Family reunion

It was about 8 pm on a beautiful August evening.  I was a transitional intern enjoying a slow but steady stream of work in the Emergency Department when a new patient arrived.  He was a young man in his early twenties.  He wore a baggy t-shirt about three sizes too large and his jeans were sagged so low it looked like he might trip over them at any moment.  His hair was buzz cut and he wore a look of defiance and contempt on his face.  He had a couple gold necklaces on long chains and a few tattoos were visible peeking out from his sleeves.  His only other accessory was a pair of handcuffs.

I watched as a nurse took the kid and his police escort to one of the patient beds.  I had just picked up a new patient and was currently working up the maximum number that an intern was allowed.  This patient didn't look like he'd be much fun to be around, anyway.  I was happy to let well enough alone.

Some patients are loud and belligerent.  That's doubly true if they were just arrested.  This kid was no exception.

"You got it wrong!  It wasn't me!  That old lady just attacked me!" he was saying to the police officers.  The officers were unimpressed.

I decided then and there that if an old lady ever beat me up, I would not go around announcing it.

This continued for some time, the patient protesting his arrest and the officers ignoring him.  Watching from a distance, anyone could see there was nothing seriously the matter with this patient.  But some of us were having trouble putting together what appeared to be a fascinating backstory, so one of the nurses eventually called an officer over to ask what exactly had transpired prior to their arrival.

Evidently, an "old lady" (she was actually about 50) was just leaving a local 7-Eleven when this young paragon of virtue (and manners!) accosted her.  He demanded her purse, at which point she complied and asked if he'd also like a ride home.

Just kidding.

She actually responded by taking her purse and bashing him in the face with it.  He wasn't expecting a fight and this stunned him, so the woman got a couple more hits in before running back inside the 7-Eleven.  Our fine young gentleman was angry about all this.  In his mind, he had committed no crime since his attempted robbery was unsuccessful; moreover, he'd been assaulted (!) and humiliated (!!) in a public place.  So he decided to telephone the police.

When the police arrived, they took in the situation and were able to identify the guilty party without trouble.  The "old lady" (well, the kid used a different word for her but I doubt he'd actually ask a dog for its purse) had stayed inside the 7-Eleven since her would-be mugger was still loitering outside, so she had no trouble identifying him.  Apparently, being placed under arrest came as quite a shock to this fine young man, and he attempted to delay his own trip to the precinct by claiming he needed to be treated for his assorted scrapes and bruises.

By the time the police officer finished telling us the story, a decent-sized crowd of nurses, techs, and doctors had gathered around him.  We were all either doubled over laughing or gaping aghast at the stupidity of this young patient.  Whatever our reaction, we all figured the story couldn't get much better.

How wrong we were.

About thirty minutes after the patient arrived, a nurse came back from the waiting room with a similarly dressed youth in tow.  For simplicity, I'll refer to the patient as "Biff" and the new arrival as "Skippy."

Skippy came over to Biff's bedside in a huff, wide-eyed and frothy-mouthed at seeing Biff handcuffed to the gurney.  Like Biff, he couldn't understand why the police chose to arrest an upstanding youth rather than a violent "old lady."

"I saw the whole thing!" he exclaimed.  "She just attacked my cousin!  We wasn't doin' nothin' and she beat his face with that big purse!"

Several of us who had been watching this trainwreck unfold started snickering.  We knew what was coming.

"Wait, you saw this whole thing happen?" asked one of the officers.

"Yeah!" Skippy replied.

Dumb, dumb, dumb.

In short order, Skippy found himself handcuffed to a chair at Biff's bedside.  Apparently, the police don't like accomplices any more than they do perps.

Again, we thought we'd seen all there was to see.  Again, we were wrong.

Half an hour or so after Skippy's arrest, Biff Sr. arrived.  He wasn't quite as foul-mouthed as his son and nephew, but he was just as upset over seeing the two of them handcuffed next to each other.  He started to say so to one of the police officers but was cut short.

"Hey, I recognize you!" the officer announced.

Biff Sr. didn't like this and tried to avert his face while replying, "No, I don't think so."

