Tuesday, December 9, 2014

A World of Nightmares

O Rose thou art sick.
The invisible worm,
That flies in the night
In the howling storm:

Has found out thy bed
Of crimson joy:
And his dark secret love
Does thy life destroy.
—William Blake, “The Sick Rose

As I rotate through psychiatry, I have noticed that certain facial features and dispositions uniquely characterize diseases. I wrote this in a previous post about a depressed patient:

Corridor of psychiatric hospital Saint Anne, Paris.
By Jules Gaildrau, 1868.
Image via Shutterstock
I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid gaze lingers longer than it should on various objects or people or nothing at all.... His visage is neither pale nor tan nor some variation on one of these — it is like a bare tree on a late and chilly fall day. His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely audible over the ambient sounds in the room.

Much of this description also applies to a schizophrenic patient whom I saw, a young adult in his twenties whose life had been thrown into disarray by psychiatric disease. But there are some differences. The schizophrenic patient was far more active than the depressed patient, rocking back and forth the way some Orthodox Jews shuckle when they pray. And while his façade was inexpressive, we could tell when speaking with him that his mind was as active as ever. He stared, not lazily or vapidly, but intensely, as if analyzing each of our movements and expressions.

The hospital staff had taken the shoelaces out of his sneakers so he could not use them to strangle himself. He was not allowed to shave with a razor because of the risk of suicide. Not being able to grow a full beard, a five o’clock shadow grew only over his upper lip. His fingernails were cut and neatly blunted (again, a safety measure) and he had been wearing the same clothes for weeks. When he did get up, he simply paced around the psychiatric unit, occasionally muttering to himself as he stared at the ground. He ignored everyone else around him even though many of the other patients were manic, depressed, or bombastic. He believed that aliens were coming down from outer space and putting thoughts into his head; other ghost-like creatures told him to do “violent things” to himself. As he rocked back and forth he seemed to be entreating the voices to go away.

It is tempting when hearing descriptions like this to laugh. The claims are so absurd and so beyond the realm of normalcy that they drag us into the land of poorly made sci-fi movies. However, patients with schizophrenia sincerely believe in these sorts of delusions and hallucinations.

Schizophrenia usually occurs in younger adults and involves paranoid delusions, hallucinations (mostly auditory), social withdrawal, disorganized speech and other symptoms. Here is a video of a schizophrenic patient which gives a sense of the illness. The voices which patients hear demand, in many cases, that the patient hurt himself, leading eventually to suicide (the voices more rarely implore the patient to hurt others). Patients have no control over these and don’t comprehend that they are fictitious. These victims are secluded from reality and trapped by their minds.

The pathophysiology of this disease, as is true of depression, is not completely clear. But we do know that patients have an unusually increased amount of dopamine within the brain. Additionally, the brains of persistent schizophrenics shrink and the ventricles of the brain, which contain cerebrospinal fluid, enlarge. The etiology of schizophrenia is also complex, with genetic and environmental factors both presumably playing a role

Abandoned building from the Manteno State Mental Hospital,
Manteno, Illinois.
Image via Shutterstock
The prognosis can be devastating. In this case, a young adult in the middle of a budding career in academia could no longer work, attend university, or interact with fellow human beings. Fearful of violent outbursts his family had no choice but to place him in a psychiatry ward. According to the numbers, this is not a singular outcome. Only 15 percent of patients with the diagnosis eventually function again at their pre-illness level, while one third are severely and permanently debilitated. About 80 percent of patients with schizophrenia at some point in life also experience major depression, and substance abuse plays an important role in about 50 percent of patients.

The prognosis is not necessarily better for those who take antipsychotic medications, which block dopamine receptors in the brain. The treatments themselves can affect the patient negatively. Side effects from antipsychotic medications like OlanzapineChlorpromazineClozapine, and Risperidone include diabetes, decreased white blood cell counts, myocarditis (inflammation of the heart), tic-like movements, sedation, and neuroleptic malignant syndrome (a syndrome consisting of fever, altered mental status, and muscle rigidity). No wonder, then, that patients frequently dislike taking their medications.

The patient we saw on the psychiatry ward did not respond to any of these pharmaceutical options. In fact, no matter what medication he took, the voices continued to haunt him, telling him to do terrible things to himself. In an act of desperation we turned to electroconvulsive therapy (ECT, which I wrote about here). After the first couple of treatments, the patient improved slightly. But the illness quickly came roaring back. The attending physician proposed other combinations of medical therapies and more ECT. But at this point, we persevered in searching for treatments only to delay lifelong institutionalization and a helpless retreat to a dark world of nightmares.

Monday, November 24, 2014

In the Clutches of Depression

Oh, that this too, too sullied flesh would melt,
Thaw, and resolve itself into a dew,
Or that the Everlasting had not fixed
His canon ’gainst self-slaughter! O God, God!
How weary, stale, flat, and unprofitable
Seem to me all the uses of this world!
Fie on ’t, ah fie! ’Tis an unweeded garden
That grows to seed. Things rank and gross in nature
Possess it merely. That it should come to this.
Hamlet

I need not speak to him to know he is not well. A simple glance tells me all. The patient’s unshaven face wears no smile and, at once, no frown. His vapid gaze lingers longer than it should on various objects or people or nothing at all. The slippers, pajama pants, and torn t-shirt express the disposition of their owner, unkempt and exhausted. His visage is neither pale nor tan nor some variation on one of these — it is like a bare tree on a late and chilly fall day. His brow barely responds even when he speaks and his susurrant replies to our questions are scarcely audible over the ambient sounds in the room. In conversation he rests his hands on his knees, palms up as if hoping to receive something to make this all end. I can only claim that he exists in physical form.

We, the psychiatry team, confronted in this patient a true disease of the mind; unchecked and unmitigated depression, eating away at the soul and destroying its possessor. One doesn’t require the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association to diagnose this young father with depression. But if we wanted to, we could look through it for criteria on diagnosis and treatment of this disease. A diagnosis of Major Depressive Disorder requires five of nine specific symptoms, which include depressed mood, decreased pleasure, change in appetite, change in sleep, and others, present nearly every day for more than two weeks. This makes the diagnosis “official,” though the definition and the name of the diagnosis lack the descriptive power to characterize its severity (and perhaps also a crispness that one wants out of any definition). Algis Valiunas, a fellow at the Ethics and Public Policy Center and a contributing editor to this journal, points this out in a wonderful 2007 essay in The New Atlantis, “Melancholy’s Whole Physician.” He writes that the term “depression” was “never appropriately ferocious to begin with, suggesting a mere dip in the road rather than the sulfurous sinkhole that engulfs you and all you love and sends you into infernal freefall like the host of wicked angels, plummeting in terror with no end in sight, no hope of seeing the beautiful face of God again.”

Still, we’ve chosen “depression” as the name for it and unfortunately this gives a false sense of innocuousness to the whole experience. We also, frankly, overuse the term which may contribute to that perception. Whenever we feel down or something hasn’t gone our way we claim depression, as if getting a flat tire marks a trough in our lives. But to see someone truly depressed gives new meaning to the word.

There was no triggering factor for this particular patient. He had dealt with depression his whole life. He never attempted suicide but his illness waxed and waned, sometimes waxing so powerfully that he could not work, love, or live outside of the pseudo-security of a dark room under his blanket.

