Sunday, April 10, 2016

Sunday Rain

Almost two years ago I moved to California; didn’t think that time was going to pass this quickly, but it did. Now, I am faced with a little more than two months to go before I finish my clinical rotations in fellowship.

Over two years ago, I faced one of the most important decisions I had to make for myself – choosing a fellowship program. I remember the feelings - nerve racking, uncertain, and nervous; so many programs to rank and so little information I had despite my best efforts to learn about each program as thoroughly as I could. At the end, I made a decision, mainly based on the program’s location and how close to home it was; factors such as how easy it would be for me to visit my friends and family members and vice versa played a key role. It’s worked out well – my mom visited California for the first time; my sisters have made it out at least once to visit. The city has been nice, people friendly, and I don’t have much to complain about after living here for almost two years.

Now, I am approaching yet another important decision, how to approach my future beyond fellowship training.

I had a day off yesterday. I went running, along highway 101 to do my long run to train for the marathon I signed up to run in a couple of months. It was hard; a lot more up and down than I anticipated, and along with the length of 16 miles of asphalt, the run was not as smooth or pleasant as I imagined; somewhat my fault - should have put in more time to do the short runs in the past couple of weeks. But I did finish, despite pain and fatigue and all that.

I gained back a bit of myself in the past couple of days. Besides the running and the resting that happened afterwards, I spoke to a few friends, to catch up, share, complain, and talk. Tonight, I’m working the night shift. Tomorrow I present journal club. The next couple of weeks I need to revise and resubmit a manuscript. But today, I watch rain, in a coffee shop, feeling my next move, instead of thinking it.   

Sunday, August 23, 2015

Quote from Amy Tan Autobiography

"I remembered those times in my life when I tried to believe that my father and brother would not die. I remembered those times when I desperately wanted to see my friends who had passed too soon. And I remembered also how I didn’t want to hope too much, knowing that those hopes might turn into almost unendurable pain. In spite of what I didn’t hope, the pain was still unbearable, avoid so empty, so completely without meaning that it made me hope our existence did not end with the last breath and heartbeat. That same hope now made me remembered all that had happened during the writing of The Hundred Secret Senses: how the made-up stories turned out to be true; how the research I needed dropped into my lap; how the ironies and co-incidences accumulated, played off one another, forced me to wonder and consider that everything that happens is neither grand plan nor random coincidence. It is a crazy quilt of love, pieced together, torn apart, repaired again and again, and strong enough to protect us all.

Did the ghosts of friends and family come and serve as my muses? Aren’t ghosts merely delusions in grief? I know now that these questions are meaningless and the answer is absolute. What are ghosts if not the hope that love continues beyond our ordinary senses? If ghosts are a delusion, then let me be deluded. Let me believe in the limitlessness of love, the beauty of contradictions, the miracle that is an ordinary part of life."

- Amy Tan

Thursday, July 23, 2015

The Emergency Room

The emergency room is a common place where patients come to get access to medical care. The medical problems that patients present in the emergency room varies, from bodily complaints such as headaches or stomachaches, to needing to be given life-saving medications such as albuterol for and asthma attacks, to impending life threatening conditions such as heart attacks and serious infections.

Not everyone who shows up in the emergency room needs emergent medical care. The emergency rooms have found this out a long time ago Most emergency rooms use a triage system, where the seriousness of the complaint is assigned a color, or a level of urgency, to prioritize medical attention. A level one situation (coded blue) designates one that is life-threatening and therefore needs immediate attention, whereas a level four (green) or five (no color) designate those that are less urgent, or non-urgent, and therefore can wait. This triage system is designated by the triage nurse, to help the emergency room physician pay attention to the sicker patients, while leaving the less-sick waiting.

After coming through the triage, the patients wait to be seen by the emergency room physician, whose job is to further recognize serious conditions from those that are not-so-serious. The job is not as easy as it seems, since the initial triage system is not exactly perfect, and patients’ conditions can change quickly while waiting in the emergency room. As you could have guessed, not everyone who presents to the emergency room have a serious medical condition, even after they have “urgent” complaints as designated by the initial triage system. If you've spent more than a half-day waiting in the emergency room, to be seen by the emergency room physician, only to be told that you should follow-up with your primary care physician to get your problem addressed, then you, even after all that triaging and waiting, do not have a medical condition that needs emergency room care. If you are looking for a quick high on pain killers and have found that emergency room physicians are the most ready to give you a quick high, then you are not likely to read this blog, but nevertheless, you should recognize this problem of abuse and seek professional help. If you ran out of your blood pressure pills, and your primary care physician did not respond to your call to request a refill, it is unlikely that you need to come to the emergency room.

