Our terminal patient who was going to die on extubation Sunday: things changed. A cousing flew in and changed the wife's mind. When I went in Monday he was still alive, and alarmingly, fitting the ventilator pretty hard (did NOT look comfortable). They were going to prepare him for surgery, etc they said.
We were sad - he had expressed that he did not want to live like this, yet not everyone was prepared, so on he lived.
When we came back Tuesday they had changed their minds again - he would be extubated and let die. Everyone was now ready.
Finally, today we returned to see him, and they had extubated him. He was gasping and gurgling, arms flailing. To our alarm the family had STOPPED his pain medicine drip that morning. I almost lost it. It was one of the saddest thing youve ever seen, and I'm not sure they even realized it. Doing what they did was purely selfish.
We immediately ordered the pain drip back on. I was disgusted. Here was a man who clearly said he did not want to live with tubes, etc and now they had stopped his pain meds because they seemed to think he had some chance of living that way. It was sad - he was drowning in his own secretions - choking on his spit and flailing his arms, unable to get air. I listened to his chest and could not even hear his heart through the "rales" of fluid in his lungs.
His eyes bulged out his head. He strained.
When I left he was still alive, if you can call it this. Hoepfully he was not in any more pain.
Lesson? Listen to your doctors as your loved ones approach death. There is one thing we ALL have in common - we all die. But we should be able to choose to die in comfort, not choking and gasping for hours on end. Sadly, most people only realize how this goes once they have already been through it.
In these times, think of your loved one that is dying,not yourself. Think of what you would want and what they would want. If you are unsure, ask them, get them to put it in writing, AND ask them to assign a health care proxy in writing as well. This is person that makes the health care decisions in difficult times like these.
What a tragic day, BUT it confirmed further my desire to work with terminal patients.
On another note, my residents all wrote extremely nice evaluation notes about me and my work on the team.
Wednesday, July 27, 2011
Sunday, July 24, 2011
Are we all Charlatans?? On Evaluations
Time for end of rotation evaluations. I actually am supposed to hand these forms to people and then ask for them filled out with grades and comments about me. Upon talking to ANY upperclassmen I have been told this:
"Have them fill it out and give it back to you. Even if its sealed open it - if yuo received even average marks throw it away. Cornell doesn't track how many you get, only what you get score wise. An average mark from a resident that doesnt get it kills your chance of honors."
Even in my lame attempts to protest this i have been told "gotta learn to play that game, that's all. those that work hard and dont play the game get screwed, period."
It just made me reflect on how so much of training to be a Dr is about schmoozing, almost like we are salespeople. I guess in a away we are, always trying to convince people to do things healthier.
either way the eval stuff seems crazy.
"Have them fill it out and give it back to you. Even if its sealed open it - if yuo received even average marks throw it away. Cornell doesn't track how many you get, only what you get score wise. An average mark from a resident that doesnt get it kills your chance of honors."
Even in my lame attempts to protest this i have been told "gotta learn to play that game, that's all. those that work hard and dont play the game get screwed, period."
It just made me reflect on how so much of training to be a Dr is about schmoozing, almost like we are salespeople. I guess in a away we are, always trying to convince people to do things healthier.
either way the eval stuff seems crazy.
Friday, July 22, 2011
July 22, 2011. Medicine: DEATH
Today at the hospital we got to deal with one of those life and death ethical situations that you learn about in cheesy "medicine, patients, and society" classes that most blow off. Turns out those classes are pretty useful.
This patient is an older man on a ventilator, unable now to breath on his own. He has a wife and children here and other children in other parts of the world. They do not speak English. They also are from a culture that views surgery and intervention as extremely dangerous. One family member referenced someone in their family who had a surgery and died when we were discussing his need for a permanent trach tube and a line into his stomach to feed him.
When we rounded on him in the morning, the sedative was letting up some and he was responding to our requests to raise his eyebrows, close his eyes, etc. Because he had a tube in his throat and was restless we turned up the sedation.
Suddenly three of the daughters arrived. We explained the situation and they argued over what to do. One wasn't ready for him to die, the other said he would never want to live like this. We explained we could send him to a nursing come cognitively intact but with a trach tube and a tube to his stomach. They argued, we asked where the wife was. She was in NY, somewhere, but old and unable to easily travel. We finally explained that if she were to come to the hospital, she could decide on what to do with him. Otherwise, all the 10 children would need to sign that they agreed with extubating him and letting him die.
Finally, the wife came and made the decision. She said he didn't want to live like this, and that was that. He will die on Sunday, when they remove the tube and say goodbye. I could go on forever about how we keep people alive for way too long, thinking "being alive" is the same as "having life." If we wanted, we could keep blood clean (dialysis) and lungs breathing (ventilators) and blood pumping (bypass) for years and years...Sadly, many people don't have living wills (directions as to what to do) or a "health care proxy" - someone designated as the decision maker.