Nobody is sure about the exact pathophysiology of depression, but physicians suspect it has to do with an imbalance of neurotransmitters, small molecules that bind receptors in the brain affecting happiness, sadness, and desire. Specifically, depressed patients often lack the neurotransmitter called serotonin, which functions in many different biological activities including vomiting, memory, blood pressure, pain, and others. Therefore, psychiatrists often begin treating depression with an SSRI (Selective Serotonin Reuptake Inhibitor) as well as cognitive behavioral therapy, which in combination are better than either alone. SSRIs work by preventing neurons from absorbing serotonin after they have transmitted a neural impulse, which allows serotonin to remain active for a longer period of time. And there is a 60–70 percent response rate to initial therapy with antidepressants. Other medications can be tried if these fail, including multiple SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, and others.

After seeing multiple psychiatrists the patient had unsuccessfully tried many of these medications. Dr. Paul McHugh, former psychiatrist-in-chief at Johns Hopkins Hospital, describes the kind of hopelessness a patient like this feels when confronted with depression in a wonderful essay for Commentary Magazine. (A collection of his essays can be found in The Mind Has Mountains, a fascinating collection reviewed here in The New Atlantis). “You cannot choose for or against this disease. It chooses you, just as does epilepsy, cancer, or heart disease. It turns you into a stereotyped copy of every other person afflicted with it. You are not in charge of it, you are not to blame for it, and you can do little about it except seek the help that may enable you to escape its clutches.” When the medical help fails as it had for this patient, imagine the tightening of clutches, the sheer hopelessness compounded with the underlying pathology.

Image via Shutterstock
The next option for this patient was Electroconvulsive Therapy (ECT). This is an effective last-ditch possibility for some patients with intractable depression as well as some patients with schizophrenia. (I will write about a schizophrenic patient in the next couple of posts.) The side effects of ECT include some ephemeral cognitive decline and memory loss. Anesthesiologists sedate the patient and the psychiatrist hooks the patient up to a machine and sends a series of electrical waves through the patient’s brain. The response to this therapy, which is relatively safe despite the possible conception of it as some barbaric torture method, depends on the individual. Some patients respond and feel better after one treatment. Others may need multiple treatments. Psychiatrists don’t fully understand why this works. Also, ECT does not always permanently fix depression; it often merely gives a brief respite, sometimes half a year, before the disease comes roaring back.

And this persistence of disease leads to even more problems, as Valiunas explains in his essay — it actually causes anatomical changes that further exacerbate depression, a vicious cycle. Examples of changes include destruction of glia, which supply nutrients to neurons and clean up their garbage, and atrophy of the hippocampus and amygdala, parts of the brain involved in memory and emotion.
This, of course, is why treatment of depression is so important and it explains why this disease, as Dr. McHugh points out, is not due to some “great personal or moral flaw, one that can be corrected if only [patients] would not let their emotions run amok.” No, the disease is very real and vicious.

I don’t know if ECT ever worked for this particular patient because, as seems to be so common a trope in this blog, I left the psychiatry service before I got to see the procedure performed on him. But I cross my fingers that when I run into him again I won’t recognize him at all.

Tuesday, November 18, 2014

On Evidence-Based Medicine

Physicians throw around the term “evidence-based medicine” a lot. Whether it’s an antibiotic, IV fluid, or blood-pressure pill, the decision about how to use a drug often comes down to the question: is the treatment evidence-based? But what does that mean? Evidence-based medicine is “the conscientious, explicit, and judicious use of current best evidence in making decisions” about patient care. This definition suggests that clinicians or researchers fastidiously tested and confirmed the effectiveness of an intervention with a robust, replicable, and accurate scientific study.

Designing a valid study, however, is difficult because there are many potential biases that can render its conclusions inaccurate. Here are some examples:

  • Selection bias occurs when subjects are assigned in a nonrandom manner to different study groups. If a physician runs a trial to test the efficacy of a drug he may put those who have a better prognosis in the treatment group, as opposed to the non-treatment group. Consequently, scientists can claim this new treatment is successful even though it was tested on those who were most likely to improve anyway.
     
  • Sampling bias, where subjects chosen for the study do not represent the general population, can mean that a study’s findings do not apply to the general population.
     
  • The Hawthorne effect arises when subjects change their behavior because they know they’re being watched by a researcher or physician.
     
  • Confounding bias describes a situation in which one factor can distort the effect of another. If a researcher studies the effects of alcohol on health but ignores the fact that many people who drink alcohol also smoke, alcohol will appear to have a worse effect on one’s health due to the consequences of smoking.
     
Another kind of bias has been in the news a lot recently with regard to prostate-cancer screening. Here’s how Dr. Michael S. Cookson, a urologist at Vanderbilt University, describes this kind of bias:

Lead-time bias suggests that the natural history of the disease is not truly affected by screening. For example, a patient may be diagnosed with prostate cancer at 50 years of age through ... screening. He then undergoes treatment but ultimately progresses and dies at 60 years of age. Accordingly, the same patient without screening develops symptomatic bony metastases [late stage cancer] at age 58, undergoes treatment with androgen deprivation therapy, and dies at age 60. Thus, in this theoretical scenario, even though he was diagnosed 8 years prior through screening, his death was not affected by screening or early detection.

In other words, early detection of cancer makes it seem as if your lifespan is increased simply because you know that you have cancer for a longer period of time. But you don’t necessarily live longer because of that.

Image via Shutterstock
There are many other kinds of bias but the descriptions above give a sense of how difficult it is to design experiments without it. The most powerful studies account for bias with a double-blindedrandomized, and controlled trial. Participants and researchers are both blind in that they do not know who is getting the placebo treatment and who is getting the trial treatment. Participants must also be randomized to the treatment group or the placebo group — that way, there is no selection bias and there is less confounding bias. Controlled just means that there must be a control group, which is a group that does not receive the disease therapy or that receives the current best therapy for the disease. Researchers can then compare the effectiveness of the newest therapy to the current best available therapy. Another way to avoid confusing results is to use crossover studies, where a patient serves as his or her own control. The patient receives the real therapy for a given period of time and then receives the placebo for a given period of time thereby eliminating confounding bias.

A statue of Avicenna in Tajikistan
Nikita Maykov / Shutterstock.com
Interestingly, this approach to scientific studies, albeit a much less sophisticated version, dates back to the eleventh-century Islamic philosopher and physician, Avicenna. In his Canon of Medicine, a multivolume medical encyclopedia, Avicenna expanded upon the work of Galen, the ancient Greek physician. In her 2008 article “Islamic Pharmacology in the Middle Ages: Theories and Substances,” Danielle Jacquart explains that Avicenna endorsed the concept of using drugs based on past results of experiments:

As for the powers only known through experiment, these were not deduced from the qualities or the appearance of pharmaceutical ingredients, but they rather acted through their whole form or substance. Their action could only be revealed by an experimental test. Yet this did not mean that ordinary physicians themselves had to undertake such experiments. Rather, they relied upon experiments carried out by their predecessors.

Similarly, when today’s physicians choose, say, an antibiotic for a bacterial infection, they rely upon experiments carried out by their predecessors.

When I started medical school, I assumed that everything in medicine was evidence-based; that scientists rigorously studied and validated every treatment. After all, we should not treat a patient with a drug unless we know it works. But it turns out that there is not always evidence to support every decision physicians make. Perhaps a study has simply not been done or the evidence collected was equivocal or inconclusive. Or perhaps some real-life situation has arisen that is complicated in ways that could not possibly have been tested in an experiment. In these cases, physicians must base their decisions on experience.

Let’s take the example of IV fluids, which are a basic staple of medical care, as I’ve mentioned in multiple posts. One would think that the data would be fairly clear on which types of IV fluids are best. Unfortunately, it’s not at all evident. Some background: there are two major types of IV fluids, colloids and crystalloids. Crystalloids contain water and electrolytes that are similar to those circulating in the blood. Some examples of these are Lactated Ringer’s and Normal Saline. Colloid fluids contain water and electrolytes, too, but they also contain osmotic substances like albumin, which draw fluid into the vascular space. Fluid in the body can be inside the blood vessels or outside the blood vessels, and colloids keep fluids in the vessels.

