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.

Image via Shutterstock
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.

Image via Shutterstock

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.

Image via Shutterstock
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...

Friday, August 1, 2014

Physicians in Wartime

“Here is a hand-to-hand struggle in all its horror and frightfulness,” wrote Henri Dunant, a nineteenth-century international activist, in his book A Memory of Solferino. The book concerns the Battle of Solferino in June of 1859 between the Austrians and the French. Dunant describes the combatants “trampling each other under foot, killing one another on piles of bleeding corpses, felling their enemies with their rifle butts, crushing skulls, ripping bellies open with sabre and bayonet.”

An 1897 illustration depicting ambulance corps from
Russia (left) and England (right).
Image via Shutterstock
But amidst these horrors, Dunant gives us at least some hope in the form of the field hospitals. As a volunteer there, he points out that French surgeons did not rest for more than twenty-four hours, amputating legs and taking care of soldiers, eventually fainting from exhaustion. And this was not just done for French soldiers. Dunant observes that many wounded Austrians and Hungarians were “given the same food as the French officers, and their wounded were treated by the same doctors.” In the hospitals only the soldiers’ uniforms on the shelves above their beds, not the quality of the care they received, indicated which side they fought for.

After witnessing this, Dunant proposed that the international community establish relief societies composed of volunteers and sanctioned by a convention that would govern the treatment of the wounded during wartime. His proposal drew huge international support and on August 22, 1864, 16 countries signed onto the first treaty of the Geneva Conventions which, in its first article, reads that “Ambulances and military hospitals shall be recognized as neutral, and as such, protected and respected by the belligerents as long as they accommodate wounded and sick. Neutrality shall end if the said ambulances or hospitals should be held by a military force.”

Implied in this law is a principal far more ancient, one embodied in the physician’s Hippocratic Oath. In it, the doctor swears, “in every house where I come I will enter only for the good of my patients, keeping myself from all intentional ill-doing....” The physician, therefore, is responsible only for the good of the patient no matter what uniform that patient may wear. The Oath makes no exception for wartime or for the treatment of an enemy. Even if physicians disagree about who bears the blame for a conflict, they must abide by this ancient promise and its nineteenth-century ideological successor.

But what if one side in the conflict obstructs or prevents physicians from following this code? On July 23, during the latest war between Hamas and Israel in Gaza, more than twenty leading physicians and scientists from the U.K. and Italy sent a letter to the distinguished British medical journal The Lancet, claiming that Israel does exactly that. This letter is filled with accusations leveled against Israel regarding the political origins and conduct of this conflict, but I’ll let others in the medical field and outside the medical field cover that ground. There is one aspect of the letter I would like to address — specifically, the role of medicine in this conflict. On the basis of their “ethics and practice,” the physicians go on to claim:

As we write, the BBC reports of the bombing of another hospital, hitting the intensive care unit and operating theatres, with deaths of patients and staff. There are now fears for the main hospital Al Shifa. Moreover, most people are psychologically traumatised in Gaza. Anyone older than 6 years has already lived through their third military assault by Israel.
The massacre in Gaza spares no one, and includes the disabled and sick in hospitals, children playing on the beach or on the roof top, with a large majority of non-combatants. Hospitals, clinics, ambulances.... As we write, other massacres and threats to the medical personnel in emergency services and denial of entry for international humanitarian convoys are reported. We as scientists and doctors cannot keep silent while this crime against humanity continues....

Though there is death and destruction in every war, the physicians want to point out that Israel, and not Hamas, is particularly bad in trampling on the inviolability of the medical profession and its principled goal to care for all, Israeli or Palestinian.

And yet, this accusation glosses over some very important information. Financial Times reporter John Reed tweeted that rockets are being fired by Hamas from Gaza’s main hospital, Al Shifa. William Booth at the Washington Post reported that Hamas has been using Shifa Hospital as “de facto headquarters for Hamas leaders, who can be seen in the hallways and offices.” In another article in the Washington Post, Adam Taylor reports that the Israeli military targeted Gaza City’s el-Wafa Rehabilitation Center (after calling the hospital and telling them to evacuate), because they believed that rockets “were being fired from the vicinity of the hospital” and that there were “militants firing from the building.” In an al Jazeera article describing an Israeli attack on al-Aqsa hospital in Gaza, Israeli officials claim that there was a weapons cache near the hospital which the military was targeting.

There are those who doubt these reports. But Hamas has a history of doing this. The United Nations Relief and Works Agency (UNRWA) recently released a statement saying that its inspectors had found rockets, for a second time, in a UNRWA school for Palestinian children. As Adam Taylor points out in the Washington Post, “If Hamas is hiding missiles in schools, why not in hospitals?” And Hamas has a long track record of exploiting civilians and civilian infrastructure in this way. In an article for the New York Times in 2009, Steven Erlanger wrote that “Weapons are hidden in mosques, schoolyards and civilian houses, and the leadership’s war room is a bunker beneath Gaza’s largest hospital, Israeli intelligence officials say. Unwilling to take Israel’s bait and come into the open, Hamas militants are fighting in civilian clothes.”

And what of the Israeli hospitals? Israeli physicians recently treated the mother-in-law of Ismail Haniyeh, the leader of Hamas, for cancer in a Jerusalem hospital. Israeli physicians also treated, though unsuccessfully, the granddaughter of Haniyeh in a children’s hospital in Israel. Even as the fighting started, Israeli physicians were operating on Palestinian children with heart defects. As Dr. Akiva Tamir, head of pediatric cardiology at Wolfson Medical Center in Holon, stated, “It does not matter what side of the political map you are on. The parents of these children want them to live — just like parents [in Israel].” Indeed. And, as ABC News has reported, Israel opened up a field hospital at the Gaza border to treat Palestinians wounded in the conflict. CNN reports that Barzilai Hospital in Israel, which treats soldiers, civilians, and injured Palestinians, is “frequently hit by rocket attacks from Gaza.”

These facts make the letter from the international physicians and scientists incomprehensible: the signatories support an organization that defies the very principles integral to the job of the physician. While Israeli physicians hold to the oath of Hippocrates and to the principles of Henri Dunant, Hamas uses the very place where lives are supposed to be saved as a place to plan the end of human life. This renders their hospitals in clear violation of the original Geneva text: “Neutrality shall end if the said ambulances or hospitals should be held by a military force.” And the consequences have been devastating for Palestinians in need of medical care. Physicians, in the spirit of Dunant, must seek to treat enemies and friends, combatants and noncombatants. Hamas and its defenders are obfuscating this principle.