Make someone a health care proxy today...let them know to the best of your ability what you would and would not want to live with, and then fill out your states papers showing this. Then let your family know. This way, one person is clearly in charge, and if your wishes are known to the family, there isn't much to argue about come that ill-timed moment that many people haven't planned for. We all die, so there is no harm in talking about it now to make it easier on everyone.
I went to look for Rico but he had been discharged to come back to the Onc clinic.
This patient is an older man on a ventilator, unable now to breath on his own. He has a wife and children here and other children in other parts of the world. They do not speak English. They also are from a culture that views surgery and intervention as extremely dangerous. One family member referenced someone in their family who had a surgery and died when we were discussing his need for a permanent trach tube and a line into his stomach to feed him.
When we rounded on him in the morning, the sedative was letting up some and he was responding to our requests to raise his eyebrows, close his eyes, etc. Because he had a tube in his throat and was restless we turned up the sedation.
Suddenly three of the daughters arrived. We explained the situation and they argued over what to do. One wasn't ready for him to die, the other said he would never want to live like this. We explained we could send him to a nursing come cognitively intact but with a trach tube and a tube to his stomach. They argued, we asked where the wife was. She was in NY, somewhere, but old and unable to easily travel. We finally explained that if she were to come to the hospital, she could decide on what to do with him. Otherwise, all the 10 children would need to sign that they agreed with extubating him and letting him die.
Finally, the wife came and made the decision. She said he didn't want to live like this, and that was that. He will die on Sunday, when they remove the tube and say goodbye. I could go on forever about how we keep people alive for way too long, thinking "being alive" is the same as "having life." If we wanted, we could keep blood clean (dialysis) and lungs breathing (ventilators) and blood pumping (bypass) for years and years...Sadly, many people don't have living wills (directions as to what to do) or a "health care proxy" - someone designated as the decision maker.
Make someone a health care proxy today...let them know to the best of your ability what you would and would not want to live with, and then fill out your states papers showing this. Then let your family know. This way, one person is clearly in charge, and if your wishes are known to the family, there isn't much to argue about come that ill-timed moment that many people haven't planned for. We all die, so there is no harm in talking about it now to make it easier on everyone.
I went to look for Rico but he had been discharged to come back to the Onc clinic.
Thursday, July 21, 2011
July 21, 2011. Medicine: METs
This morning we received a woman going through alcohol withdrawal. This of course can be very disturbing. She is heavily sedated, and yet when we ask her to stick her tongue out, it shakes wildly, fasiculating like I didn’t know a tongue could do. She hears bugs crawling, her hands are shaking wildly. This lady will die if we don’t keep intervening. After some other decisions, we decide we need a blood sample (I actually don’t remember why now).
My resident turns to me “You can get the blood, right?”
“Of course,” I say. As a medical student anytime you can do a procedure it’s a good thing. I gathered up my supplies and we all walked over to the bed. But as we looked for good veins they just weren’t there. Finally a resident told me to just get it from the radial artery (arteries don’t collapse like veins do – you should really always be able to get into an artery and get some blood).
I began feeling the wrist and then cleaned it. A resident gave me a few pointers.
“Feel the pulse with both fingers, and dive right between them with the needle,” he said.
Since I was on the left side of the bed, I held the shaking arm in my right hand and the needle in my left. I didn’t even think about it. During my PhD training I had done dog surgeries. For whatever reason (thinking I might pursue surgery one day) I began doing the surgeries with my left hand. Many dogs later I was almost equally good with needles and suturing with both hands.
“Is that your dominant hand?” the resident asked.
“I use both” I replied, as 5 doctors and a nurse looked on.
I dove in with the needle. Boom. Bright red blood on the first try!
“Nice work!” a few of them said.
Walking away I realized what a cocky asshole thing it was to say that right before I dove into her artery with the needle in my left hand. Luckily, it worked and felt pretty easy. Luckily.
On rounds in the attending's office he was explaining a complicated acid base problem to us. He is brilliant and seemingly knows a ton about a ton. But I noticed he was saying the completely wrong enzyme in talking about glycolysis.
“And PFK is inhibited, so pyruvate backs up” he said.
“PFK? You mean PDH complex” I asked him. (PDH is the correct enzyme).
“No, PFK” he says. And explains it again.
I just sat there.
You have to understand the hierarchy in medicine. The attending knows TONS of medicine. Under him are many other doctors, the residents and interns. Interns are first year MDs, and residents are in their residency, which is anywhere from 3-7 years after getting their MD. They run hospitals, with an attending over teams of them. THEN there are a few medical students scattered over a few teams. That’s where I am. Each interaction with a doctor is a grading opportunity. They all evaluate you, all of 3rd year. And the cumulative result is how good your record for residency applications is.
Finally I couldn’t take it.
“I’m sorry, did you mean PDH?”