However, if you ran out of your asthma inhalers and are feeling short of breathing, coughing, wheezing (signs of an asthma exacerbation) then by no means, the emergency room is a very appropriate place for you – to get the medication you need because without it, you might die. If you suffered a large hand laceration and bleeding, the emergency room is a great place to get your injury checked out and fixed if possible. If you have a boil that seems to be getting bigger, more painful, and you feel that it might be infected, the emergency room is a very fitting place to get your boil examined, incised and drained in some cases, and you will go home filling better after it is properly treated.

If you are one of those people who will not go to the emergency room until your family is so concerned about you that they insist you come, then you should probably come to the hospital; you will likely need hospital admission. A proportion of patients who present to the emergency room will be admitted to the hospital, either for a diagnosis that needs a few days in the hospital to be properly treated and monitored, or if its determined (by the emergency room physician) that while the diagnosis if unclear (which is the case in a lot of admission), further testing is needed and that you need to be monitored in the hospital while these testings are done; in other words, we don’t know what’s wrong with you, but we don’t think it’s safe for you to go home just yet until we “rule out” some serious conditions.

After the initial testing and you are deemed to be needing a hospital admission, a few things will happen to you. Your emergency room physician will first call the appropriate admitting services to come evaluate you. That task if not as simple as you think. First, there are different services within the hospital to serve patients according to their primary medical conditions. The cardiology service will take care of patients with heart disease as the primary issue, while the hematology/oncology service will admit patients with cancers who get ill, either from progression of their cancer or the treatment side effects, or simply having a urinary tract infection. Needless to say, one is not mutually exclusive of the other. In other words, a patient with lymphoma can also have heart trouble, and when you present with shortness of breath and we are unsure of your exact diagnosis, your emergency room physician may end up calling both services to come evaluate you, to see which service is most appropriate for your condition. Even after being seen by both admitting services, if your doctors don’t have a diagnosis yet for you, it is still not that clear to your doctors which service you end up. You might ask, does it really matter? Why don’t they just admit me, either way I’m going to be admitted. No physician wants to admit a patient with a condition with which they are not familiar treating. Doing so will not only lead to more work for that physician, but will end up not being the most optimal setting for which the patient receive the best possible medical care.

Not only is there a question of which service is most appropriate, within each category of conditions, there are different levels of care. You can be admitted to the hematology/oncology service, under the regular nursing floor, or to the intermittent medical care unit, where you are monitored more closely under watchful nursing and ancillary staff support. For one condition, there can even be different services depending on the level of care you need. The intensive care unit is a place where serious, life-threatening conditions are treated. Two different patients with pneumonia can end up being in completely different settings and treated by a different group of physicians. One that has a simple pneumonia without issues with oxygenation of low blood pressures might be most appropriately admitted to the regular nursing floor, where daily antibiotic dosing and vital signs every four hours to make sure the level of oxygen support and blood pressure are stable, might be sufficient. The pneumonia that leads to low blood pressure, difficulty with oxygenation, and altered mentation will need to be treated in the intensive care unit, since it is a much more severe presentation of the same diagnosis, pneumonia, and is part of what medical care providers call the sepsis syndrome – infections that affect other organs in addition to the primary infected organ. The patient with pneumonia leading to sepsis, therefore, will be treated by a group of physicians in the intensive care unit, called intensivists, critical care specialists, or ICU docs (intensive care unit doctors).

As you can imagine, conditions do change with time. The patient might have a simple “pneumonia” initially when he or she initially presents to the emergency room, but after four hours, this pneumonia can progress to severe sepsis simply because of the course of the disease. The physician room physician, therefore, might call the internist to evaluate you initially for admission, but after you are seen by the internists, he or she might recommend that be admitted to a higher level of care, to the intensive care unit, and therefore a different group of doctors, should be called to evaluate you for admission to their service. Therefore, if you get admitted to the hospital, in addition to your emergency room physician, you might be evaluated by one, two, or three other group of doctors, each part of a different service, to make sure you end up at the most appropriate location/setting for the rest of your medical care in the hospital.

The time it takes for you, from the minute you step in the emergency room, to the time you end up in the hospital bed, under an admitting service, most likely takes at least half a day, if not the whole day. Sometimes, because of bed shortage, you might be admitted to the hospital, but still stay in the emergency room because there is no hospital bed available (in medical lingo, this process is called “boarding”).

What I hope to convey here is a not a discouragement for patients to seek emergency room medical care, but to raise the awareness of what to expect from an emergency room visit, and how to avoid going to the emergency room unnecessarily, both for your sake and your emergency room physician’s sake.