Ostensibly, colloid fluids ought to work better in certain situations. For instance, when a patient has very low blood pressure, the way to increase blood pressure is to increase fluid within the vasculature. However two studies, one in the New England Journal of Medicine in 2004, and one in the Annals of Internal Medicine in 2001, concluded that there were no significant differences in mortality in various medical situations when using one type of fluid versus the other. So, barring significant differences in cost, which fluids does one use in the hospital when patients need hydration or increased blood pressure?
Image via Shutterstock
Given that the evidence is unclear, we use what our mentors use. During surgery rounds, for example, I asked “why are we using Lactated Ringer’s (LR)?” A resident replied that the evidence was inconclusive and the attending used LR so he used LR. Until we have better evidence, this seems completely legitimate even if it makes us uneasy because there’s no clear consensus. Furthermore, this demonstrates that though certain ideas may make sense in theory, they fail when standing against the test of scientific rigor. Thus, evidence-based medicine also requires open-mindedness.

Let’s also look at an example of how evidence-based medicine changes medical practice rapidly on a day-to-day basis. This past summer, the treatment for Parkinson’s disease (PD), a disease of certain neurons in the brain, underwent a change. Previously, movement disorder neurologists recommended dopamine agonists as a first-line treatment for the disease. The alternative is carbidopa-levodopa, a medication that is more effective at controlling PD symptoms. However, carbidopa-levodopa causes more side effects, such as dyskinesias, or compulsive and uncontrollable movements (some of these can be irreversible), the longer one takes the medication. And, given that patients with PD can live a long time, neurologists wanted to put off using it so that patients would not experience these effects so soon after starting medication.

But this past June, a study in The Lancet compared starting a dopamine agonist with starting carbidopa-levodopa in patients with newly diagnosed, early PD. And the researchers found that there is not a significant difference in patient-rated mobility scores (a fancy way of saying movement difficulties as well as quality of life) when starting with levodopa rather than dopamine agonists. I observed the direct practice changes as a result of this study. In the neurology clinic, the attending, after reading this article, changed the way he spoke to patients with newly diagnosed PD. Instead of saying that it is better to avoid carbidopa-levodopa first, he told patients that it was their choice what drug they wanted to start taking. This is a wonderful example of why evidence-based medicine and research is so important and how it can affect the practice of medicine — very concretely, very directly, and very soon after the research is published.

Monday, November 3, 2014

Pregnancy and Awkward Realities

I can’t think of a more awkward social situation for a single, twenty-six-year-old male to be in. A previous experience as the only Jew in a room full of Catholics singing songs about Jesus didn’t hold a candle to this. I was observing a group of fifteen pregnant women discussing pregnancy and getting pregnancy screening tests. Nurse practitioners run this group to aid and educate pregnant women who do not have enough money to pay for individual physician visits or are uninsured or even undocumented. Some of the screening tests, which occur at specified times during pregnancy, include maternal blood pressures and weights, labs to identify low blood counts, tests for sexually transmitted diseases that are a danger both to the mother and the fetus, ultrasounds of the fetus, dopplers of fetal heartbeats, fundal heights (a measurement of the top of the pelvic bone to the top of the uterus) to assess fetal growth, and more.

Image via Shutterstock
These tests provide obstetricians with abundant information about the health of the mother and the fetus. For example, a test for gestational diabetes determines whether the pregnant mother may have insulin resistance — a state in which she is unable to store sugar properly, which could cause the fetus to receive excessive sugar and grow too large, resulting in shoulder dystociahyperinsulinemia, and hypoglycemia at birth. Screening tests help physicians to identify these sorts of problems early enough to prevent complications.

Obstetricians also examine the cervix, which is the lower part of the uterus. It may be most helpful to think about it as the passageway between the vagina and the uterus. As females progress through childbirth the cervix dilates up to 10 centimeters to allow for passage of the baby from the uterus. The cervix effaces as well; that is, it shortens. Obstetricians check for fetal station, too, an assessment of how far down the fetal head lies in the pelvis — the range is -3 to +3, where +3 indicates imminent birth. They use monitors with probes to assess the fetal heart rate and uterine contractions. The fetal heart rate gives the physician a sense of the baby’s health status. If the baby’s heart slows down too much, the baby lacks oxygen, necessitating immediate delivery.

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The nurse practitioner performed these tests and more for each member of the group over the course of nine months. After some brief screening tests in this particular session, the women sat in a circle and played games. As the only male in the room, I had a difficult time participating in some of these. One game consisted of suggesting an object to bring to the hospital when it was time to have the baby and then listing all the objects the previous patients had come up with — one had to propose something new and remember what others had proposed. Some objects included: a fluffy pillow, baby clothes, a stuffed animal, an R&B CD, a scented candle (cinnamon), and others that I can’t recall. When it came around to being my turn, although I appreciated not being treated as just a fly on the wall I couldn’t help but feel at this moment like a knight in those scenes in Monty Python and the Holy Grail: “Run away! Run away!” I had the eyes of fifteen pregnant women on me. Some of them giggled, either with anticipation or, more likely, because my face turned red and I sheepishly grinned, declaring, “I shouldn’t be here.” I blurted out: “I feel like Arnold Schwarzenegger in Junior.” The reference was lost on every single person in that room; too young, I guess — or too terrible a movie to bother with. So I started to name the objects they had chosen, things that I probably would not take anywhere even if I did own them. I stumbled a bit but managed, with some help, to claw my way through it. When I then had to suggest an object I would bring if I were expecting, I said food. This was met with nods of approval. A love of food is one of those things that certain pregnant women and I share in common.

We next took a short break, during which the conversations mostly covered topics I couldn’t relate to: potential baby names (my only reference for that is this Seinfeld episode but after my previous pop-culture reference fell flat, I knew better than to mention it), pregnancy clothes, car seats, baby clothes, nail polish, and past episodes of morning sickness. I excused myself to “go to the bathroom,” which really meant “avoid the conversations and wander the halls until the break was over.” What else is a twenty-six-year-old male to do in this situation? This was so far removed from any of my experiences or thoughts. After the break, we watched a corny video about the process of giving birth — the acting was so bad that all the actors convinced me that they felt opposite what they claimed to feel. It was a nice time for me to check out mentally.

As ridiculous as this experience seemed at times, there is a deeper, more serious matter worth thinking about here. Many of these women were young enough to be in high school and needed a doctor’s note to excuse them from school. Some of them did not know who the baby’s father was; all except for two were unmarried; and many could not rely on anyone but a single parent for help. Sociologists have thoroughly studied the deleterious effects of these kinds of social situations. As Derek Thompson asserts in The Atlantic:

Among what you might consider “modern families” (e.g. the 61 million people married and living together, both working), there is practically no poverty. None. Among marriages where one person works and the other doesn’t (another 36 million Americans) the poverty rate is just under 10 percent. But take away one parent, and the picture changes rather dramatically. There are 62 million single-parent families in America. Forty-one percent of them (26 million households) don't have any full-time workers. This is something beyond a wage crisis. It’s a jobs crisis, a participation crisis — and it’s a major driver of our elevated poverty rate.

Indeed, Kay Hymowitz, the William E. Simon Fellow at the Manhattan Institute, writes in the Wall Street Journal that homes without married parents put children “at an enormous disadvantage from the very start of life.” Additionally, teen pregnancy itself causes a range of harmful consequences for both children and their mothers. The National Institutes of Health points out here that teen mothers are more likely to live in poverty, have infants with developmental problems, have baby girls who grow up to be teen mothers and have baby boys who grow up to be arrested and jailed. Furthermore, teen pregnancies have higher rates of illness and death for both the mother and the infant. Though the rates of teen pregnancy are dropping, the problem and its manifestations are evidently very real.