“No, PFK.”
“You’re saying pyruvate into mitochondria and TCA cycle, right?”
“Yeah”
“Yes, that’s pyruvate dehydrogenase” I say.
“I think its PFK” he says, and he looks it up on his computer. He sees it is PDH.
“Oh, I guess you're right,” he says, and moves on.
It felt weird, correcting him, but PFK and PDH complex are two VERY different enzymes with two very different jobs and what he was saying made no sense. I really was confused as to what he was saying. Nonetheless, I am sure my grade just dropped a few points. I am told that that is who wins in medicine - the ones who respect their elders and don’t questions things.
I hope they are all wrong about this. We need more thinkers in medicine.
The scan of RICO’s head came back. More mets. I went to find him on the Onc unit but couldn’t find him in a room. The computer says he is in the hospital somewhere, but I couldn’t find him.
At this point we don’t need the pathology results. He has testicular cancer everywhere. And somehow the surgeon was worried about an ambiguous ultrasound. More thinkers needed.
My resident turns to me “You can get the blood, right?”
“Of course,” I say. As a medical student anytime you can do a procedure it’s a good thing. I gathered up my supplies and we all walked over to the bed. But as we looked for good veins they just weren’t there. Finally a resident told me to just get it from the radial artery (arteries don’t collapse like veins do – you should really always be able to get into an artery and get some blood).
I began feeling the wrist and then cleaned it. A resident gave me a few pointers.
“Feel the pulse with both fingers, and dive right between them with the needle,” he said.
Since I was on the left side of the bed, I held the shaking arm in my right hand and the needle in my left. I didn’t even think about it. During my PhD training I had done dog surgeries. For whatever reason (thinking I might pursue surgery one day) I began doing the surgeries with my left hand. Many dogs later I was almost equally good with needles and suturing with both hands.
“Is that your dominant hand?” the resident asked.
“I use both” I replied, as 5 doctors and a nurse looked on.
I dove in with the needle. Boom. Bright red blood on the first try!
“Nice work!” a few of them said.
Walking away I realized what a cocky asshole thing it was to say that right before I dove into her artery with the needle in my left hand. Luckily, it worked and felt pretty easy. Luckily.
On rounds in the attending's office he was explaining a complicated acid base problem to us. He is brilliant and seemingly knows a ton about a ton. But I noticed he was saying the completely wrong enzyme in talking about glycolysis.
“And PFK is inhibited, so pyruvate backs up” he said.
“PFK? You mean PDH complex” I asked him. (PDH is the correct enzyme).
“No, PFK” he says. And explains it again.
I just sat there.
You have to understand the hierarchy in medicine. The attending knows TONS of medicine. Under him are many other doctors, the residents and interns. Interns are first year MDs, and residents are in their residency, which is anywhere from 3-7 years after getting their MD. They run hospitals, with an attending over teams of them. THEN there are a few medical students scattered over a few teams. That’s where I am. Each interaction with a doctor is a grading opportunity. They all evaluate you, all of 3rd year. And the cumulative result is how good your record for residency applications is.
Finally I couldn’t take it.
“I’m sorry, did you mean PDH?”
“No, PFK.”
“You’re saying pyruvate into mitochondria and TCA cycle, right?”
“Yeah”
“Yes, that’s pyruvate dehydrogenase” I say.
“I think its PFK” he says, and he looks it up on his computer. He sees it is PDH.
“Oh, I guess you're right,” he says, and moves on.
It felt weird, correcting him, but PFK and PDH complex are two VERY different enzymes with two very different jobs and what he was saying made no sense. I really was confused as to what he was saying. Nonetheless, I am sure my grade just dropped a few points. I am told that that is who wins in medicine - the ones who respect their elders and don’t questions things.
I hope they are all wrong about this. We need more thinkers in medicine.
The scan of RICO’s head came back. More mets. I went to find him on the Onc unit but couldn’t find him in a room. The computer says he is in the hospital somewhere, but I couldn’t find him.
At this point we don’t need the pathology results. He has testicular cancer everywhere. And somehow the surgeon was worried about an ambiguous ultrasound. More thinkers needed.
July 19, 2011. Medicine: RICO
The next day I made it my job to just hang out with Rico. We had gotten the CT back and there was a very large lymph node. On rounds that day I went straight to the attending to suggest we do a brain scan. He thought and said, "yeah, I guess you're right, we should."
One resident thought it unlikely.
"Just to be sure" I suggested, thinking I knew full well there would be mets. How could there not be at this point? We know many testicular cancers go to the brain, and this one has already destroyed his lungs.
Two out of the three markers in his blood were very high, telling us it WAS testicular cancer. These markers are simply never this high for anything else. The ultrasound was ambiguous – it looked like lots of water the physician reading it said, with some strange nodules.
