Inpatient Digestive Health

Yesterday started a new rotation: Inpatient GI / Digestive Health. Will likely be a very challenging month. Pancreatitis, Liver cancers, Crohn's disease, Peptic ulcers, Diverticulitis . . . you name it, we see it. I think it'll be tough, but manageable, and a good learning experience. Days start between 6 - 7 AM and sometimes go until 10 - 11 PM. But some days are a little lighter.

Will write more later . . .

Methamphetamine

A powerful video on the effects of methamphetamine use. It cuts off at the end, but I think this is the best one on the net.



A brief summary of a recent patient encounter I had with a polysubstance abuser.

Ms. A is a 27 year old white female I recently had as a patient. She had a long history of drug abuse, including Heroin, Cocaine, Club drugs, and Amphetamines. She presented to the hospital with diffuse body aches, restlessness, high heart rate, an increased WBC count (usually a marker of infection), no fever, and a history of several weeks of nausea with occasional vomiting. In the hospital she was hysterical, crying loudly and sometimes writhing in pain and rocking back and forth. The initial differential diagnosis was broad, but high on the list for me was opiate withdrawal or possible (viral) infection. She was tested for influenza, blood and urine cultures were sent to rule out an infection of her body fluids, and a urine drug screen was sent. She was negative for all things tested for except her urine came back as positive for Amphetamines.

This young patient was on daily Methadone (a long acting opiate) via a Methadone clinic for prior Heroin addiction, reportedly in remission. Certainly a requisite for participating in such a clinic is that you are otherwise drug-free. During my initial interview with her she completely denied any past or current drug use. It took the urine drug screen, some detective work, and further interviewing with her to tease out the extensive drug history. And in all likelihood she came to the hospital with the knowledge that she could likely get a "fix", or opiate pain medications (at taxpayer expense) by putting on just the right act. Or another way of looking at it is that she was truly in "pain", but this pain was somatization of the psychological and physical stress she was putting her body through with administration and withdrawal (when money or supply ran out) of street drugs, often laced with dangerous impurities.

I did my best to rule out any fixable medical conditions, got the Substance Abuse specialists at the hospital to come see her, kept her comfortable while she was at the hospital, and then sent her on her way. Before she left I gave my best shot at an inspirational / motivational speech about the dangers of drugs and how she had much good life ahead of her. I'm not hopeful it sank in, as this patient looked to be pretty deep in the hole.

Breaking the news

The past couple of weeks have been pretty challenging. For some reason a dark cloud has been hovering over my area of the hospital and I have gotten several patients in a row with new diagnoses of lung cancer. This is all the more odd since we have a dedicated Hematology / Oncology service, still these patients have been coming to me of late on the regular Medicine wards.

It's quite tough to break the news. I won't ever forget Mr. P, a 55 year old white male with no previous medical history, a totally healthy guy who came to me with swelling of the face and neck. He had been experiencing for the last month or so increased swelling of his face and neck, particularly when leaning over e.g. when he would tie his shoes. He had also noticed some new intermittent shortness of breath. He came to the hospital to check it out and we did imaging which showed a significant "soft tissue" mass in his right lung. This mass had been likely growing for quite some time and was now almost totally occluding the Superior Vena Cava (SVC), one of the major veins that returns blood to the heart. He actually had significant "collateralization", which means that small accessory veins around the SVC had picked up the slack from the occluded big vein over time. This "SVC Syndrome" clearly accounted for his neck/face swelling and shortness of breath symptoms.



I recognized the possibility of cancer right away and had the tough job of breaking the news to this patient and his wife, who is a health care worker herself. This patient as I mentioned was totally healthy before. Had smoked cigarettes for 30 years but had totally quit 5 years ago. I explained to them sensitively and clearly what I thought was going on and what further testing we needed to do -- in this case we proceeded with a bronchoscopic biopsy of the lung mass. I got to know the patient and his wife quite well over the next several days, and was with them as they learned that the mass was in fact Adenocarcinoma of the Lung, spoke to specialists in Hematology / Oncology and Radiation Oncology, and set them up for all their future care needs. The prognosis is not good, but it was very fulfilling to be able to be there with these very pleasant people, answering their questions and helping to ease their very difficult transition into dealing with a new diagnosis of cancer. The wife gave me a big hug on the patient's discharge day, and I have been continuing to follow the patient's progress via the electronic charting. I hope his available chemotherapy and radiation therapy options, while not likely curative treatments, will at least allow this patient to lengthen his amount of quality life left and allow him to die with dignity and on his own terms. Oncology is a tough field, I'm glad that I didn't go into it, as I think that I do have a pretty high degree of sensitivity (though I can be kind of cold sometimes) and the weight of sharing in people's new cancer diagnoses over years and years would be pretty tough. I was glad though to have had the opportunity to participate in this gentleman's care and to have made a positive difference in his life.