What the emergency room should not be used for:
- Conditions that your primary care doctor can evaluate, even if this means waiting a few more days, because when do get to the emergency room, after all the tests and waiting, you will be told to go see your primary care doctor
- Getting a test more quickly simply because you are anxious and do not want to wait the seven days until your scheduled test
- Obtaining a prescription for medications because you ran out (unless not having access to this medication is life-threatening)
- Abusing pain killers

What the emergency room should be used for:
- Ideally, medical problems that need hospital admission
            - Your primary care physician’s office can help you determine this initially
- If you are too ill to call your primary care physician, you should probably come to the emergency room for evaluation

- Medical problems that need urgent interventions - bleeding, trauma/injuries

Saturday, July 18, 2015

My House In Vietnam

My house in Vietnam faced the village’s main road. In the back lied a river that was the source of the yearly floods. It was painted green, the color of spring, and had four windows, one above the bed on which my family and I slept, while the others shined light over a wooden dining table and the marble floor of an extension of the house, forming an “L” pattern when looked at from above. At first, I did not know its use.

We used the extension of the “L” for different purposes. Of no chronological order: there was a time when villagers came in to it to purchase new light bulbs for replacement. In the middle of the night, on one occasion, a middle-aged woman bicycled in, to purchase aspirin for her headache. Then it morphed, to store plates, bowls, and pots and pans, to be rented for special occasions (mostly weddings). At one time, my mom added shelves for books, containing Chinese folklore and translations of other foreign literature. One of the authors on those shelves was Jack London.

The extension can simply be extra space for business. It was, after all, not uncommon for villagers to use parts of their homes to make a living. In my mom’s case, it was a source of extra income to her job as teacher and a single mom. It could also be a sign of modernism; none of the houses in the village had such a design, which was not uncommonly seen in the city where more wealthy and presumable more educated folks lived. It could be a sign of wealth; not only did my mom have enough to build a home, there was left over to build more than just that to simply provide roof, and sleeping and eating space.

I had a pet bird that died in that extension that formed the shape of an “L” to my house in Vietnam. I didn't know why it died, but our pet cat might have been involved; the two animals did most of their living in that part of the “L.” I often sat in this part of the “L” in the summers, trying to grasp the adults’ fascinations with the Chinese folklore and the translations of Jack London. I played pool with marbles and chopsticks with my imaginary friends in it. I sometimes napped in a hammock that connected between the hinges of the window and the adjacent front door that kept this part of the “L” secure at night. And on rare occasions, my mom would let me sleep in that hammock, until the morning hours when I accidentally fall asleep while watching my favorite cartoons.

Growing up, I was glad that my house was shaped an “L”, and not simply an “I”.  

Wednesday, January 1, 2014

Frozen

Three lights are lit in my apartment – one in the hallway between the living room and bedroom, the other two – in the living room. I need two in the living room; they make the apartment look more alive. More light, more life, so I think.

Today I wake up early, on a day off from work, but I am used to the new schedule – waking up a bit earlier, hopefully be able to get more done. So I think.
                                     
Tonight, I am going to do some reading. 

The TV is on, a music video is playing on the screen. I stare. The music reminds me of the guitar. Maybe I can pick it up again. Wait, I did do that, last week, but the string broke. New strings are on their way; nothing to do for now.

My goggles arrived. Prescription goggles, so I could learn to swim, long over due goals but never accomplished. Now is the time, the next few months. So I think.

It is the middle of winter. The snow is cold outside. I haven't seen the sun for days, but the trees are alive with whiteness. The end of his residency is six months away. It is still a long time, but I feel as though it’s not enough. There are things to do, things to learn. Ah yes, that marathon I have yet to run.

I feel frozen, paralyzed, and unable to move. I sit, and stair at the TV screen, hearing but not seeing. I wonder what I need to do next.

The song sings, so I decide to listen. 

Wednesday, July 3, 2013

Lines and Ropes

The dividing line is here.

For most of us, there was a plan at the beginning of internship that we were going to carry out. Do well in residency, start research in the field we are interested in, and apply for fellowships when it becomes time for us to do so. It is now that time.

July is an interesting time in medical training. The highlight is usually with the new incoming interns; most are coming into a completely new health care system to start their paths on becoming full-pledged physicians. Not highlighted are also transitions for many others – residents who just completed their internships now become senior residents which is a big learning curve in itself. Residents who just finished their residency training start fellowships, which I’m sure also has a steep learning curve. Fellows turn staff physicians and become the last line of input in patient management, assuming the responsibility of anything and everything that happens to patients. For us, we start dividing.

We just completed our second-year of residency training, and in internal medicine, it is now the time of us to start our fellowship applications, to carry out that plan at the beginning and become the type of physician we want to be – heart, lung, and which ever organ specialists we want to become. The process is exciting but also anxiety-provoking. Exciting in that all the hard work we have put in now is coming to a time of some fruition – being in the position to apply for fellowships and start that process that takes us where we want to go. It is also a anxiety provoking, in that everything we have done up to this point will be summarized in a few pages, and along with the stress of putting the application together, asking for letters of recommendations, and gathering the necessary documents, the uncertainty of where you will end up is quite unsettling.

But the dividing line has always been there.