I sat in his room and explained everything to him from how cancer spreads to what type I thought he might have and what that might mean. Hell, I even told him about My mother’s disease and about Lance Armstrong.
“I’m really sorry to hear about your mother’s disease” he said. I felt like an asshole for even bringing it up.
He opened up to me and told me things I never would have imagined. He came from Chile originally, with his brother to work. They both stayed. All the other family was in Chile. A few years ago he was scared of the surgery and was told it was a hernia; cancer was never mentioned. I asked if he had gotten ahold of his brother, as I had seen no family since he got there (and to make it worse he had been on isolation ‘til we ruled out TB).
“My phone is dead man, he doesn’t know.”
I was shocked. I let him use mine but he didn’t recall the number – like most of us it’s just programmed in and we never actually dial it. He told me had a blackberry, so I went off in search of a charger.
Looking for the charger it hit me: This kid stopped by the hospital with a bloody cough to get checked out. We isolate him only to come back and tell him he has cancer. His phone is dead and he can’t get his one relative here. Tell me a worse nightmare.
None of the nurses on the floor had one. Into the residents room I walked, “It’s for a patient, not me,” I say to a room of 20-30 young doctors. “But does anyone have a charger for a blackberry so he can get his family?”
“What is this, a hotel?” one yells. Another mocks me.
“Yeah sure, admit it if its for you!” Another says.
I just walked out. I could’ve killed everyone that opened there mouth. I searched on.
Amazingly, one of the nurses had one in her pocket for reasons like this.
I got him the cord and he got his brother. We also had a chance to talk more as it charged. When I left to check on another patient and came back, the social worker was leaving.
“What was that all about?” I asked him.
“The social worker – telling me they’ll pay for this visit but for nothing else since I don’t have insurance. No follow up, no treatments.”
“Wait, Rico, why don’t you have Medicaid?” I asked.
We looked at each other.
“You aren’t a citizen here are you?”
“No.”
He went on to explain all about how it works. Making a living, not getting deported etc. Not following up with a surgery for a hernia a few years ago now made sense. Being so stoic in front of us now made sense. He didn’t want to get deported.
“Rico, you HAVE to get chemotherapy,” I told him.
He looked over at me, as if all along he knew he wouldn’t get it.
“Without it you’ll probably die.”
He looked at me, eyes moist. I reiterated it.
“Rico, the film is awful, you have cancer all over your lungs. Now we have blood markers back, and we found another lymph node that is huge. You have cancer. You need chemotherapy or you will die.”
A long conversation followed. I explained it all to him. He was calm but understood it.
“You are going to get the chemo, Rico,” I told him. “Somehow you will.”
I left and talked to both our team and the Oncology floor. It was decided that he would get admitted for each Chemo treatment so that it could be paid for. Meanwhile, I overheard a surgeon on the phone saying he saw the ultrasound and it didn’t look conclusive so he didn’t want to operate. I could’ve smacked this guy. Blood markers through the roof, chest film with METs, testicular mass, and para-aortic lymph node (the correct ones from testis). And he was stuck on one ambiguous ultrasound. He delayed the surgery for at least a day. I only read it in the chart – he never told the patient and he never told him he could eat (he had been fasting all day for the surgery). It was disgusting patient care.
I walked down and told the patient, then asked the nurse to bring the poor guy some food. Finally, his brother arrived and I explained it all again: Medicine, Surgery, Oncology, and Urology are all were working on it, I told him. Then I told them both everything I knew about it, every test we had run, every conversation I had about it. "Likely cancer, and likely bad," I said. "How bad? We’ll know when we get the pathology, but people beat this all the time," I told them. "All the time."
One resident thought it unlikely.
"Just to be sure" I suggested, thinking I knew full well there would be mets. How could there not be at this point? We know many testicular cancers go to the brain, and this one has already destroyed his lungs.
Two out of the three markers in his blood were very high, telling us it WAS testicular cancer. These markers are simply never this high for anything else. The ultrasound was ambiguous – it looked like lots of water the physician reading it said, with some strange nodules.
I sat in his room and explained everything to him from how cancer spreads to what type I thought he might have and what that might mean. Hell, I even told him about My mother’s disease and about Lance Armstrong.
“I’m really sorry to hear about your mother’s disease” he said. I felt like an asshole for even bringing it up.
He opened up to me and told me things I never would have imagined. He came from Chile originally, with his brother to work. They both stayed. All the other family was in Chile. A few years ago he was scared of the surgery and was told it was a hernia; cancer was never mentioned. I asked if he had gotten ahold of his brother, as I had seen no family since he got there (and to make it worse he had been on isolation ‘til we ruled out TB).
“My phone is dead man, he doesn’t know.”
I was shocked. I let him use mine but he didn’t recall the number – like most of us it’s just programmed in and we never actually dial it. He told me had a blackberry, so I went off in search of a charger.
