Year of the Dragon

Happy Dragon New Year 2012 by ~snowslotus on deviantART

January 23rd, 2012. Year of the Dragon. It came and went like any other day (partly because I was stuck in clinic from noon to 8pm-ish seeing patients). But I'm hopeful for good things this year. I foresee a year of change - whether that will be good or not remains to be seen.

Regardless of what's to come, bring on the year. Bring on the day!

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To Save a Life

On Saturday I was volunteering at a student-run free clinic. As an M3, I had an M1 and and M2 under me. They first gather a history and do a preliminary physical exam on each patient before I talk and examine them.

After briefly presenting to me, the M1 and M2 took me to see our first patient. He was a middle-aged guy who had been having nausea for the past 2 months. After talking to the patient for a bit about his history of hepatitis C, I move on to the physical exam. Per my routine, I begin by listening to his heart and lungs. Then I move to his face, eyes, and neck before asking him to lie down for an abdominal exam. I look for every sign of hepatitis and liver disease - jaundice, scleral icterus, spider angioma, etc - none of which he had, which reassured me.

Then I felt something odd. While palpating for his abdominal aorta, I found the edge of it pulse to the right of his bellybutton. I move to the left of his bellybutton and felt the same pulse of his aorta there as well. I move back to the right to double-check. I call out to the M1 and M2 to feel the edges of his abdominal aorta on either side. They confirm that they could feel the pulse on both sides. Eyeing the distance, I ballparked the diameter of his abdominal aorta to be about 4cm. He had an abdominal aortic aneurysm (aka AAA or "triple A").

This was an amazing catch! It's not every day that med students pick up on something so serious, and an AAA is a very serious matter. I ask the patient if he knew what an AAA is, and he said that his father and grandfather both died of AAA's around his age. Coupled with the fact that the patient smoked about 1/2 pack of cigarettes a day, this solidified the diagnosis in my mind. Immediate imaging was warranted to accurately determine the size of his AAA - not knowing its exact size, it might as well be a ticking time bomb inside his abdomen set to rupture at any point inside.

I reassure him that, because he was asymptomatic, he had some time and that we will figure this out. I further counsel him to reduce (and preferably/ideally stop) smoking, as smoking is a huge risk factor for AAA's. Also, smoking cessation can stop an AAA from growing any larger in some cases.

I walk out with the M1 and M2 to find a physician to assess the patient. While they do that, I move on to another pair of M1 and M2 students to see their patient. Later when I touch base again, I was glad to hear that the physician agreed with my assessment and plan. Although a CT scan is the most accurate way to determine the size of an AAA, the clinic didn't have access to "free" CT scans, and so we ordered an MRI for the patient. Really, it's kind of a waste of resources overall because in this case a CT scan is much better and cheaper than an MRI. But, we have to work within the limited resources of the clinic.

Talking to several M3's later, they were impressed that I had caught the AAA. They kept saying how I had, quite literally, saved this man's life. As much as I'd like to believe that, it didn't quite feel like I did. True, I had caught a potentially fatal condition early enough for interventions that would indeed save his life. But the imaging test we had to get for him was expensive and less than optimal, and we had to send him to a nearby hospital to get it done. For all I know, he may never go to the hospital to get the MRI. And even if he did get it, who will follow-up with him? Who will track the size of his AAA? Who will do the surgery when it reaches the dangerous size of 5.5cm? Would he survive long enough to make it to an emergency department if it were to rupture?

There were too many loose ends. This is the limitation of healthcare in the US - this patient is uninsured and we volunteer at a free clinic where continuity of care is fragmented. I may have the knowledge and ability to save this man's life, but he needs regular access to healthcare in order for that to happen. The academic and political discussions about healthcare are no longer abstract. Here is a patient with a life-threatening condition. It need not be so. But he doesn't have access to regular healthcare. Our hands our tied, our resources limited. And so, it remains life-threatening.

I hope he went to get the MRI. I hope it was far less than 5.5cm. I hope he stops smoking. I hope he is able to obtain health insurance. Right now hope is all I have to save a life. But it need not be so.

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Welcome to Life

Newborn by =bnspencer on deviantART

Welcome to life. I know you're tired and unfamiliar with this world, but open your eyes and see the love that has brought you here. Sleep in the arms that embrace you, linger in childhood while you can, but grow up healthy and strong. You are full of the world's hope and potential - anything is possible! What will you choose to be? You won't remember me, despite me prodding and poking you. But I hope my thoughts are etched deep into your heart: I wish you the best on this journey called life, and I hope you are equipped with the love and the help to get through anything. Welcome again to this thing called life.

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About a month ago, I had the privilege of rotating through the newborn nursery for 2 half-days. I had the opportunity to hold and examine a baby less than 48 hours old. His mom handed him over to me (in my mind practically throwing him at me), trusting me unequivocally that I wouldn't hurt him.