The officer had a grin on his face.  "No, I know you!  Let me see your ID!"

Biff Sr. replied that he didn't have his wallet with him, but the officer called his bluff ("What's that chain going to in your back pocket, then?").  Then he tried to dodge by giving them his library card.  Undeterred, the officer clarified that he wanted a photo ID.  Biff Sr.'s reluctance to hand over his photo ID soon became clear: it turns out there were a couple outstanding warrants for his arrest.

And so it was that father, son, and nephew all got a chance to bond while riding together in the back of a police cruiser.  And we in the ED laughed heartily at their expense for weeks.

You can't make this stuff up, folks.

There is a fracture...

A couple years ago, someone made a video about Orthopedics and Anesthesia that went viral, especially among healthcare providers.  During the fall of 2010 when I was a new anesthesia resident, the video was at its peak popularity.  Physicians all over the hospital were quoting it (well, it and the always-hilarious honey badger video).

I was at the hospital having a very uneventful day doing ortho cases.  Young, healthy patients having simple, bread-and-butter arthroscopies.  The cases were so straightforward that the orthopods didn't even have anything to say to each other.  I would put each patient to sleep, then sit in my chair and do almost nothing for an hour or so.  Then I'd wake them up, take them to PACU, and start all over again.  Second verse same as the first.  Rinse and repeat.  It was a perfect recipe for boredom.

As the day wore on, I got feeling a little mischievous.

"There is a fracture," I announced from my chair.

In perfect synchrony, three voices on the other side of the drape dutifully intoned, "I need to fix it."  We all had a good laugh.

With all the headbutting and interdepartmental rivalries that can happen in a hospital, it's nice to have moments like that with our colleagues.  Times like that remind us that we may see the world differently, but we're all still playing for the same team.

Don't get any on you

In med school, I tried to get my hands on as many procedures as I could.  I was competing with residents, though, and they outranked me in seniority, knowledge, and ability.  Some procedures were denied me because they were sufficiently complex or risky that no med student should perform them.  Other times, I wasn't allowed to do a procedure because it was uncommon and this or that resident needed to do it to satisfy graduation requirements.  I was typically assigned procedures that were either simple, common, or undesirable, or some combination of the three.  There is never a shortage of subcutaneous abscesses to lance in the ED, for example, and most residents and nurses don't mind giving up a few IV starts.

Smart med students don't complain about being handed the dregs of their team's to-do list (or, as we say in medicine, "doing scut work") for a few simple reasons.  First, behind that "scut work" is a living, breathing patient, one of our brothers or sisters who has come to us for help and deserves compassionate care from an engaged physician.  Even the most disgusting or mundane task is an important part of that patient's care.  Furthermore, as sentient beings, we can (to some degree) manipulate or sublimate our own emotions.  We can choose to hate the scut or we can choose to love it.  Either way, the scut work has to be done; so why not choose to do it with a smile?

Second, medicine has a deeply entrenched system of hierarchy.  The level of abuse to which med students and residents are subjected has lessened considerably, especially in the past few decades, but it's still important for each member of the medical team to know his or her place in the pecking order.  Med students are not supposed to talk back to residents and residents are not supposed to talk back to attendings.  There is always room for junior team members to ask questions so that they may understand and emulate the logical reasoning and medical decision-making skills of their superiors.  Senior residents may even politely disagree with an attending's assessment and care plan.  But when a superior instructs a junior team member to perform a specific task, the only acceptable answer is "Yes, sir."

The third reason med students don't generally complain is selfish in nature (which is OK, in this case).  Interactions with their superiors become impressions.  Impressions become written evaluations.  Written evaluations find their way into dean's letters.  And dean's letters are of paramount importance when residency directors have scores of applications on their desk and need to separate the wheat from the chaff.

So, to any med students reading this: Be respectful of your residents.  And don't complain.  We know it sucks to be the low man on the totem pole.  But when you whine about it, we notice.

But that's enough soapbox preaching for now.

As a med student rotating on the anesthesia service, I usually asked the scheduler for a day or two when I could be out of the OR in order to practice starting IVs in the preop holding area.  In one day, I could easily start (or blow) a few dozen IVs.  Those also tended to be good days to catch up on some studying.