It is difficult to know what exactly the physician’s role should be in this process. How much should physicians encroach on the job of parents, who ought to address this issue with their children? When there are no stable parental figures in a child’s life, how much paternalism does the physician offer? Will such paternalism backfire? At what age is it appropriate to start speaking to teenagers (or preteens) about sexuality, reproduction, and parenting? And what is the best way to do it? Here’s the CDC’s anodyne take on it: “Make your clinic teen-friendly. Provide your adolescent patients with confidential, private, respectful and culturally competent services, convenient office hours, and complete information.” It’s not that easy, nor is it that benign.

The medical profession is unusual in that the private lives of patients are relevant to nearly every visit. Consequently, no matter how uncomfortable or awkward or humorous it may be for physicians, these issues inevitably come up. Undoubtedly, then, medical practitioners will play a role in this deeply significant sociological quandary — how large that role is depends on the physician and the specialty.

Monday, October 20, 2014

Labor and Delivery

The obstetrics nurses rushed the stretcher through the triage station as the resident tore out of her chair and followed them. I jumped up and ran with her. It was the second night of my obstetrics rotation and there was no time for triaging this patient, who was on the verge of giving birth. And because she spoke almost no English we could not get a history from her. If we had been able to, we would ask all about her gynecologic and obstetric history. Most importantly, we would ask if she had been screened for sexually transmitted diseases (STDs) which can be spread to the baby leading to horrific consequences including severe developmental disorders and death. The baby, though, came too fast for any kind of serious conversation, even with a translator. In women who have given birth before, like this particular mother, the birthing process goes much faster. Therefore, when a multigravid woman comes in and claims that the baby is about to come out, obstetricians immediately rush her into the delivery room.

Image via Shutterstock

We transferred the patient onto a bed, pulled out stirrups for her patient’s legs and detached the bottom part of the bed such that half of the patient’s derriere hung off its edge. As she opened her legs I saw the tip of the emerging child’s head, mostly covered in dried amniotic fluid, blood, and other bodily secretions. The resident, attending, and I quickly put on sterile gowns, gloves, and masks and, encroaching on the woman’s privacy (though she didn’t mind just then as she began to howl in pain with each uterine contraction), stood in between her open legs at the entrance to the vagina, our hands ready to catch the baby.

With each muscular contraction of the uterus, the baby inched further and further out into the world. The resident coached the mother, imploring her to push as she continued to scream. In a not-so-surreptitious manner, the father pulled out his iPhone as he stood by his wife’s head and hit “record” to document the birth of the couple’s third child. He wore an enormous childlike grin as he did so, aware both of his slight irreverence and of the imminent addition to his family.

After a few contractions, the baby’s full head emerged and the resident and attending supervised as I delivered the baby. My heart rate skyrocketed; I sweated, trembled, and attempted desperately to remember the childbirth simulation I had been through one week earlier.

The delivery of a baby is not all that complicated when it’s first explained (here’s a proper YouTube video of it — ignore the very corny soundtrack and beware the graphic nature of the video) but try doing it when the time comes and you freeze up very fast. In an ideal world, as the baby’s head appears, one puts pressure on it so that it does not pop out and tear vaginal tissue. Make sure the head rotates so that the baby faces the inner thigh of the mother (also known as external rotation). This rotation also allows one of the baby’s shoulders to emerge. Once that shoulder is out, tip the baby towards the exited shoulder to allow the other emergent shoulder to exit as well. If you try to get both shoulders out at once there is a danger of shoulder dystocia in the newborn — the shoulder of the infant sticks behind the maternal pubic bones leading to anything from transient nerve paralysis in the baby’s arm to compression of the umbilical cord cutting off oxygen supply to the child.

With the resident’s and attending’s hands near mine, I performed the delivery. As I angled the baby’s shoulders and allowed its body to exit the vagina, a huge amount of fluid gushed out — a combination of amniotic fluid, some blood, liquid mucus, and vaginal discharge — and soaked my shoes and gown. Ignoring this, I clutched the child to my stomach to prevent her from slipping out of my arms (not very smooth). You’re supposed to hold the baby in the left arm with the head in the palm and the body resting on your forearm, not clutch the baby to your chest. When babies are born they are frighteningly slippery though. And, fearful of dropping the baby, I used both arms and my abdomen to cradle the child, praying I would not drop her.

I held the neonate below the level of the vagina to allow the umbilical cord, which has vessels that carry oxygenated blood to the baby in utero, to drain all the rest of the blood into the child before cutting it. The resident clamped the umbilical cord on two ends, waited a bit, and then cut it. This prevents the two ends of the cord from bleeding. Simultaneously, the attending suctioned out the baby’s nose and dried off the baby with a towel. Newborns are prone to temperature changes so we dry them off and then wrap them in a blanket to keep them warm. The resident took the child from me and handed her over to her mother while the father continued to use his iPhone to record this remarkable moment. The mother bawled and even the father cried as his smile enlarged to one of complete and unreserved joy. Their perfectly healthy, new daughter held their rapt attention and despite the commotion around them, nothing distracted the parents from this life.

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The pediatricians arrived in the room, examined the baby for any malformations (none were found, thankfully) and placed her in a hospital crib. We continued to deliver the placenta, tissue which attaches to the uterus and allows for the umbilical vessels to exchange deoxygenated blood from the baby for oxygenated blood from the mother. It is semi-flat and looks very much like an alien organism — nonetheless it is crucial to the survival of the fetus. After the baby is born, if the placenta remains inside the uterus, there is a greater risk of infection in the mother. I gently tugged on the umbilical cord while I massaged the lower abdomen with my other hand. This helps coax the placenta out of the uterus and also helps to stem the bleeding from the uterus (uterine contraction is integral to cessation of bleeding postpartum). The placenta slowly plopped into my hands; warm, squishy, and bloody. I placed it in a plastic tub and began to clean up all the tools, gowns, and gloves when the resident got a call on her phone: another woman about to give birth two doors down. We rushed out.

Monday, September 22, 2014

When the Patient Becomes a Specimen

He lay in the hospital bed, belly-up, staring at the ceiling. We knocked as we entered and asked the patient a barrage of questions. How was he feeling? What doctors had he seen in the past? What other medical conditions did he have? When did he first start to notice uncontrolled nosebleeds? What other symptoms did he notice? An endless series of questions for a patient already overwhelmed with newly diagnosed leukemia, a cancer of white blood cells. As these cells proliferate uncontrollably due to bone marrow dysfunction, they crowd out other cells in the blood. Platelets, for example, which create clots to stop bleeding, decrease in number leading to spontaneous bleeding. White cells malfunction, allowing bacteria, fungi, and viruses to slip past the body’s floundering immune system. Patients with certain types of leukemia also develop an enlarged spleen, called splenomegaly. This occurs because the body looks for places other than the bone marrow to produce blood products. The spleen and liver are two organs capable of producing red blood cells (or once were during embryonic development). They enlarge in their attempts to compensate for bone-marrow failure.

Red blood cells.
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“Come over here and feel this,” the attending physician said to the three of us, all medical students, after interviewing the patient and performing a physical exam. “Is it alright if they feel for your spleen?” he asked. After the patient assented, the three of us, one by one, began to poke on the left side of his abdomen, palpating up and down and subsequently tapping and listening for when our taps became dull or tympanic. We searched for where the spleen began and ended. And there it was, a large, blown-up balloon inside the patient’s belly, squirming around as we attempted to assess its size through palpation. We stood in line, each excitedly repeating what the previous student had done. It was, after all, the first time any of us had ever felt splenomegaly. In this particular interaction we converted this human being into a test tube by observing, exploring, feeling, and assessing, detached from the reality of the patient’s experience.