Looking for the charger it hit me: This kid stopped by the hospital with a bloody cough to get checked out. We isolate him only to come back and tell him he has cancer. His phone is dead and he can’t get his one relative here. Tell me a worse nightmare.
None of the nurses on the floor had one. Into the residents room I walked, “It’s for a patient, not me,” I say to a room of 20-30 young doctors. “But does anyone have a charger for a blackberry so he can get his family?”
“What is this, a hotel?” one yells. Another mocks me.
“Yeah sure, admit it if its for you!” Another says.
I just walked out. I could’ve killed everyone that opened there mouth. I searched on.
Amazingly, one of the nurses had one in her pocket for reasons like this.
I got him the cord and he got his brother. We also had a chance to talk more as it charged. When I left to check on another patient and came back, the social worker was leaving.
“What was that all about?” I asked him.
“The social worker – telling me they’ll pay for this visit but for nothing else since I don’t have insurance. No follow up, no treatments.”
“Wait, Rico, why don’t you have Medicaid?” I asked.
We looked at each other.
“You aren’t a citizen here are you?”
“No.”
He went on to explain all about how it works. Making a living, not getting deported etc. Not following up with a surgery for a hernia a few years ago now made sense. Being so stoic in front of us now made sense. He didn’t want to get deported.
“Rico, you HAVE to get chemotherapy,” I told him.
He looked over at me, as if all along he knew he wouldn’t get it.
“Without it you’ll probably die.”
He looked at me, eyes moist. I reiterated it.
“Rico, the film is awful, you have cancer all over your lungs. Now we have blood markers back, and we found another lymph node that is huge. You have cancer. You need chemotherapy or you will die.”
A long conversation followed. I explained it all to him. He was calm but understood it.
“You are going to get the chemo, Rico,” I told him. “Somehow you will.”
I left and talked to both our team and the Oncology floor. It was decided that he would get admitted for each Chemo treatment so that it could be paid for. Meanwhile, I overheard a surgeon on the phone saying he saw the ultrasound and it didn’t look conclusive so he didn’t want to operate. I could’ve smacked this guy. Blood markers through the roof, chest film with METs, testicular mass, and para-aortic lymph node (the correct ones from testis). And he was stuck on one ambiguous ultrasound. He delayed the surgery for at least a day. I only read it in the chart – he never told the patient and he never told him he could eat (he had been fasting all day for the surgery). It was disgusting patient care.
I walked down and told the patient, then asked the nurse to bring the poor guy some food. Finally, his brother arrived and I explained it all again: Medicine, Surgery, Oncology, and Urology are all were working on it, I told him. Then I told them both everything I knew about it, every test we had run, every conversation I had about it. "Likely cancer, and likely bad," I said. "How bad? We’ll know when we get the pathology, but people beat this all the time," I told them. "All the time."
July 18-19, 2011. Medicine: CANCER
Staying late to take call, my team started to get new admissions from the emergency department. One patient had come with coughing blood and shortness of breath X 5 days. I sat with one of my residents reviewing his records. Then we hit his chest x-ray. It looked terrible. White messy stuff everywhere. We looked at each other – what in the world is this? We tossed around ideas – a vasculitis (inflammation of vessels), infections (although we didn’t know one that looked like this), metastases from cancer? The thing is he was 29 yo. Hard to get such nasty looking lungs when you are 29, and it didn’t look like the diseases I knew (I knew it wasn’t TB).
The next morning before rounds our attending was very impressed with the lung film. “Wow, what is this??” He exclaimed upon seeing the film. We told him the top ideas – atypical pneumonia, vasculitis, maybe mets, but he reports no pain anywhere else. Later in the conversation our attending says, “of course, a guy this age, what should we check out just to be safe if we think mets?” I respond “his testicles.” “Exactly,” he says, “just to be sure.” (Testicular cancer hits mostly 20-40 yo).
In his room we went through a bunch of things with him. Finally we casually asked him to pull up his gown. My heart sank. I could not believe what I was seeing. His testicle was the size of a grapefruit. I knew immediately he had testicular cancer that had spread – it was likely in other places too – bone, liver, brain, lymph nodes.
We all examined it and walked out of the room. One resident said that it seemed mostly like fluid though, not a mass. I agreed that it was interesting, BUT we already know its cancer because we saw the film; it fit EXACTLY the clinical picture. I would soon learn that this idea of the “clinical picture” is reasoning new drs (and some old ones) seem to not have. Why would we think for a second that this wasn't testicular cancer? We saw the scary xray, we thought 'this is crazy,' then we said the only thing it might be is mets from a big testicular mass. We then saw just that – a big testicular mass! How could we make an argument now that he has a mass of only fluid (not cancer) AND mets from somewhere else at the same time? The odds of that would 1,000,000 to 1. Yet some people do one test and let it lead them totally astray. Little did I know that over the next few days this would become a bigger and bigger issue.