When we started medical school, we each had our own plans for the type of physician we wanted to be. When we completed our medical school training, we had to decide if we wanted to be surgeons, pediatricians, or radiologists. For us internal medicine residents, we wanted to become heart, lung, and whichever organ specialist, and because the common path lies in internal medicine, we share the road, which eventually splits. When I think about my medical school classmates, with the exception of a few close friends, I think about them in terms of their chosen paths. X is on his way to becoming an orthopod. Y is a radiology resident at this hospital, Z is an internal medicine resident there. When I think about my co-residents in the future, I will also think about them with respect of their chosen career paths – X is a gastroenterologist at this hospital, Y is a cardiologist here, and Z is an oncologist there.

Between the dividing lines, we do share. My classmates from medical school and I had the same immunology professor and therefore experienced his humor and brilliance in the same classroom. A group of us dissected the same cadaver and therefore had the same difficulty finding the ansa cervicalis. We learned the cranial nerves a certain way together. We went to the VA where we heard our veterans’ stories and saw the challenges they faced. We then went on to become neurosurgeons, obstetrics and gynecology specialists, and internists. But before that, we were the same.

In residency, between the underlying desires to be whichever specialist, my co-residents and I also share. We work on the same internal medicine floor in H80. We deal with the same wonderful social workers from G100, experience the emergency department first hand as consultants, and share the same food in our academic half day. We also had the same wonderful program director, complain together about the food we eat, and take care of the same patients when they come to the hospital on repeated occasions. The dividing line is fast approaching, but the rope that has always been there will always be there, hopefully bigger and bigger. C**IM whoop whoop!

Sunday, May 12, 2013

Blur

I grew up with fear and hope. My father passed away in 1983, the same year I was born. In fact, he passed away 2 months after I was born, in a flood, on his way home from his job as a school teacher. My mom raised me and my older sister. It was hard.

My mom married my father after graduating college. It was rare for a Vietnamese woman at that time to graduate from college. My father was the first in his village to graduate from high school, college, and became its first teacher. I don’t know how they met, but they were in love. My mom talks greatly of him. They had my sister in 1980, and three years later, in their late twenties, they had me. When my father passed away, I wasn’t old enough to know, but throughout the years, I’ve pieced together a story. And this is my version.

When my father passed, my mom was scared. A woman in her late twenties, whose parents were farmers and had no riches, in a poor village, recently moved out of her parents’ house to start her own family, now widowed, single, with 2 kids to raise own her own. So in addition to her job as a teacher, she started her career as a saleswoman. She was one of the few people in the village with a bicycle, so she took advantage of it. On her bicycle, she would bike 9.5 km to downtown Hue to buy goods to sale to the villagers. She bought and sold. The few items she sold became several items, then many items. Goods she could fit in front of the bike now required an additional rack in the back of her bicycle. From our front porch grew a shop. My mom, a teacher and a saleswoman, in a village in Vietnam, raising her 2 kids, alone.

My mom did well and eventually built her own home, as a single woman at a time when I’m sure even with the help of a husband, not many women could do. She replaced her bicycle with a motor scooter. It was not money she struggled with. It was with my sister, and it made me scared. As children, my sister and I were called names. Our father had passed, and many people expected my mom to re-marry. Once that happened, we would be left with no parents, since my mom would then dedicate her efforts to her new family. They started their version of the story early, and treated my sister and me like we were orphans. I was too young to hear their stories, but my sister heard them, and they stuck. So at home, she threw fits, became difficult to talk to, and very disobedient. My mom did not know what to do with her, because scolding, spanking, threats did not work. Neither did Buddhism teachings from the temple or summer behavioral education at my uncle’s. I became more and more afraid of their fights. The older my sister got, the more violent and scary the fights became. I wished for them to stop, but was never brave enough to ask. I feared, but hoped.

My mom did eventually remarry, in 1992, nine years after my father passed away. He wasn’t exactly kind to my sister or me, but I had no trouble with him living in our home. Unlike the villager’s stories, my mom did not leave us. My mom gave birth to two more children in Vietnam, my two younger sisters who are now in college at the University of Colorado. In 1995, we immigrated to the United States, to Denver, Colorado where my mom and sisters still reside.

When we came to the U.S., I had less fear and had more hope. I was hopeful that the new beginnings would make my family more together, and my mom and older sister would stop fighting; at least for the while when they adjust to their new lives. It wasn’t long before they started fighting again though. I was older, and had my own troubles to deal with. I had to adjust to a new school, learn a new language, and fought kids from school who picked on me because I was new. I don’t remember being afraid as much, since I have seen their fights many times before.