We do this regularly during our third year of medical school — we violate patients’ privacy for the sake of our education. Part excited, part nervous, part sheepish, we come when called by our teachers to listen to lung sounds and heart sounds; to inspect wounds and infections; to feel for various organs, tendons, and muscles in living human bodies. Though this experience feels new and uncomfortable for us, it is worth noting that medical students have learned in this way — with a lot less regard for the patient — for quite some time.

In a 1946 issue of Now, a political and literary journal, George Orwell published an essay entitled “How the Poor Die.” In this essay we accompany Orwell, who in 1929 experienced a bout of severe pneumonia, through a frightening, dark, and even humorous tour of a French hospital he simply calls the Hôpital X.

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Orwell describes the admissions process: “I was kept answering questions for some twenty minutes before they would let me in.... At my back a resigned little knot of patients, carrying bundles done up in coloured handkerchiefs, waited their turn to be questioned.” From here, with a 103 degree fever, Orwell disrobed, put on a short hospital dressing gown and walked, without shoes, 200 yards outside on a February evening to his hospital ward. Unfortunately, his quarters were no better than the journey to them. There was a “foul smell, faecal and yet sweetish,” [my comments on hospital smells are here] and the room contained three rows of beds “surprisingly close together.” It seems, from Orwell’s description, to have been more of a mess hall than a hospital floor.

In the bed across from him, Orwell witnessed a patient undergoing a medical procedure: “a doctor and a student performed some strange operation on him. First the doctor produced from his black bag a dozen small glasses like wine glasses, then the student burned a match inside each glass to exhaust the air, then the glass was popped on to the man’s back or chest and the vacuum drew up a huge yellow blister.... It was something called cupping, a treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.” (A recent review of the efficacy of this treatment has shown the evidence for it to be largely inconclusive.)

Subsequently, Orwell, who ostensibly also required cupping for his illness, joined in the medical education as “the doctor and the student came across to my bed, hoisted me upright and without a word began applying the same set of glasses, which had not been sterilized in any way. A few feeble protests that I uttered got no more response than if I had been an animal.” And in his classically dark humor, Orwell notes, “I was very much impressed by the impersonal way in which the two men started on me.... It was my first experience of doctors who handle you without speaking to you or, in a human sense, taking any notice of you.”

On a daily basis, nurses woke the patients at five in the morning and measured their temperatures but never washed them. Orwell remarks, “if you were well enough you washed yourself, otherwise you depended on the kindness of some walking patient.” The doctor typically dropped by later with interns and medical students and “there were many beds past which he walked day after day, sometimes followed by imploring cries.” Only if there was a patient with some interesting medical illness or presentation would the doctors attend to them. The attention they paid Orwell was almost too much for him, with “a dozen students queuing up to listen” to his chest.

It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery.... You were primarily a specimen, a thing I did not resent but could never quite get used to.

Orwell proceeds to describe in great detail the other patients in the hospital, a potpourri of characters. We read about an older man who cannot urinate, and about a veteran of the Franco-Prussian War of 1870, dying as female relatives look on, “obviously scheming for some pitiful legacy.”

Then Orwell discovered a patient with cirrhosis of the liver due to alcoholism (a surprisingly common type of patient in hospitals these days, too). “About a dozen beds away from me was Numéro 57 — I think that was his number — a cirrhosis-of-the-liver case.” This patient’s liver was so enlarged that he was “a regular exhibit at lectures.” The physician lectured to the medical students on 57, describing the particular physical findings of someone with chronic alcoholism and an enlarged liver. The doctor felt for the patient’s liver and showed his students what it was like. “Utterly uninterested in what was said about him, [the patient] would lie with his colourless eyes gazing at nothing, while the doctor showed him off like a piece of antique china.”

Numéro 57 died in the middle of the night, although no one knew it until the morning. “This poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number, then a ‘subject’ for the students’ scalpels.” Orwell, as soon as he had gained enough strength, fled the hospital: “it was a hospital in which not the methods, perhaps, but something of the atmosphere of the nineteenth century had managed to survive, and therein lay its peculiar interest.”

Finally, Orwell offers an incisive comment on hospital medical care: “Whatever the legal position may be, it is unquestionable that you have far less control over your own treatment, far less certainty that frivolous experiments will not be tried on you, when it is a case of ‘accept the discipline or get out.’” Orwell directs his social critique at hospitals which treated and took advantage of the poor — forcing them into crowded quarters, ignoring their cries for help and even operating on them without anesthetic.

Despite the comparative pleasantness of my own experience in my medical studies, whenever I read this essay I wince at Orwell’s descriptions because of how familiar they are to me. The instances of the patient as a kind of specimen resemble in some remarkable ways the example I gave at the beginning. To be sure, we always thank a patient, ask if we can perform the appropriate physical exam maneuver, and acknowledge the patient’s right to refuse an exam. Nevertheless, we treat the patient as a test subject, which, however unfortunate, is necessary for our future profession. As patients we must ask ourselves whether we want to be treated by physicians who have never heard wheezes on a physical exam or never felt for an enlarged liver. Patients at teaching hospitals indeed make sacrifices for our education and for the welfare of our future patients.

Orwell also points out the patients’ abdication of privacy in the hospital. Unquestionably, this is accurate even today. When patients arrive, they put on a hospital gown, or uniform, depending on how you look at it. The gown is, humiliatingly, almost completely open in the back except for a meager string that, even after being tied, barely holds the back together. With the uniform on, they become hospital patients under the supervision and care of the nursing staff and doctors. Each patient has the same gown with the same color scheme. Each patient is similarly under our watch.

When we enter a patient’s room, the knock at the door is more of an announcement than a question. Overnight, patients are poked and prodded for their blood samples. How strange that even their blood seems to be property of the physicians, nurses, and lab technicians. Many patients are attached to an IV pole which holds bags of fluids and medications being pumped into their veins. And thus, they cannot get up without dragging hospital property along with them. Of course, the staff does not usually treat patients like hospital property; of course, patients can choose to leave at any time; and of course, patients are there so they can get better. Regardless, the situation is one in which a patient submits himself or herself to the hospital so completely that, inevitably, some aspect of the patient’s sense of privacy, independence, and humanness is lost.

Even taking all these similarities into account, Orwell's hospital experience is more of a nightmare from our perspective. But the parallels should give us pause. Has something of the atmosphere of the nineteenth century managed to survive even in the latest and best conditions? Must it?

Friday, September 5, 2014

The Costly Complications of Emergency Medical Care

During one Emergency Department (ED) shift, EMTs brought in an older woman to the hospital. She had called emergency medical services (EMS) and explained that she had low blood sugar, or hypoglycemia. Hypoglycemia can lead to coma, brain damage, and death as well as other more minor symptoms such as tremors and sweats. But when the EMTs arrived to pick this woman up, her blood sugar levels were normal — there was no emergency at all. In fact, as she admitted once she was in the back of the ambulance, she only called EMS because she had run out of glucose strips, which diabetic patients use to monitor their blood sugar. A family medicine doctor can easily procure these for a patient, and running out of these strips in no way constitutes a medical emergency. Once this woman got to the ED, the physicians drew her blood for labs, examined her, and measured her blood sugar again in order to make sure there was no emergency.