We ordered blood work for HCG, AFP, and LDH, and ultrasound of his testicles, and a CT scan. All looking for cancer.
I decided to follow him as my patient since I intend to go into oncology as a specialty. Later in the day I returned to chat. I just sat down and watched some TV with him. Seems stupid but I knew he needed someone to help with this stuff, and not one family member had visited. I also didn’t know if he understood exactly what we thought was happening.
After a few minutes the Urologist dropped by.
He introduced himself to both of us, then told me to grab some gloves so I could do the exam with him. I did just that.
Then, like a real teacher, he walked me through feeling the testicles and then checking the rest of his superficial lymph nodes.
“Ok, Rico, I’ve gotta check out your prostate” he says. Rico rolls over.
Urologist looks at me “Get over here and get in on this too” he says. Now, seems odd to most, but this was exactly how you have to teach in the hospital, particulary when it comes to sticking your finger up a patient’s ass. The last thing you want is him to ask “Matthew, would you like to stick your finger in this guy’s ass?” But he knows you gotta learn. I walked over.
“How many of these have you done?” He asked me.
“One.” I was trying to talk so Rico couldn’t hear me.
“Ok, well, you’re about to get number two,” he says cheerfully. His prostate was normal.
We took our gloves off and he broke the news to Rico.
“You have testicular cancer that has spread to your lungs. We will need to remove the testicle soon and you will need extensive chemotherapy.”
Rico took it all very stoically, asking only a few questions. It did get revealed that only a few years ago a Dr. noticed a lump in his testicle and scheduled a surgery. At the time, Rico was told it was from lifting heavy objects, and when the pain went away, he skipped going for surgery. Turns out it was cancer, and now its destroying his lungs.
After the urologist left I went up and broke the news to my team; Rico knows the deal, he has cancer as far as we can tell (the true diagnosis comes back when a biopsy from his lungs returns). I said goodbye to him and went home. I wanted to give him a bit of time to digest what we told him. 29 years old. My age. Cancer.
The next morning before rounds our attending was very impressed with the lung film. “Wow, what is this??” He exclaimed upon seeing the film. We told him the top ideas – atypical pneumonia, vasculitis, maybe mets, but he reports no pain anywhere else. Later in the conversation our attending says, “of course, a guy this age, what should we check out just to be safe if we think mets?” I respond “his testicles.” “Exactly,” he says, “just to be sure.” (Testicular cancer hits mostly 20-40 yo).
In his room we went through a bunch of things with him. Finally we casually asked him to pull up his gown. My heart sank. I could not believe what I was seeing. His testicle was the size of a grapefruit. I knew immediately he had testicular cancer that had spread – it was likely in other places too – bone, liver, brain, lymph nodes.
We all examined it and walked out of the room. One resident said that it seemed mostly like fluid though, not a mass. I agreed that it was interesting, BUT we already know its cancer because we saw the film; it fit EXACTLY the clinical picture. I would soon learn that this idea of the “clinical picture” is reasoning new drs (and some old ones) seem to not have. Why would we think for a second that this wasn't testicular cancer? We saw the scary xray, we thought 'this is crazy,' then we said the only thing it might be is mets from a big testicular mass. We then saw just that – a big testicular mass! How could we make an argument now that he has a mass of only fluid (not cancer) AND mets from somewhere else at the same time? The odds of that would 1,000,000 to 1. Yet some people do one test and let it lead them totally astray. Little did I know that over the next few days this would become a bigger and bigger issue.
We ordered blood work for HCG, AFP, and LDH, and ultrasound of his testicles, and a CT scan. All looking for cancer.
I decided to follow him as my patient since I intend to go into oncology as a specialty. Later in the day I returned to chat. I just sat down and watched some TV with him. Seems stupid but I knew he needed someone to help with this stuff, and not one family member had visited. I also didn’t know if he understood exactly what we thought was happening.
After a few minutes the Urologist dropped by.
He introduced himself to both of us, then told me to grab some gloves so I could do the exam with him. I did just that.
Then, like a real teacher, he walked me through feeling the testicles and then checking the rest of his superficial lymph nodes.
“Ok, Rico, I’ve gotta check out your prostate” he says. Rico rolls over.
Urologist looks at me “Get over here and get in on this too” he says. Now, seems odd to most, but this was exactly how you have to teach in the hospital, particulary when it comes to sticking your finger up a patient’s ass. The last thing you want is him to ask “Matthew, would you like to stick your finger in this guy’s ass?” But he knows you gotta learn. I walked over.
“How many of these have you done?” He asked me.
“One.” I was trying to talk so Rico couldn’t hear me.
“Ok, well, you’re about to get number two,” he says cheerfully. His prostate was normal.
We took our gloves off and he broke the news to Rico.
“You have testicular cancer that has spread to your lungs. We will need to remove the testicle soon and you will need extensive chemotherapy.”