What happened between 1995 up until recently has been a blur. I did learn a new language, got through middle school despite dealing with racism. I started working in high school and was able to support myself while living at home. I bought my own car in 10th grade, and was accepted into a good college with a scholarship to the University of Denver. I graduated from college in good standings and did not have much student debt with income from three different jobs. After college, I was luckily offered a position in the National Institutes of Health Undergraduate Scholarship Program, where I met many like me, from disadvantaged backgrounds and interested in biomedical science. From my time at the NIH, I was fueled with the confidence I needed to apply to medical school. In between, my youngest sister, who is now a ninth grade and loves music, was born.

Behind that blur, the troubles of my home continued. My stepfather went back to Vietnam to start a new family so that he could have a son, since my younger three younger sisters are females and therefore cannot carry on his family name. My mom filed for divorce, and my older sister, perhaps ceasing the opportunity, stood by my stepfather’s side in court to fight for custody of my youngest sister who is the only minor in the family. She succeeded, and my mom now is again single, and lives by herself. Needless to say my mom has gone through hills and vallies. Today, ironically, is Mother’s day. I am afraid to call my mom, since I am afraid my anger would ruin her day. But I know that if I called, she will be very happy.

The blur showed me the troubles of my family. I am it, part of it, and am stronger and better with it. Seeing it, I am less afraid, and more hopeful as I have ever been.



Saturday, May 11, 2013

Transplant Evaluation

It used to snow here. Ice used to cover the side walks. My bicycle used to shake as the wheels hit the chunks of ice on my way to work in the morning. But no more. Winter is no longer with me in Cleveland. Instead, rain comes intermittently, with sparks of sunshine throughout the day as if to teasingly tell me to hurry up and leave work each day. Today is my day off. A real day off, no work.

It has been a busy stretch in the past few months. I am in my third straight service month in the hospital, with intermittent research work taking away any free time I have on my days off. Work has been trying, and the grind of internship has noticeably taken a toll. No matter how much I try, being an intern has become more and more irritating. I no longer smile on my way to work despite trying. The sound of pages becomes more and more unbearable. Daily progress notes seem unnecessary and mundane. The thoughts of owning a place “where everybody knows your name” becomes more and more attractive. But I am stuck, with internship and residency.

Last month, while on service in the hospital, I learned of the phrase “transplant work-up.” This used to be my least favorite part about my job. It involved calling every service in the hospital for consultations so that patients with end-stage liver disease can be evaluated for transplant. This included asking a dermatologist evaluate my patient's skin so that he or she can be “cleared”. It also meant requesting a cardiologist to assess the risk of heart disease, which almost everyone had. It also included scheduling lung function testing for those who were obese and therefore had difficulty with expanding their lungs, or anyone with a history of tobacco exposure to rule out chronic obstructive lung disease, typically present in heavy smokers. Of course, whoever answered my pages for these consults were not happy with me. They thought, like I did, that the transplant evaluation process was comber-some and had no obvious added benefit to the patient getting transplant. To us, the consultations were usually unnecessary, monotonous, and brought no real educational value. My skepticism told me that I did not need a dermatologist to inspect my patient's skin so that he can be “cleared” for transplant. Not everyone needed to have a skin exam to rule out skin cancer, the voice in my head told me. Despite the many consults and evaluations, not one of my patients underwent transplant. Livers do not come by that easily, I thought to myself. The more transplant work-ups I was involved in, the more unhappy and frustrated I became. Then, a lab error happened that made me change my mind. 

Mr. D was a gentleman from Pennsylvania. He had a history of obesity and end-stage liver disease due to fat infiltration. He was admitted for confusion, a frequent complication in patients like him. He had already been listed in Pennsylvania for transplant, but he and his family wanted him to be evaluated in Cleveland as well, to be double-listed for transplant to enhance his chances of getting a new liver. He, like everyone else who wanted a transplant evaluation, needed a dermatology consult, pulmonary consult, cardiovascular consult, infectious disease consult, and social work consult before he could be considered. 

I consulted the specialists and ordered the many labs and tests he needed to have, including a catheter to be inserted into his penis so that we could collect his urine for 24 hours, to investigate the cause of his elevated calcium level. Of course, as the result of the insertion, he had trauma which caused him to have blood in his urine, requiring yet another consult, to urology. His blood pressure then became low, due to an infection in his abdominal cavity and we had to emergently place a central line on the regular nursing floor because he lost all of his intravenous (aka IV) access. His hospital stay had more complications, including blood loss related to spontaneous bleeding into his chest cavity, which supposedly can happen in patients with end-stage liver disease like him. For this, he needed care in the intensive care unit.  