I was enjoying such a day during the last month of my third year of medical school.  It was late in my second anesthesia rotation, and I was getting pretty decent at IV starts.  I was even learning how to do them without getting blood everywhere.

My patient was a thin man in his late 40s.  The hospital gown he wore was, in some ways, a great social equalizer.  Each patient in the hospital wore an identical one, from the millionaire philanthropist to the homeless beggar.  But there were things the gown couldn't hide.  His eyes were sunken, his hair unkempt.  Those teeth he still had were yellowed and cracked.  There was a heavy layer of grime under his fingernails.  He appeared much older than his 48 years.  He bore unmistakable signs of poverty and years of self-neglect.

I wanted to help out the anesthesia resident assigned to this man's case, so I took a preop assessment form with me when I went to start his IV.  As might be expected, the man's medical care was sporadic and discontinuous, and there was little information to be gleaned from his medical record.  The patient didn't make my information-gathering job any easier, avoiding eye contact and answering many of my questions with shoulder shrugs.  About the only useful information I got from him was that he was HIV-positive.  As we spoke (or rather, as I spoke and he shrugged), I realized he was a man who had simply given up.

He held out his hand for me to start his IV.  Despite my burgeoning IV placement skills, I was still very uncomfortable attempting IVs on patients who looked like "hard sticks."  I was grateful to find that my patient had veins roughly the size of the Alaskan pipeline.  I tied the tourniquet, put on my gloves, and selected an 18-gauge IV catheter.  After numbing his skin with some subcutaneous lidocaine (I consider placing IVs without local anesthesia to be cruel and unusual) I placed the IV and took down the tourniquet.  The patient had watched all of this without a word.  He didn't even flinch or look away, as most patients do.  I placed my thumb on his vein upstream of the catheter to prevent it from bleeding back.  With the other hand, I picked up the IV tubing and then withdrew the needle from the IV.

As the needle came out of the catheter, it was followed by a single drop of blood.  My patient and I both watched as that drop rolled across the back of his hand and fell, landing on my knee.  With a completely blank expression, the patient looked me in the eye for the first time and said, "Don't get any on you, doc.  That's death right there."

To my credit, I remained composed as I hooked up the IV tubing, secured the IV, and cleaned my patient's hand.  I wished him an uneventful surgery and a speedy recovery.  As I parted the curtains around his bed to go change my scrubs, he called over to me, "Hey, doc?"  I stopped and turned back.  "Thanks for the numbing medicine.  I didn't even feel the IV."

In the four years since that encounter, I've thought many times about that man.  I wonder if he's still alive, or if AIDS or some other enemy has ended his journey.  I wonder if he managed to find hope.  I hope he at least found peace.

Medication allergies

Just about all medications cause side effects of one kind or other.  Sometimes they're not unpleasant, and some can actually be helpful.  Other times they're harmful or even deadly.  Patients tend to classify all unpleasant medication side effects as "allergies."

Most adverse reactions aren't true allergies, though.  For example, I know from experience* that morphine makes me vomit.  A lot.  That doesn't mean I'm allergic to morphine.  On the contrary, nausea is a known side effect of many narcotics (morphine and closely related drugs).  It can usually be controlled with medications.  But most patients who get nauseated from one narcotic or other will say they're allergic to that drug.  There are plenty of other medication "allergies" that doctors hear very commonly.

Examples:

- "I'm allergic to lidocaine!  The dentist injected it and my heart started racing!"  (Dentists use lidocaine mixed with dilute epinephrine.  If it gets injected into one of the copious tiny blood vessels in the mouth, the epinephrine causes an increased heart rate that can tell the dentist that the injection is intravascular.  This is a normal reaction; it means the epinephrine is doing what it's supposed to do.)

- "I'm allergic to (enter antibiotic here)!  It gives me diarrhea!"  (Actually, antibiotics often kill the good bacteria in our bowels as well as the bad ones that make us ill.  The absence of the normal gut bacteria leads to diarrhea.)

- "I'm allergic to (enter narcotic here)!  It made me really constipated!"  (That's another normal side effect of narcotics, just like nausea.  They stop stuff from coming out down below and make it come out up above.)

