plan to spend some of my extra time studying, preparing for the harder rotations, and staying in good physical shape.

Today I saw a 74 year old tetraplegic veteran with Congestive Heart Failure (CHF) who had previously been having some trouble with his breathing. Chest X-ray showed fluid in his lungs so starting a couple of days ago we gave him some diuretics to pee off the extra fluid, and put him on some pulmonary therapy in addition to medications for his heart condition. Today, much improvement showing blood oxygen saturations of 100% without any supplemental oxygen. Yay! It was certainly rewarding to see this veteran feeling better from a lung perspective, even as many of his other health issues are not fixable. I was very glad to have my first case as an MD being one that showcased health IMPROVEMENT. I'll do all I can to make that a theme for the year . . .

Dr. K