Rico took it all very stoically, asking only a few questions. It did get revealed that only a few years ago a Dr. noticed a lump in his testicle and scheduled a surgery. At the time, Rico was told it was from lifting heavy objects, and when the pain went away, he skipped going for surgery. Turns out it was cancer, and now its destroying his lungs.
After the urologist left I went up and broke the news to my team; Rico knows the deal, he has cancer as far as we can tell (the true diagnosis comes back when a biopsy from his lungs returns). I said goodbye to him and went home. I wanted to give him a bit of time to digest what we told him. 29 years old. My age. Cancer.
Tuesday, July 19, 2011
July 17, 2011. Medicine: BEDPANS
I finally get to admit my own patient with a full H&P. Problem is that shes postictal (after a seizure) and this barely arousable. Luckily, her boyfriend shows up and explains to me exactly what happened. This is a story in itself. Turns out that most people are simply poor story tellers (seriously, think of the last dinner party you were at where person X droned on and on, jumping back and forth between past and present, etc. Now imagine trying to summarize that story CORRECTLY to someone when you got home. It aint happenin unless you ask LOTS of questions to redirect them to some sort of timeline (e.g. "now wait a minute, a few minutes ago you said she has seizures every night, now you say once a month - which is it now?...REPLY: yeah, what i meant was 5 years ago they were every night, then for a year or so every month, now every night..." And on and on.
At any rate, the best part of the story was this:
Lethargic, postictal woman BEFORE boyfriend arrived, "Doctor, I really need to pee."
Now, she is obviously in no shape to even sit up, much less walk to the bathroom.
"Ok, let me get a bedpan" I tell her.
I walk to the Nurses station, "umm, I'm sorry, where do I get a bedpan."
Nurse laughs, then shows me.
I return to her "Ma'am, I'm sorry, I've never actually used one of these with a patient, how the heck do i do this?"
Nurse laughs again and says "no problem, I'll come show you."
As we walk into the room I already feel a bit silly about all this, but I keep thinking that I am just looking out for the patient, so its ok. PLUS, the nurse has been VERY nice to me about it, so I was happy to learn.
Learn I did. As we uncovered the patient and rolled her over what do we see?
A foley catheter draining her bladder.
Nurse laughs at me. I laugh at me.
"Let's just keep this between us, eh?" I say to her.
"Happens all the time," she says "don't worry about it."
I put the bedpan down in the corner, not wanting to walk back out with it.
At any rate, the best part of the story was this:
Lethargic, postictal woman BEFORE boyfriend arrived, "Doctor, I really need to pee."
Now, she is obviously in no shape to even sit up, much less walk to the bathroom.
"Ok, let me get a bedpan" I tell her.
I walk to the Nurses station, "umm, I'm sorry, where do I get a bedpan."
Nurse laughs, then shows me.
I return to her "Ma'am, I'm sorry, I've never actually used one of these with a patient, how the heck do i do this?"
Nurse laughs again and says "no problem, I'll come show you."
As we walk into the room I already feel a bit silly about all this, but I keep thinking that I am just looking out for the patient, so its ok. PLUS, the nurse has been VERY nice to me about it, so I was happy to learn.
Learn I did. As we uncovered the patient and rolled her over what do we see?
A foley catheter draining her bladder.
Nurse laughs at me. I laugh at me.
"Let's just keep this between us, eh?" I say to her.
"Happens all the time," she says "don't worry about it."
I put the bedpan down in the corner, not wanting to walk back out with it.
Saturday, July 16, 2011
Clinical Medicine Begins
Clinical medicine. I have started year three of medical school, which means clinical medicine. Traditionally, students complete 2 years of "preclinical" years consisting of physiology, pathology, pharmacology, etc and then transition to "clinical" years for year 3 and 4 of medical school, where they learn to apply those basic science principles before becoming official MDs or DOs.
During the first two years of medicine I struggled with many things. Foremost among these was the type of thinking required. During college, I knew I had an excellent memory. Sadly, I studied very little in my life until college. I went to a typical southern public high school, where I made mostly Cs and Ds, spending half my day at the Fine Arts Center doing drawing, painting, and ceramics. The rest of my day was spent running and lifting weights. As a senior I was the state champion in the 2mile, and had scholarships to run in college. Then, as a freshman at Brevard College in NC, I recall studying for 2 hours before a psychology test and making a 100. Afterward I thought - man, what a big investment but it paid off! Little did I know most people studied much more than this throughout their lives and in college. Upon transferring to Furman University in SC for my sophomore year, I learned to really study.
And from then on, I made all A's as I would study an hour or two each night and then cram 2 hours of facts in my head at 5am on test days. Little did I know my classmates were studying much more than this and really learning material. I instead spent a great deal of my time training and well, frankly, talking to people! I also drifted more and more toward the lab and coaching athletes.