- "I'm allergic to (pick a drug, any drug)!  It didn't work!"  (Not sure I need to actually explain why this isn't a real allergy.)

Generally, doctors don't correct patients when they incorrectly claim to be allergic to medications.  If a patient specifies symptoms that are unpleasant but are not true allergies, we note the drug and the reaction and move on.  There are usually alternatives that prevent us from having to give patients the medications they dislike.  And if it's unclear whether a patient truly has an allergy to a medication, we would always prefer to err on the side of patient safety.  After all, some non-allergy adverse reactions can actually be life-threatening themselves.

As a fourth-year med student, I was on an anesthesiology rotation in a city hospital.  I had recently decided to pursue a career in anesthesiology and was excited to be on the rotation.  On this particular day, I was evaluating a pleasant middle-aged woman together with my attending.  I no longer recall what procedure she was having done, but I do remember the patient clearly.  She was an obese black woman from the inner city who looked like she would be right at home in a gospel church choir.  She was a sweet lady and my attending and I both liked her immediately.

"You're wearing an allergy band, Ms. Jones.  What medications are you allergic to?" I asked.

"I'm allergic to penicillin and lisinopril," she replied.

"What happens when you get penicillin?"

"Oh, I get a terrible rash and hives all over my body!"

"Mm-hm," I said, making a note.  "And what about lisinopril?"

I expected my patient to reply that lisinopril gave her a dry cough, a common side effect that isn't harmful but can be so irritating to people that they stop taking the drug.  But lisinopril hadn't made this patient cough.  With a look of horror on her face, my patient exclaimed, "It was so bad!  I got all swelled up like a mongoloid!"

Angioedema is a rare but potentially life-threatening side effect of lisinopril.  Further inquiry in the patient's medical record showed that she had, in fact, developed angioedema a few years earlier and had required intubation and ICU management.

My attending thought her description of the lisinopril event was hilarious.  For the rest of the day (and a couple days afterward), he could be heard in the hallways of the OR suite singing the lyrics from Devo's song.

*No, I haven't been naughty.  A doctor gave me IV morphine in the ER several years ago, before I'd even started med school.

Drugs?

A hospital never closes, but it does go down to bare bones staffing at night.  Some smaller private hospitals have few doctors in-house overnight, and some specialties aren't in-house at all.  Large tertiary care centers like the one I work at have virtually every specialty represented overnight.  The hospital is still running with minimal staffing, though, and the rules dictate that only urgent or emergent surgeries should be performed in the middle of the night.  That rule is important since we are a large trauma center and a major trauma case requiring immediate surgical intervention could arrive at any time.

Despite that rule, there are some surgeons who constantly want to operate at night rather than book their cases for the morning (Orthopedics, I'm looking at you).  I was once called by an orthopedic resident who wanted to book a case at 2:00 am.

"Who is the patient and what is the case?" I asked her.

"His name is Mr. Jones and he fell from a ladder.  He broke his right femoral neck."

"What else can you tell me?"

The resident told me what she knew of the patient's medical history (which was not much).  Fairly healthy man, mid-50s, apparently stable, closed fracture.  So far, it didn't sound like a case that needed to be done in the middle of the night.

"Why do you guys want to operate now?"

"We've got a few other cases scheduled for tomorrow so we'd like to get a head start on the day."

Not a great reason to go to the OR in the wee hours, but I asked for the patient's room number and the orthopedic resident gave it to me.  I reviewed the patient's chart and found a few other morsels the orthopedic resident hadn't mentioned, including an EKG that showed tachycardia at a rate of about 140.  Then I went to see the patient.

Mr. Jones was sitting in his bed and looking a bit edgy.  I introduced myself, then looked at the vital sign flowsheet.  The first thing that caught my eye was his blood pressure: 220/120.  It was a surprise he didn't have blood shooting out his ears.

Several things can cause a hypertensive crisis with significant tachycardia, but one of them is more common than the others, especially in a hospital in a big city.

"Mr. Jones, do you use any drugs?  It's important that you're forthcoming with me since that can affect your anesthesia and surgery."