Clemency

Mr. C is a 57 year old african american male prisoner with a history of hepatitis C liver cirrhosis who presented to the emergency department with complaints of abdominal pain, diffuse bony pains, nausea, and loss of appetite. After pan-scanning Mr. C it became evident that he had widely metastatic cancer. Given the history of Hepatitis C and the prominent masses in his liver as well as a lab test called AFP which had rapidly doubled, it was thought that he had a type of Liver cancer called Hepatocellular Cancer. A biopsy of his Virchow's Node (left supraclavicular lymph node) confirmed my suspicions. The imaging showed likely metastases to his rib cage, spine, hip, adrenal glands, and spleen. This was late stage cancer, associated with an extremely poor prognosis. Mr. C probably had less than 2 months to live, and I had the tough job of telling him his diagnosis and likely prognosis. The attending physician and I decided to try to put a silver lining on this bleak grey cloud by petitioning to the judge to award Mr. C clemency, so that he could leave prison and spend his remaining days on earth with his family, including his young grandchildren who he had not yet gotten to see much of at all. I made numerous calls, and faxed over official paperwork to the judge's office stating that death for him was "imminent". There wasn't too much that we could do for Mr. C medically, but I did feel good to have helped him and his family in this small way.

Hammer paged

Being hammer paged is the phenomenon during intern year where your pager goes off every 1 minute. While on the phone & putting in orders into the computer for one patient you are getting paged about the next, and then pages can stack up pretty quick. Having an organized system for dealing with being hammer paged is key.

Just say no

Today I had to tell a patient that I wouldn't give her a prescription for more pain pills. While this patient, a 52 year-old woman with atypical chest pain (i.e. NOT a myocardial infarction or angina) was in the hospital I put her on Morphine to manage her chest pain. This was appropriate given the severity of her pain and the fact that the initial workup did include acute coronary syndrome (i.e. a real deal heart attack). However, when arranging her discharge she asked for more pain meds and on research I found that she had already been prescribed a month supply 1.5 weeks ago . . . so likely this was drug-seeking behavior and I could not in good conscience double cover this lady . . . despite the fact that she told me I was "the best doctor she had ever had" . . . which may have been more attributable to her learned skill of successful drug-seeking behavior than to my skills as a physician. There's a dose of Richmond, VA reality for ya.

Night float

Working the night shifts at the Cardiac / Coronary ICU. Day starts at 7:45 PM and usually ends 9-10 AM this next morning. The part that feels weird is coming back to work the same day you left . . . I am though starting to get used to coming home and getting some sleep during the day. Which is tough to me because I think I have a sensitive Suprachiasmatic Nucleus. Whaa??

We think that the day / night circadian rhythm in humans is regulated by sunlight hitting the retina and triggering signals to flow down neurons to the suprachiasmatic nucleus (SCN), a small area of the brain located in the hypothalamus. The SCN in turn causes the pineal gland (another brain structure) to dole out certain amounts of the hormone melatonin. Melatonin levels in your body peak at night and get low during the day, and are involved in creating your proper sleep / wake physiologic balance.



So the bits of sunlight coming past the shades in my bedroom during the day is kind of messing with me a little. But I'm adjusting. Wonder how much the flip side -- sitting in a dark room all day as a Radiologist -- will affect me . . . think I should probably make sure to eat lunch outdoors every day to trigger the SCN / pineal gland (and take care of sunlight-derived vitamin D production too!)

still going strong

Still going strong in the Cardiac ICU. 30 hour shift (with no sleep) from Fri --> Sat. Then starting night shifts on today --> Thu. It's pretty intense. Have also already encountered many interesting ethical issues. Whether or not to continue life support in a patient who is brain dead . . . how much care to provide for patients who are illegal immigrants . . . how to handle patients whose own reckless lifestyle keeps landing them back in the Emergency Department or ICU . . . the list goes on and we see these cases every day.

One great piece of advice passed along to me by a really excellent resident: always assume a test you're ordering will be negative (or an intervention you are ordering won't help) and know what you'd do next. In other words, always be thinking one step further down the chain. It's an essential skill in chess and is equally important in inpatient wards. You don't take that pawn with your rook just because the move is there . . . you do it because affects your opponent's next move, which sets you up for the next move, which affects your opponent's next move . . . which sets you up further. The person with chest pain who looks like he's having a heart attack but the cardiac enzymes you ordered are negative and the EKG is non-ischemic . . . always gotta have a "what's next" in mind . . .

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.

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

"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

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

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

Let the fun begin

I'm done with a week and a half of orientation and am very excited to start officially working as a doc tomorrow. The nerves are definitely firing a little faster today . . . I think I'll be running around a little scared the first couple of months. But that's probably a good thing -- I plan to channel that extra energy into making sure I provide excellent care for my patients. Just hope I don't have to run any codes early on in the game . . .

So I plan to make as many (short) posts this year as possible, just to give myself a record of what the year was like and to hopefully provide for others some entertainment and insight into the life of an intern.

One thing I'm going to _try_ to maintain this year is a semblance of life balance. I plan to keep up with exercising, hanging out with my sweet wife as much as possible, and occasionally finding time for all those little things I like to do on the side -- reading, playing guitar, snapping photos, romping around in nature, etc. The key for me is balance. I plan to work my butt off this year, study a lot (for USMLE Step 3 but also just for lifelong learning-sake), but also maintain my self -- including those parts outside of the realm of the hospital.

Cheers,

Kowawa, M.D.