But things did improve. His low blood pressure resolved with fluid supplementation and antibiotics. His urine eventually cleared of blood with irrigation. The bleeding in his chest cavity stopped. He was better, and was ready to be discharged from the hospital. I arranged his discharge paper work, and the case manager arranged for transport to come and pick him up. Then the lab error happened. His morning labs came back that day, coincidentally at the same time transportation arrived to pick him up. His sodium level which was previously low was now normal, without any interventions. His kidney function, previously normal, was now high. On top of that, his liver function which was previously grossly abnormal, now seem to indicate he no longer has end-stage liver disease. It could only be a lab error, and since we did not have evidence to prove this, we had to hold him back from leaving. We told transport to leave, so he could stay to get his labs repeated. We drew repeat labs, and of course, just as expected, his repeat lab values were not anything similar to the results from the morning labs. “Great, just another reason for him to stay longer in the hospital,” I thought. But his kidney function on repeat, at 1.7, was still slightly elevated compared to his prior values. And like every patient with end-stage liver disease, there was concern that he was developing hepatorenal syndrome, a term used to indicate that the severity of his liver disease was now becoming bad enough to affect his kidneys. We treated him for such syndrome and monitored his urine output. We consulted yet another specialty, nephrology, just in case he needed dialysis. 


He stayed on our service for another two days while we awaited his recovery. I had a day off, and when I came back the next day, he was listed to be on a different floor - the intensive care unit. “Oh no, things must have taken a turn for the worse.” I thought. I read his chart and quickly realized that he was in the intensive care unit not because of worsening medical condition, but rather he just had undergone a liver transplantation. Thrilled, I quickly ran down to see him. There he was, lying in bed, angulated at 45 degrees just like most post-operative patients. He was just taken off the breathing machine. I walked in to say hello to him and his wife. Needless to say, they were very happy that he had a new liver. After the quick visit, I left to go back to my regular floor. I walked away smiling. All that work, all those phone calls for consultations, all those orders and hours of following his blood pressure, labs, urine output and the numerous studies he underwent paid off. One of these transplant evaluations eventually resulted in a patient getting a new liver, all thanks to a lab error that prevented him from leaving the hospital.

In medical school, I was given the last chapter of “Better”, written by Atul Gwande as part of our humanities curriculum. I read it and discussed it in small groups with my classmates. I remember telling my friends outside of school about it, how the message in the chapter was insightful and resonating. I told myself I was going to practice it. Now, eight months into internship, I find myself doing the opposite. The message I remember emphasized resisting the temptation to complain, or talk negatively about work while sitting down with co-workers. My co-workers are my co-interns, and whenever we get together, I find myself making sarcastic comments on the practice of medicine, from the multiple improper hospital-to-hospital transfers happening in the middle of the night with no useful medical records, patients admitted to the hospital on multiple occasions without real medical needs, the disrespectful comments from the nurses on the phone, the frustrations in dealing with other specialties, and on and on. And of course, I also notice other people doing it, including residents, fellows and sometimes attending physicians.

The spring rain in Cleveland does have a calmness to it. It keeps the air cool, sometimes with intermittent breezes to remind me that in this training process, while sometimes can be trying, that I do not lose my mark on reality, including trying to leave lasting impacts on my patients. I did not give my liver to Mr. D, nor did I perform the surgery to give him a new one. I did, though, call for the consults, placed all the necessary orders for tests, treated his infection, and monitored his blood count while we waited his bleeding to stop. I did write his daily progress notes. I did see him everyday, asked him how he felt, and touched his hands on multiple occasions. I saw him improve, and I did share a smile with him and his wife. All that, there for me to do.

Friday, March 8, 2013

Float Week

I recently got back from vacation. I am currently on my float week, which requires me to physically be in Cleveland for the duration of the week, in case I get called to cover some one in the hospital. This is the 3rd time this year I am subjected to such week, and the previously two times, I was asked to cover someone on a call shift for the GI service, and one shift on the cardiology consult service. This time again, I was called to cover someone, in the CICU, on a call day, on the weekend. Probably the worse shift available in the hospital.

I expected to be called, given the fact that the previous two times, I was called to cover 2/2 times. Last year, I did not get any calls. I get the feeling that being pulled as a senior residents happens more frequently compared to intern year. I think there are several explanations for this. First, I think during the intern year, you have the most energy and enthusiasm for work. Most interns just recently completed 4th year of medical school, considered the lightest year of medical school training at many places. The 4th year in medical school is a time to recharge, any many of the residents I met when I was a 4th year student acknowledged and emphasized that. Now as a resident, I concur. Also, I think residents, compared to interns, know the system more, and therefore, are better to utilize the system. I don't think I really knew what the procedure was to get someone to cover for me in the hospital when I was an intern. I was simply focused on surviving.

The reasons for needing coverage vary, and I think includes conference attendance, needing to go to interviews (applicable for 3rd year resident interviewing for fellowships), illness, or family/personal reason - child being sick, weddings etc...I don't know what the most common reason is, but of all those reasons, the "personal" category is the one I am most uncomfortable with. My first time on coverage this year, I covered for someone who needed to go away for a conference. The 2nd time, someone else needed to go on an interview. I was not happy that I was called to cover, but accepted the need. This time, it was a "personal" reason, and I am not going to ask why nor is it my place to do so. My job is to cover, regardless if I like it or not. 