"Sometimes."  He clearly didn't like this line of questioning but seemed resigned to it.

"Did you take anything tonight?"

"Yes."

"What was it?"

He looked around the room and said, "I took a little cocaine.  Smoked it."

I nodded.  It was exactly as I suspected.  "Mr. Jones, we're going to postpone your surgery.  If we proceed while you're still under the effects of cocaine, it could kill you."

The patient didn't have anything else to say so I left and called the orthopedic resident.

"Listen, we're going to cancel the case."

She didn't like hearing that.  "Why?!"

"Well," I said, "your patient is flying high on crack."

Silence.  Then, "Oh.  He is?"

"Yes, he is.  And his blood pressure is through the roof."

"Oh."  This had caught the resident by surprise; apparently her evaluation of the patient hadn't included a glance at his vital signs.  "Well, can't you give him a beta blocker?"

I wanted to bang my head against the wall.   Not only had she just proposed a treatment that would almost certainly kill the patient, but she had shown complete disregard for the professional liability she was asking me and my department to accept.  Tact, I'm afraid, abandoned me.

"Well, in a purely hypothetical sense I suppose I could give him anything I wanted.  But if you're going to have me give him a beta blocker, you really should have him sign a consent form for an autopsy first.  It'll save us having to wake his family this late at night."

The other end of the telephone was silent for a moment.  When the orthopedic resident spoke again, she sounded worried.  "You could give him something else for his blood pressure, though, couldn't you?"

Exasperation joined my anger.  She was still trying to find a way to do the case before morning.  "Look, let me break it down for you.  Your patient is high on crack cocaine.  His blood pressure and heart rate are out of control.  You've got him sitting in an unmonitored bed on the floor.  He is being completely mismanaged right now.  You need to move him to a monitored bed, either in stepdown or the ICU, and get his blood pressure under control.  You should only give him beta blockers if you want him to die.  If you don't know what else to give him, then you should consult Internal Medicine if you haven't already.  And when the drug has run its course, you should call Anesthesia to book your case.  But we are not doing the case tonight."

Sounding a bit rattled, the ortho resident replied, "We've already called our attending and he's on his way in.  You need to call him and tell him you're canceling the case."

I now understood the reason for her nervousness.  Her attending had been woken up in the middle of the night; surely he would be angry about losing sleep just to find that the case was canceled.  The orthopedic resident was trying to save herself the inevitable tongue lashing that would fall to whomever had just wasted the attending's sleep time.  Alas, she would not find salvation from me.

"No, you need to call him and tell him you failed to appropriately evaluate the patient.  This is your problem, not mine."

With that our conversation ended.  The orthopedic resident took my advice, moved the patient to the ICU, and got Internal Medicine involved.  When the orthopedic service called us a day later to book the case, the patient was sober and much more thoroughly evaluated.  He sailed through surgery and out of the hospital without further incident, although he did receive several strenuous admonitions to "just say no."

All in the family

When evaluating a patient, it's always important to take a good history.  A thorough medical history includes information about the present complaint as well as established medical problems, prior surgeries, allergies, medications, and family and social history.  The family history is often abbreviated or omitted, particularly during short clinic visits.  It's an important facet of the patient's medical profile, though, and it can often yield valuable information.

Sometimes the information it yields is less than helpful.

As a fourth-year medical student I once asked an emergency room patient for her family history.  I ran through the most common things, including hypertension, diabetes, cancer, cardiovascular disease, and stroke.

"Lots of people in my family with high blood pressure and diabetes," the young lady told me.  "Not those other things, though."

"OK.  Anything else come to mind?"

"Syphilis runs in my family, too."

Indeed.

Epidural hematoma

As a CA-1 (first year of clinical anesthesia training, second year of training after med school), I got called in the middle of the night by a floor nurse who wanted me to evaluate her patient.

"Doctor, my patient had a laparotomy a couple days ago and she has an epidural in place.  We turned off the epidural today at the patient's request, but I'm concerned she may have an epidural hematoma."

