American Thinker Blog: A doctor responds to Obama's NYT op-ed

American Thinker Blog: A doctor responds to Obama's NYT op-ed

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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.

Butterflies

Some photos taken at a Butterfly exhibition at Lewis Ginter Botanical Gardens in Richmond, VA:

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!)

Buddycare

The latest crisis in the health care world: our cat "The Buddy" has been vomiting for several weeks straight. He's still eating, drinking, pooping normally, he just vomits out partially digested feeds 1-2 times per day. The vet initially thought it was a stomach bug and gave him an antibiotic shot (Flagyl, I think). This didn't help. I was wondering if he might even have pain-induced vomiting from a kidney stone. Sweewawa took him back to the vet today. Turns out cats don't usually get kidney stones (get bladder stones instead). Got an xray of The Buddy (a process which I hear hey enjoyed immensely) which is quite cool to see! I've included it below.



Some things to point out that are fun to see --> you can clearly see the spine along the top of the image going to join with his hip / rear legs on the right, and you can see the tail leaving the spine. You can see the thin kitty ribs along the left side of the image and the dark area with the thin white lines is his lungs with vessels. To the right of the lungs in the image is a bright (white) area that is his kitty liver (not kitty litter). The loopy loops in the middle are his intestines, and you can see air (dark color) and stool (mottled whiter color). Apparently (I wouldn't have picked this up from my own Radiology training) this pattern of air / stool in the intestines is consistent with some serious hairball buildup. So he's on some oral treatments (special food & some tuna-flavored laxative) that will help him with this. So $275 later we have a correct diagnosis and an appropriate treatment . . . I hope. One thing, I was glad that the diagnosis arrived at was hairballs -- something completely out of the realm of what I learned in medical school and beyond. So I have an excuse for not arriving at the diagnosis before the vet :)

US Health Care is top notch

An interesting report was prepared by a senior fellow at the Hoover Institution and a professor of radiology and chief of neuroradiology at Stanford University Medical School by the name of Scott W. Atlas:

http://www.hoover.org/publications/digest/49525427.html

Not a doctor

Beware the High Cost of Unintended Consequences

Beware the High Cost of Unintended Consequences

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.

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