In another instance of misused resources, a middle-aged gentleman called an ambulance because, supposedly, he could not walk. However, the patient was able to get himself up from the stretcher and climb onto the ambulance, which his daughter said was normal behavior for him. He received a full workup in the ED with labs and x-rays. Similarly, a mother brought her son into the ED because he needed a full physical before playing sports. The ED physicians spent time speaking to the patient, doing a physical exam and drawing basic labs to look at his blood.

These kinds of situations occur daily — we squander emergency medical resources on non-acute medical conditions. Sadly, emergency physicians and EMTs do not have a choice in the matter, which can be disheartening in a system where resources are precious. And while there are many factors affecting inefficient emergency medical care, we have a law to blame for at least some of the daily inefficiencies — EMTALA (the Emergency Medical Treatment and Labor Act).
*   *   *
Congress passed EMTALA in 1986 with Ronald Reagan’s signature, ensuring, among other things, that patients requesting emergency medical care receive it regardless of their ability to pay. In a 2001 article published in the Baylor University Medical Center Proceedings journal, Dr. Joseph Zibulewsky puts the law in perspective. In 1986 and 1987, case studies from Cook County Hospital in Chicago described how other hospitals transferred patients to Cook County because the patients could not pay for their care, a practice known as “patient dumping.” The studies concluded, as Dr. Zibulewsky writes, that “this practice was done primarily for financial reasons.” In fact, “the reason given for the transfer by the sending institution was lack of insurance in 87% of the cases.” Moreover, the patients who were transferred were twice as likely to die as those who were not transferred. Nor were these isolated events: “This practice was not limited to Chicago but occurred in most large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983.” As a result of widespread patient dumping, EMTALA was signed into law.

EMTALA consists of three basic tenets all of which must be followed regardless of a patient’s insurance or financial status. First, any person who presents to the hospital for medical care must receive a medical screening examination (MSE) to ensure that there is no emergency medical problem. As the law reads:

if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition...exists.

As the examples at the beginning of this post illustrate, no matter what a patient comes in with, an emergency medical condition must be ruled out, so a medical workup must be performed. Additionally, the ED must “provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility.” In other words, the patient’s condition must be stabilized before discharge. If the hospital is not equipped to care for a particular medical condition, the hospital must transfer the patient to another hospital capable of providing the needed care.

And all this does not just apply to ED physicians. Any specialist consulted by the ED (in fields like neurology or psychiatry) must see the patient within 30 to 60 minutes of being called. EMTs are also beholden to this law. As Zibulewsky explains, an “appeals ruling in Hawaii has extended this [EMTALA] to virtually any ambulance, even those run by city or county services.” Thus, once a patient is in an ambulance, he or she “can be considered to have come to the ED.”

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Hospitals and physicians face stiff consequences for failing to abide by EMTALA. The law applies only to those hospitals and physicians who participate in Medicare, which nearly all of them do. And if the hospital violates EMTALA, reimbursements can be taken away. On an individual level, physicians can be responsible for up to $50,000 in civil court if they violate the law. Given how many hospitals and doctors receive reimbursements from Medicare and how much money hospitals receive from Medicare (hundreds of billions of dollars), it behooves institutions to follow EMTALA as best they can.

Unfortunately, the law is incredibly problematic for many reasons. In the first place, vagueness abounds: what counts as a medical screening examination? Is it just a physical exam? Is it just a history of the patient’s present illness? Must a CT scan be included? This is completely nebulous. Also, what counts as stabilized? If a person is bleeding to death with a broken leg and a physician stops the bleeding and casts the leg, can the patient be discharged without a follow-up appointment with a physician? If the trauma has left someone severely debilitated and is surviving only on a ventilator, is it now the hospital’s responsibility to find an acute care nursing home and continuous care for this patient? Does the hospital keep the patient in the ICU and eat the cost indefinitely?

Furthermore, the law adds population burden and financial cost to a floundering medical system. A 2008 article by Dr. Damon Dietrich and Dr. Michael Crapanzano concluded that while “EMTALA was intended to provide all patients the right of medical care in the ED regardless of ability to pay, a cost: benefit analysis performed by Duke University...suggests it did just the opposite.” Moreover, “EMTALA actually impedes access for an EMC [emergency medical condition] by overwhelming resource capacity.” Many people who come to the ED actually need emergency medical care, not just glucose strips. And putting time and resources into non-emergency care takes away resources and time from emergency care. Also, because care is “free” in the ED, patients have no qualms about coming in whether their problems are or are not acute. In turn, this leads to overcrowding. Some statistics, though not proven to be a direct consequence of EMTALA, demonstrate the severity of the problem. In 2001, “two out of every three hospitals reported diverting ambulances to other hospitals” due to ED overcrowding. Additionally, “ED visits in 2003 rose to 114 million, up from 97 million in 1997.” This overcrowding with uninsured patients costs the hospitals and its patients tremendous amounts of money. As a result, emergency rooms close, further exacerbating the problem of ED overcrowding. Between 1988 and 1998, 1,128 EDs closed, leading to dramatic increases in patient volumes and waiting times at other EDs.

Then, of course, there is the financial burden. An ambulance ride itself can cost over a thousand dollars. Also, the authors of the Duke study estimated that EMTALA has a net cost on hospitals, government agencies, and social welfare that runs in the billions of dollars. We thus have good reason to think that EMTALA places financial strain on our medical system as well.

But it’s not just patient care and hospital emergency rooms that are negatively affected by this law. According to the American College of Emergency Physicians, ED doctors “on average provide $138,300 of EMTALA-related charity care each year, and one-third of emergency physicians provide more than 30 hours of EMTALA-related care each week.” Unfortunately, ED physicians have no say in the matter — the federal government mandates that they donate their time and money. Some physicians are rightfully upset that they are not receiving compensation for the work that they have no choice but to do.

And yet, I support the idea of EMTALA. It would be callous to kick patients in need of emergency care to the curb simply because they can’t pay. As Avik Roy, health care policy expert and Opinion Editor at Forbes, has written in National Affairs, “There are some instances in which we should obviously consider more than economics: Certainly no wealthy nation should allow a destitute woman who has been hit by a car to die in the street. Likewise, in a pressing emergency, catastrophic care should be provided to those who need it, and the costs can be sorted out later.” Absolutely.

However, this law, a classic example of unintended consequences, is not the way to assure that care. It increases the cost, time, and population burden on the ED and also mandates that physicians give up their time and money to treat patients whether or not those patients need emergency medical care. And this is not just a partisan fight: political and healthcare activists of all stripes find this law deleterious and inadequate and have called for its repeal. But repeal of EMTALA seems distant as we try to sort out the effects of the Affordable Care Act. Nevertheless, if we cannot repeal it, we must improve upon it and rectify its effects as best we can to ameliorate patient care in the emergency room.

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Incidentally, the problems arising from this law also illustrate an important point about medicine and politics. Politics is not some drama playing out on a distant stage and leaving most of us unaffected; it affects physicians and patients — so at some point all of us — every day in very practical, tangible ways. Whether EDs or hospitals face overcrowding, closures, or mandated care, all roads lead through the workings of politics, a topic which we can’t ignore if we want to understand medical practice. As John Adams famously wrote in a letter to Abigail Adams, “I must study Politicks and War that my sons may have liberty to study Painting and Poetry Mathematicks and Philosophy.” Adams’s point, though meant for his generation, holds true for all of us. We must familiarize ourselves with politics and ideas — these affect every interest and every profession as all are confined and freed by law. Medicine is no exception.

Tuesday, August 26, 2014

Imagine

Imagine, for a moment, that your kidneys have failed. Perhaps you had longstanding, uncontrolled diabetes. Or, you might have had persistently high blood pressure (hypertension). You could not afford your medications, you refused to take them, or you never even visited your doctor and thus never knew you were sick. Whatever the reason, your kidneys no longer work.