And I don't like lit. 

The CICU is probably the most talked about rotation. I'm not sure exactly why, but I think it used to be very hectic for many residents. It is likely still is for many, and therefore, is stress inducing. I haven't done it yet, so therefore I really don't have much to refer to, except for what people have said about it, and to be honest, I would have preferred to not hear anything. The anticipation, expectations and imaginations about a challenging rotation is always more difficult than the going through the process without such negative expectations. It's funny, because 2 of the residents I've talked to actually enjoyed it, but I don't think that has offered any relief for what I'm feeling now. 

In addition, the timing of it is bad - it is Friday today. If I didn't have to start work at 6am tomorrow (and therefore will wake up at 5am) I would have enjoyed my Friday night. Instead, I will be getting sign out, on however many patients I'm covering for. My Saturday will be in the CICU, and so will part of my Sunday. On Sunday, after getting home, I expect to hopefully fall asleep, which will take me to Sunday afternoon/evening. The weekend is pretty much done for. The timing is also unsettling. The "personal" reason just suddenly became a bit more unsettling just because this weekend is the last weekend of the rotation and therefore the last call shift.

The upside? I guess it will give me a good idea of what to expect in ~ 1 month, when I start my own CICU rotation. It will also give me a good idea of it is like to go through what I'm quite sure is the worse coverage you can get during a float week - CICU weekend call. Besides that, I'm not sure what else is good....

I am anxious.

I think this has been one of the more anxious couple of days during my residency, since I learned about this coverage. I think there are multiple reasons for this. Even though I just came back from vacation, my vacation did not feel like an actual one. I did spend time doing something I like - snowboarding, but for the most part, I spent time doing other things. I took my mom's car to the mechanic a couple of times for a transmission/computer problem, which is still in ongoing investigation. I spend a few days helping a good friend buy a car. I worked on my research projects, in addition to spending sometime hanging out with friends/family. The fact that I did not have a car on many of the days to commute also made it more difficult. In all, the 3 wks seemed to pass by very quickly. I am also trying to finish up a few research projects, which likely has caused some additional stress/anxiety. In addition, I am preparing for an upcoming interview in front of many people, planning my reading plan for a couple of my upcoming rotations - pulmonary clinic, followed by CICU. Of all those things, I think completing one of the research projects and the interview are the most anxiety provoking - mainly they are are not something with a known/definitive endpoint. Adding all of that to a call shift for a rotation that I have not done, on one of the more difficult rotations, is not ideal. 

And then this email: 

Don’t forget to turn your clocks AHEAD one hour on Saturday evening (March 9).
We will all lose one whole hour of sleep this weekend. Regardless, have a great weekend everyone!!

WTF!!!

Tuesday, January 8, 2013

Voices

It is 5:15 a.m. The alarm goes off. I quick get out of bed. Half awake, I push the alarm button haphazardly, not knowing if it is the snooze button or the one I really need  to push to turn it off. The slippers are at the edge of the door exiting the bedroom, I slip my feet into them, and when I walk to the bathroom, I can hear my sleepiness. My feet can't seem to get off the floors. My goal is to get in to the hospital by 6 a.m., so that I can learn about the overnight events on my patients. On most days, I know this is manageable when I get up without hitting the snooze button. Today is one of those days; I figure I will not have much of a problem getting in on time. By the time I get to the bathroom and turn on the bathroom light, I fully open my eyes. 

My eyes are dry, from staring the computer screen before going to sleep the night prior. I was reading about leptomeningeal metastatic disease, which one of my patients had. I read so that when I see my patients the next day, I can become more familiar with the underlying condition. While brushing my teeth, I start to wonder if Mrs. R's INR was therapeutic so that she could be discharged home. If it was, I would need to make sure she has the appropriate appointments, so her care can be continued when she leaves the hospital. I make a mental note to make sure that I talk to the social worker that day, to make sure my patient have coverage for Lovenox before she leaves. Hopefully she does. 

There is enough time for a bagel if I wanted to, but I choose not to eat breakfast. Most days, I choose to leave my apartment on an empty stomach. I seem to not think that my body needs food this early. But if I did this long enough, I know that by 10 a.m., when after 4 hours of pre-rounding, note writing, presenting, and rounding, my stomach will growl. My efficiency will go down, and I will not be at my best, to take care of my patients and learn at the same time. But I am too early in the training process to realize this. All I needed was a cup of Starbucks.

When I get to the hospital, after getting my white coat from the locker on the first floor, I dash to the line at Starbucks across the hallway from where my locker lies. Lucky for me, it is 5:55 a.m, and there are only two other people in line. I pay for my coffee and rush to the elevator to the seventh floor, where my co-intern is already there. She just got there, she says. There we are, in the resident work room, together, about to page the over night resident to get sign-out. 