In the end, I decided to pursue a Masters degree in Education at Furman while teaching high school, then moved to Auburn Alabama to work on my PhD in LB Gladden's lab on lactate metabolism. When I arrived at Auburn I had not made a B since my first year at Furman, and I never made a B again through the courses at Auburn. However, I soon realized that memorizing facts contributed very very little in the research world. In fact, it became apparent that many researchers would say I was waisting my time memorizing lists of information, and I soon came to see how right they were. Often in the lab it was an idea or connection between ideas that changed the course of experiments, not a list of facts. In fact, I soon learned that the “very best” in research world were not the best memorizers, but were a different breed of flexible, creative, “out of the box” thinkers that seemed to be able to integrate ideas and concepts in such a way that new original ideas were generated. I was impressed with Mike Hogan from San Diego early in my career as one of these people.
So when I arrived at Medical school, I was continually disappointed with the lack of depth with material. Rather, we would have 1 week to cover a very broad topic (say cardiology) before moving on to the next topic. Often my grades suffered most in the blocks I was most interested in. I made a 67 on the heme/onc exam, mainly because I was reading articles on the nuances of bone fibrosis in diseases such as polycythemia vera (which my mother has), failing to memorize the mundane lists given to us. In fact, often times learning was not encouraged, memorizing was. I find it a dangerous place where facts are memorized with no understanding of the process.
Even as we completed year 2 and took our first medical certification exam, I was amazed at the great emphasis on factual recall, NOT patient care or problem solving. Often times patients complain of two things: doctors being cold and not caring and (from the brighter patients) doctors not being very curious or good at problem solving. Both are a direct result of how we select our doctors and then train them. This needs to change.
With two years and a board exam behind me, I was ready to hit the floors. But what awaited me turned out to be less about medicine or science and much much more about other things. Enjoy my account of these years; please note that names and places may be altered to confine to patient confidentiality. Everything else will be as true to my experience as possible.
During the first two years of medicine I struggled with many things. Foremost among these was the type of thinking required. During college, I knew I had an excellent memory. Sadly, I studied very little in my life until college. I went to a typical southern public high school, where I made mostly Cs and Ds, spending half my day at the Fine Arts Center doing drawing, painting, and ceramics. The rest of my day was spent running and lifting weights. As a senior I was the state champion in the 2mile, and had scholarships to run in college. Then, as a freshman at Brevard College in NC, I recall studying for 2 hours before a psychology test and making a 100. Afterward I thought - man, what a big investment but it paid off! Little did I know most people studied much more than this throughout their lives and in college. Upon transferring to Furman University in SC for my sophomore year, I learned to really study.
And from then on, I made all A's as I would study an hour or two each night and then cram 2 hours of facts in my head at 5am on test days. Little did I know my classmates were studying much more than this and really learning material. I instead spent a great deal of my time training and well, frankly, talking to people! I also drifted more and more toward the lab and coaching athletes.
In the end, I decided to pursue a Masters degree in Education at Furman while teaching high school, then moved to Auburn Alabama to work on my PhD in LB Gladden's lab on lactate metabolism. When I arrived at Auburn I had not made a B since my first year at Furman, and I never made a B again through the courses at Auburn. However, I soon realized that memorizing facts contributed very very little in the research world. In fact, it became apparent that many researchers would say I was waisting my time memorizing lists of information, and I soon came to see how right they were. Often in the lab it was an idea or connection between ideas that changed the course of experiments, not a list of facts. In fact, I soon learned that the “very best” in research world were not the best memorizers, but were a different breed of flexible, creative, “out of the box” thinkers that seemed to be able to integrate ideas and concepts in such a way that new original ideas were generated. I was impressed with Mike Hogan from San Diego early in my career as one of these people.
So when I arrived at Medical school, I was continually disappointed with the lack of depth with material. Rather, we would have 1 week to cover a very broad topic (say cardiology) before moving on to the next topic. Often my grades suffered most in the blocks I was most interested in. I made a 67 on the heme/onc exam, mainly because I was reading articles on the nuances of bone fibrosis in diseases such as polycythemia vera (which my mother has), failing to memorize the mundane lists given to us. In fact, often times learning was not encouraged, memorizing was. I find it a dangerous place where facts are memorized with no understanding of the process.
Even as we completed year 2 and took our first medical certification exam, I was amazed at the great emphasis on factual recall, NOT patient care or problem solving. Often times patients complain of two things: doctors being cold and not caring and (from the brighter patients) doctors not being very curious or good at problem solving. Both are a direct result of how we select our doctors and then train them. This needs to change.
With two years and a board exam behind me, I was ready to hit the floors. But what awaited me turned out to be less about medicine or science and much much more about other things. Enjoy my account of these years; please note that names and places may be altered to confine to patient confidentiality. Everything else will be as true to my experience as possible.
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