Engraving of a section of a kidney,
from a medical journal edited by
Dr. Paul Labarthe in the 1880s.
Image via Shutterstock
But these two baseball-sized organs used to work so efficiently, even beautifully. They filtered out toxic compounds and electrolytes from the blood. These filtered-out, noxious materials then traveled through abundant yet minuscule tubes which were divided up into different parts like the Thick Ascending Limb and the Distal Convoluted Tubule. These tubes contained channels like Aquaporin and Sodium Potassium Chloride Cotransporter. In turn, the channels used various physical laws of concentration gradient, electrical charge, and chemical-bond energy and transported electrolytes and water into and out of this conglomerate of toxic compounds which eventually became urine. Amazingly, these small organs controlled your blood pressure, thirst, and hydration status — among many other vital aspects of life. The kidneys did this with such grace that you didn't even know it was going on.

Now, however, your chronic disease has destroyed these organs. Proteins, which shouldn't normally be in the urine, pour out of the body causing fluid buildup outside the vascular spaces. Proteins like albumin normally maintain fluid in the blood vessels by using osmotic pressure to draw fluid out of the extravascular spaces and into the vasculature. But when proteins disappear, this no longer occurs and fluid leaks out of blood vessels. Consequently, your legs and fingers swell with fluid, also known as edema. If your kidneys can’t even produce urine to excrete protein, edema still manifests. Without urine excretion, sodium and fluid accumulate in the blood and are eventually pushed out into the extravascular space.

Kidney failure affects electrolytes other than sodium as well. Potassium, for instance, is an electrolyte vital to muscle and heart function. But with kidney failure, your body retains too much potassium. With an excess of potassium (hyperkalemia), cardiac cells experience chaotic functioning potentially leading to cardiac arrest. Furthermore, your blood pressure, which depends on the kidney’s balance of electrolytes like sodium and chloride as well as hormones called aldosterone and renin (these involve the kidney in complex feedback loops) becomes higher and less malleable.

Other systemic effects include the inability of your infection-fighting cells to work as they ought to, a dysfunction of your body’s platelets which help to stop bleeding after you've cut yourself, seizures, shortness of breath, insomnia, inflammation around the heart, restless legs, muscle twitching, brittle bones, blurry vision, and death.

Is there a cure for this? What should you do now? You need a form of dialysis. If your kidneys can’t do all these things, a machine must do them for you. It sounds simple but it is no pleasant experience. First, the surgeons create an arteriovenous fistula in your arm so that the dialysis nurse can easily access your blood. The arteriovenous fistula directly connects an artery and vein mixing oxygenated and non-oxygenated blood. This is not flattering to the skin — the veins, because they now receive more blood flow, pop out and frequently look like blue worms squirming beneath the epidermis. Next, you must go to a dialysis center three times a week with dozens of other patients just like you.

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After you check in at the dialysis center, you walk into a long and expansive room filled with chairs next to machines that stand nearly four feet tall. The machines look complex and, at once, amateur. There are wheels inside the machines which spin next to each other like the wheels that spin an audio tape or a video tape from the 1990s. Long, clear tubing comes out from the machine, splits into two prongs, and attaches to needles which enter your arteriovenous fistula.

As you walk into the room you see all the other patients sleeping in their reclining chairs or watching TV in silence; their arms lie out on the small tables attached to the dialysis machines, as if in some opium den. That creepy feeling you experience as you walk into this large room is understandable but you’ll habituate to it. In order to get started, simply sit in an empty chair next to a machine. Offer up your arm with the arteriovenous fistula to the nurse and relax as the machine does all the work.

Dialysis replicates the actions of the kidney. Inside the dialysis machine, a semipermeable membrane acts as a strainer with microscopic pores, allowing substances like water, sugar, electrolytes, and urea to exit as the rest of the blood, now without toxic substances, is pumped back into the body. This takes some time — around four hours — so take a book or multiple movies for entertainment. Oh, don’t forget about the potential complications that can occur during this time: low blood pressure, itching, muscle cramping, headache, chest pain, heart arrhythmias, and possible seizure or coma. If you miss multiple dialysis sessions, you may expire. So don’t vacation anywhere without a dialysis center. And you should probably put yourself on a kidney-transplant list — you can join the 100,602 others who are waiting for one . Or, if you have the money, perhaps you can buy a kidney on the international organ transplant market . If not though, it’s okay, because we can continue to give you dialysis.

Tuesday, August 19, 2014

A Day in the Life, Part 2

This post continues my description in the last one of a day in the life of a medical student on rotation, where I've left off at lunchtime of an inpatient service day.

During the afternoon, the work of executing plans continues. If the team discharges a patient, that patient needs a follow-up appointment in clinic to make sure there are no complications from the hospital visit. We call up the outpatient clinics and schedule patients for their next appointments. In other cases, we need a patient’s hospital records from his or her previous visit to another hospital. Because electronic health records are usually closed within a hospital system, we have to request that other hospitals fax us medical information. This is a rate-limiting factor in getting complete access to lab and imaging results, which are integral to patient care. For instance, if a patient comes in with a severe headache and another hospital performed a CT scan of his head, access to that scan may be essential to ruling out a diagnosis of something serious, like a brain tumor or infection. And if we can’t get the images from the other hospital we may have to do one at our hospital. This is, undoubtedly, one of the major weaknesses of a non-universal electronic health record system.

The medical team may also discharge a patient to a skilled nursing facility (SNF) or an old-age home, in which case the facility needs documentation regarding what further care is needed. Some patients do not have anywhere to go after the hospital; some abuse alcohol or drugs and must go to a rehab program; some can’t pay for the oxygen they need at home or medications for HIV; others started taking a blood thinner called warfarin and need to schedule appointments at a lab to get blood levels of this medication checked. To deal with all this, the residents, attending, pharmacists, nurses, and social workers all coordinate with each other and with governmental and private organizations to get the patient where he or she needs to be and what he or she needs in order to stay healthy. The healthcare team takes on this Sisyphean task with varied success. Given the number of factors involved in this transition, one of which is whether the patient takes his or her medication, the result is not always ideal. I’ll write more about this later.

Additionally, the residents and attending physician sometimes admit new patients to the hospital during the afternoons from smaller hospitals in the community. Community hospitals are not always capable of caring for patients with a rare tumor or disease, while academic medical centers, which are attached to medical schools, have more physicians who specialize in and research rare disorders. For example, a patient having seizures that cannot be controlled with first or second-line medications is sent over to an academic institution where neurologists experienced in handling refractory seizures can care for the patient.

The medical team may also admit a patient from the Emergency Department (ED) for a full diagnostic workup and treatment of an acute or chronic disease. For instance, a patient with worsening Chronic Obstructive Pulmonary Disease (COPD) needs temporary high-potency medications for a few days before going back home. Some patients with an exacerbation of this disease need constant monitoring so they don’t experience respiratory failure. Clearly, then, the afternoons can get busy, especially if the residents have to finish their notes.

At 6 p.m., the night intern arrives and receives checkout from the day team: The day intern runs through a list with the night intern, describing the new admissions to the hospital service, the events over the course of the day for each patient, and which lab and imaging results the night intern needs to follow.

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Outpatient and the ED

The time that we spend in a doctor’s office — on our outpatient weeks — is a lot less hectic. Whether we are in family medicine, pediatrics, or obstetrics/gynecology clinic, we arrive at 8 a.m., which gives us time to exercise in the morning or stay up a bit later at night. The residents arrive at the same time. We look at the clinic schedule for the day on the electronic health system and begin to read old notes in the electronic health record to get ourselves up to date with the latest medical information on each patient.