An epidural catheter, when properly placed, is positioned outside the dura, or membrane surrounding the spinal cord and cerebrospinal fluid.  Uncommonly, bleeding or infection may result from epidural placement.  If a pocket of blood or pus grows large enough to compress the underlying spinal cord, irreparable nervous system damage may result.  Needless to say, the first word that went through my mind was an obscenity.  It's not polite to say those, though, so all I said out loud was, "I'll be right there."

I ran up the five flights of stairs thinking about the radiographic studies I needed to order and dreading the prospect of waking up the neurosurgeon on call to perform emergency spinal decompression.  I arrived on the floor less than a minute after hanging up the phone.  Predictably, the patient's nurse was nowhere to be found, so I went to the patient's bedside alone.  The patient was sitting comfortably in bed reading a book.

"Ms. Smith, your nurse asked me to see you.  She's concerned about your epidural."

"Oh.  Well, I asked her to turn it off earlier because I wanted to walk around.  And I haven't been in pain so I didn't have her turn it back on."

"When was the last time you were up walking?"

"About an hour ago."

"Any problems?  Weakness or numbness in your legs?"

"No."

"Numbness or tingling along your inner thighs?"

"No."

"Have you lost control of your bladder or your bowels?  Or do you have pain in your back?"

"No.  I feel fine.  The surgeons even said I could go home in the morning."

I performed an examination of the patient's strength and sensation.  Everything was normal.  I thanked the patient for her cooperation and left to find the nurse.  I told her that I'd examined the patient and hadn't found anything amiss.

"What specifically made you concerned about an epidural hematoma?" I asked.

"Well, you can see it!  And feel it!"

The image at the top of this post shows fluid in the epidural space.  An epidural hematoma would occupy that same space.  It is not something that can be seen or felt.  Rather, it would be suspected due to the patient's symptoms and confirmed by MRI.  The nurse must have seen the skepticism creeping over my face because she motioned for me to follow her into the patient's room.  She had the patient sit forward and pointed at her back.  "See?  Right there!"

I looked at the patient's back.  Then at the nurse.  Then at the patient's back.  Confusion was replaced by abject disbelief.

"Nurse, that's one of the patient's spinous processes.  It's part of her vertebra.  We all have them."

The nurse who was old enough to be my mother looked at me the way she might if I had told her that the sun wouldn't rise the next morning.

"You're not worried about that being an epidural hematoma?"

"No.  It's part of her bone.  It's supposed to be there.  Have you never examined a patient's back before?"

With that, she went silent.  We stared at each other, she in shock that a young doctor would speak to an experienced nurse that way and me dumbfounded that an experienced nurse would fail to identify a basic, universal part of the human body.  After several moments I spoke again, giving her instructions that I have only given to one other person.

"In the future, please run all after-hours calls to the anesthesia service through your charge nurse first."

Beginnings

I've recently spent some time on the blogosphere looking at medical blogs.  Some of them I've found to be funny, others sad.  Some have been snide and others have been sensitive.  All of them have been insightful in their own way, though at times it's been the inadvertent insightfulness that comes by tactlessly relating a story that another person can connect to.  I've connected with many of those stories, and while reading them I realized I may have a few stories of my own that are worth telling.

I'm a senior-level resident anesthesiologist in a program in Texas.  I love my job and the diverse group of patients who entrust me with their lives.  I've often looked at my patients, asleep and intubated, and reflected on their utter helplessness.  That reflection has generated a profound sense of responsibility to do for my patients what they are powerless to do for themselves.  It's no mistake that the motto of the American Society of Anesthesiologists is "Vigilance."

My enthusiasm for my job and my patients, however, has been tempered to a degree by the utter inanity of many of the patients and situations that I must face.  It is very difficult to hold cynicism at bay while sucking beer out of yet another drunk driver's stomach in the wee hours of the morning.  But despite my moments of cynicism, I do not believe I'm a cynical person.  Snide?  Perhaps.  Wry?  Certainly.  But I still love what I do and the people I serve.

So it is that after much consideration I've decided to add my voice to the medical blogosphere.  My intent here is to tell my stories.  As a group, they are humorous, irritating, joyful, tragic, exciting, and mundane; but all share the commonality of being uniquely mine.  I just hope they're worth reading.