The rest of the day would go similarly to most days. After I get sign out, I go to see my patients and starts writing daily progress notes. My finish seven to nine notes on most days, and while most of them can be better in quality, I usually finish them on time, before starting morning rounds at 8:30 a.m. I work with me senior resident and attending physician to take care of my patients. Mrs. R's INR is therapeutic. I am able to make all the necessary appointments. Lovenox is covered by her insurance. Yay, one discharge down, three more to go. When the discharges are done, I proceed to update the list of patients I was responsible for, so that when the overnight resident comes in, I can tell them about the important things that need looking after that night. It is a busy day like most days, and I do make it out of the hospital. At 6 p.m. I left work, to go home, eat, shower, and stare at the computer screen a bit before going to bed.

For the next twenty days, I would continue this routine, with variations in between including some days when there are more admissions than discharges. There are also days when there is no discharge but only admissions. But for the most part, this routine is what I usually do. In fact, for the next three hundred and thirty five days, this is my routine for at least half of the time. And the other half? I wake up a bit later, comes home a bit less stressed, and sleeps a bit more on clinic and consulting months. Either case, I am relatively busy, with work and activities that I need to do including staring at the computer screen to enhance my training. I want to be the best he could be, so that when I am on my own, I can take care of patients the right way. This has been the goal all along, and internship and what is scheduled in the three hundred and thirty five days is a founding start to achieve those goals. 

The voices never go away though. They started in medical school and then went on to residency. Residents nowadays don't know what it's like to really take care of patients. They don't know what continuity of care is. Nor do they know stress, sleep depression, or insanity after long calls. "I used to sleep in the hospital for a week, shower once a week, and when I slept, it was never more than three hours." At first, I did not pay attention to the voices. They were just there, and my job was to focus on doing what I could to be the best he could be. But they became louder, to the point of being distracting and almost omnipresent. They were there when I woke up at 5:15 a.m. They were there preventing me from placing the right order at Starbucks. They told me after rounds when I was by myself that I will never be good enough to take care of sick patients, because I never stayed long enough to watch patients struggle, to see and learn the things that need to be done to take care of them the right way.

As the year went on, I hear more voices. In the intensive care unit (ICU), the voices tell me that my colleagues and I are one of the reasons why patients stayed longer in the hospital - because the lines we put in are not clean enough. We give patients infections. Because of this, there is now a team of professionals, very clean, set up to place these lines. They are so clean that I have to stay far away from the work area, to watch and take mental notes, so that when my chance comes, I will not give my patients infections. I watch, and watch, but am never clean enough. I finish my ICU rotation without placing any lines. The voices tell me, "when I was an intern, I put in thirty lines by myself in the first week." I feels helpless, weak, and almost beat down. 

I eventually learn to clean myself well. On my own, I come with no bacteria on my skin and ask the professionals to teach me how to put in these lines. They think I am clean enough, so they let me place lines. But then another voice chimes in. It tells me I needs to learn to save someone from dying. "When I was an intern, I ran codes by myself all the time," the voice tells me. Running codes was the ultimate thing to do as a doctor. It involves putting in lines, command of the life-saving algorithm, electricity to shock the heart, and doing whatever else is necessary to save a life. Unless I do this on my own, I was not a real doctor. Problem is, since my colleagues in the past failed to do this, either by not showing up quickly enough or performing them improperly, there is now another team of professionals of code experts to take care of these situations. So when I run to these codes, I have to squeeze in between the one million people in the room, to watch, take note, and think of what I would do when it is my turn. I hurry to these codes, watch, wait, and when I have the nerves to step up to say something, the nurses think it is only for practice. The patient, as far as they are concerned, is already dead, and I am just trickling into the sea. I go home helpless, weak, and beat down. 

I am an internal medicine resident who entered residency in 2011. My co-interns and I are the first to be in the new “eighty hour" rule, meaning we cannot work more than eighty hours in one week. This rule is not new. What is new, is that interns like me can only work for a maximum of sixteen hours straight before having to physically leave the hospital. The idea is to protect against fatigue, which prevents me and others like me from learning and putting patients at harm's way. The new rule sounds logical, but the voices disagreed. They spoke, but data outspoke them. Data was not loud but was convincing. On top of that, my co-interns and I are also in the middle of waves of changes taking place. Hospitals now are to be paid on how well they deliver care to patients. The definition of quality health care is being defined to include giving no extra pay for longer than needed hospital stays. In other words, if patients stayed in the hospital longer than expected due to a complication suffered in the hospital, like a dirty line, hospitals do not get paid. So to minimize the cost, hospitals now do everything they can to minimize complications. Sounds fair and good, but maybe this should have happened many years ago, so that at least one of the voices would not be there when he goes to work. 

So I go to bed, weak, beat down, and worried. Can I actually achieve my goals? Will I be able to be the best physician I could be? Right now, the voices don't seem to think so.