When patients arrive, the medical student goes in first to interview a patient and do a focused physical exam, after which the student reports his findings and his plan to the resident, just like we do in the ED. The attending and the resident then see the patient and come up with a tailored plan for how to proceed. We have an hour for lunch at noon and then come back from 1 p.m. to 5 p.m. (This is similar to our ED shifts, since they are both eight hours — except of course our ED shifts are sometimes late at night or overnight, and there are no scheduled meal breaks during an ED shift.)

After our days finish, we are expected to do research on a disease process we saw during the day. If a patient comes in with pneumonia, we read up on the common causes of pneumonia and the various treatments available for it. We also study for our shelf exam, which is a national multiple-choice test that we must pass after each third-year rotation. At the end of pediatrics, for instance, the shelf exam tests us on pediatric illnesses and treatments. These tests are difficult and so we frequently study from various third-party review resources — Kaplan, UWorld, PreTest, Case Files, and others. A whole industry is built around these shelf exams, which eventually culminate in a nine-hour, eight-section national licensing exam called STEP 2 CK. This comprehensive exam tests basic clinical knowledge at the end of third year. So on a day-to-day basis we not only worry about learning how to deal with patients and their illnesses but we also study for our exams, which is a requirement that ensures we know the important information involved in our daily practice.

Thursday, August 7, 2014

A Day in the Life, Part 1

My editors here at The New Atlantis suggested I write about what a day is like for me and other members of the medical team. What exactly (aside from rounding) do we do all day? When do we have to be in? When do we leave? What goes on when we’re not rounding?

We can divide the third year of medical school into three distinct categories of rotations. There are inpatient weeks (hospital work), outpatient weeks (doctor’s office work), and the Emergency Department, or ED. The roles differ as do the schedules. I have already described a bit about how the ED works here. The hospital is for patients who need urgent medical attention or medical procedures. If a patient is having a heart attack, for instance, a cardiologist in the hospital will make sure the patient does not suffer complications from the disease process. Outpatient work, by contrast, involves less urgent medical problems, like adjusting blood pressure medications or prescribing antibiotics for an ear infection. Let me take you through a day on inpatient and outpatient medicine.

Inpatient

On an inpatient service the interns arrive at approximately 6 a.m. or, if on a surgical service, at 5:30 a.m., and print out a patient list from the electronic health record. This list of patients contains the patient names, chief complaints, possible diagnoses, ages, and other basic information of the patients we need to see. It contains a summary of tests and test results as well. It may seem a bit silly that physicians need a reminder about which patients they are taking care of; however, the hospital experiences quick turnover. A patient may be present for only a couple of days before leaving. Then, a new patient with a new history and a new problem takes his or her place. Additionally, when there are sixteen patients on the list it is difficult to keep up with every story.

Medical students arrive shortly after the interns (the residents are a bit like our supervisors, letting us know when we can leave and when we ought to come in). Given how early in the day we usually have to be in, there is little time in the morning to do anything but eat a quick breakfast while bleary-eyed before driving to the hospital in the dark. If we’re there early enough, we receive checkout from the night intern. The night intern goes through each patient on the list and discusses the latest news on each patient. Did the patient vomit? Did he or she have trouble breathing? What interventions, tests, or treatments were done? Additionally, if the night intern admitted new patients overnight, what is the story behind the hospital admission? These questions are vital to the care of each patient. If the day resident does not know, for example, that a patient was having trouble breathing or received an imaging study then the resident does not know to look at the results of that study, potentially missing a life-threatening problem like a collapsed lung or a heart attack. In an ideal world, the transition between resident shifts is so seamless that it is as if the day resident took care of or admitted patients during the night.

Subsequently, the interns assign medical students to “follow” one, two, or three patients (depending on how far along we are during our third year). Following a patient means knowing the vital signs daily and keeping up with the results of x-rays, CT scans, and lab tests. It also means we come up with a plan for that patient’s care and propose it to the attending and residents. In truth, the residents and attendings already know what they are going to do for the patient and our proposals are merely an exercise for our own edification.

After these assignments, we go through the chart on the electronic health record and read about the patient’s history. We read the night intern’s note on the patient and we look at the labs (tests) that the intern ordered. These notes give us a sense of what the residents or attendings thought the patient had and needed. For example, if the patient came into the ED with a fever and a cough, the notes will usually mention a workup and treatment for a possible pneumonia, or lung infection (which includes a chest x-ray, sputum culture, and empiric antibiotics). More importantly, students and residents look at the vital signs of the patients we follow. These indicate if the patient needs immediate treatment. Is the blood pressure too low with a fast heart rate and a high body temperature? This indicates a possible blood infection and we take blood cultures and administer antibiotics.

Despite the fact that the sun has not yet peeked through the hospital windows, we subsequently visit patients in their rooms to do a physical exam. We look at new rashes that patients have, listen to hearts and lungs with stethoscopes and perform neurological exams. We target our exam at the patient’s presenting illness. For a patient with pneumonia, we listen closely to the patient’s lungs for abnormal breathing sounds due to the infection. All this, of course, entails waking the patient up. And since residents, appropriately, will come in after us to make sure that we have done the physical exam correctly and that the patient is in no distress, we unfortunately wake the patient up at least twice during the early morning hours. This is separate from the instances where the nurses wake the patient up to draw blood for morning labs. Such is one difficulty of being a patient at a teaching hospital, something I will discuss in future posts.

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Once we’re finished seeing the patients, we have a little bit of time left before rounds start at 8 a.m. We look up information about the illnesses our patients have. We also write down the information we will need to present the patient to the attending physician on rounds. I’ve written a bit about patient presentations in this post, but in sum, our presentations report the relevant medical information and treatment plan in an organized and concise matter.

At 8 a.m., the attending arrives and we round on patients. Aside from the few patient presentation(s) we do for the attending we remain silent and watch and learn as I’ve described previously. Once we finish rounding we go over the patient list in the physician work room. We make sure that we all agree on the plans for each patient for the rest of the day. Some patients need to leave the hospital. Some need more IV fluids or medications. And some need an imaging study or a blood test.

After we’ve confirmed all of this, the residents write “notes” about each patient for the electronic health record. A note is similar in format to a patient presentation. It contains a brief history of the patient’s chief complaint and illness as well as the blood test results, imaging test results, diagnosis, past medical history, and past surgical history, as well as the treatment plan for the patient. These notes, though incredibly time-consuming, serve a valuable purpose. First, legally, the note can help protect a physician from future lawsuits. The note documents a physician’s train of thought and actions. It justifies the tests and treatments which patients receive in the hospital. Second, it is used for billing purposes by documenting what was done for the patient. And third, when the patient goes for a follow-up appointment with another physician in clinic, the note acts as a standardized form of communication to update the clinician on what was done in the hospital.

At lunchtime, medical students usually receive a lecture from a physician in the rotation. In pediatrics, for instance, we may listen to a lecture on pediatric respiratory complaints from a pediatrician. Meanwhile, the residents remain in the workroom or, if they’ve finished with their notes, they can grab a quick bite to eat in the cafeteria. Sometimes, though, the residents are swamped. They carry around pagers or phones, and nurses and other physicians page or call throughout the day with questions about specific patients. A patient may get a headache or feel nauseous and the nurse may page the resident to ask if it’s okay to give pain medication or antiemetics (medication for nausea or vomiting). Given that there are a limited number of residents, if multiple patients fall extremely ill and need medications, it can be difficult for the residents to respond to other more minor complaints. A cardiac arrest on the floor, for example, may prevent the resident from ordering pain medication for a patient with a headache.

More on a day in the life, in a bit...