He peeked at me through suspicious eyelids before returning to his tenuous sleep. Of all the people to have examined him in his brief existence, he tolerated me the best - perhaps he liked me best. It's something special to hold a baby and not have him instantly cry at you to get away, but rather to tolerate you in a way that almost says, "I don't like what you're doing, but you're okay so I'll let you."

All the meanwhile the parents watch your every move, searching you for the slightest hint that their baby is not all right. The breath in the air hangs suspended as you move methodically through each motion designed to detect the slightest defect, the slightest indication that something may be wrong. And when you finish and everything is okay, the breath falls almost as a sigh of relief.

I read an article, A medical student experience in the newborn nursery, and it struck me just how true his account and his words resonated with me. I'm not sure I can even adequately express in words what it is like to have a family accept and trust you, a total stranger, to hold their newborn child. It's almost like holding unadulterated hope and potential in your arms - so fragile yet resilient.

My interaction with this child is but a flicker of time in his life ahead, mere minutes out of the potential years he could/will have on this earth. But all the same, it was truly an honor and a privilege to welcome him to life, in my own way.

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A Good Death

Death is something that someone working in the medical field will encounter at some point in his/her career. It's always curious how different people handle death. Regardless, people tend to have a difficult time dealing with death, primarily with "letting go." The questions I've quickly come to ask myself when faced with a patient on death's doorstep include: Is this what the patient would've wanted? Are we prolonging suffering, or are our heroics actually giving the patient another chance at life? Is this a good death?

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My first patient died on my 2nd month of medicine. He came in with a massive stroke. Even if he were to survive, his quality of care would be very poor. Knowing this, the family decided that he should be DNR (do not resuscitate). They kept him on life-support long enough for his son to call their entire family and they flew in from all over to be with him as he died. My attending put the patient on palliative doses of morphine and withdrew all machines. He died some hours thereafter.

My second patient died on my 2nd month of surgery. I had met this patient from the outset. He came to us in clinic with terrible pain - pain that every doctor he had seen up to now had failed to take away. We warned him that the surgery we'd do could have a mortality rate of up to 50% due to his co-morbidities. He understood and wished to either have this pain taken away or die trying. He did survive the surgery but he suffered several complications that involved further surgeries. As my resident foretold one day, "He isn't getting worse but he's also not progressing. If he doesn't get out of here, he will die here." Later that day, he coded and CPR was done for almost an hour before a pulse was found. He was rushed to the SICU (surgical intensive care unit) where he was later found to be in PEA (pulseless electrical activity). The surgeon called his daughter who made the decision to withdraw care that night.

The following morning when the other JMS (junior med student) and I were pre-rounding, we read his death note. The other JMS gasped, "What?! She withdrew care? His family killed him!" I was furious because to me, his daughter saved him from what otherwise would've been a week of agony in a painful limbo between life and death.

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Why did we go into medicine? For many of us, it's because we wanted to help people, to treat people, to cure people. We want to make people better. Death is an endpoint. Death is THE endpoint, and one that some can't accept. We defer the decisions to treat or withdraw treatment to the patient and/or the patient's family (or other power of attorney). If they ask for heroics, we comply. If they ask to withdraw treatment, we comply.

But we could do better by our patients. I read an article, A good death is a right we must fight for, that spoke directly about this. In there the physician agrees that, when there's a real chance, we must do what we can to treat/fix/cure patients. But we also have a duty to ease pain and suffering. Many patients on death's doorstep are in a state of pain and suffering that only death can release them, precisely because we don't have the ability to bring them back towards life to the point where their quality of life would be tenable. We have technology to keep lungs breathing and hearts beating, but we don't have the technology to magically make diseases go away.

That all said, the decision to withdraw care is not an easy one and definitely not one to be taken lightly. There is indeed anguish and turmoil within those who must make such decisions. On the healthcare professional side, we may see the obvious answer as withdrawing treatment. But it's not that obvious to patients and their families, and we sometimes forget that. This video reminded me of what it must be like to be in the position to make that decision:

My Friend Jason. from Shot at The Dark on Vimeo.

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This lead to another interesting and poignant discussion that I came across:

When Doctors Face Death

How Doctors Die

Both of those articles talk about how physicians choose to die. In general, there are no heroics or struggles against death, but an appreciation for a life lived and a peace with death. They choose to die on their own terms in conditions they wish to die in. I'll wager that few people want to die in a hospital. More likely, people want to die at home with their family around them.

After seeing patient after patient suffer in the ICUs, at first a burning fire in defiance of death that later becomes a cool ember of surrender, I've quickly come to understand the profoundness in the words of those 2 articles. After hearing death rattles, after watching a patient on death's doorstep twitch and seize uncontrollably - unable to speak or communicate, after witnessing the pains of recovery from a heroic surgery to buy more time, I've to realize that that's not what I want.

What I think we all way is "a good death." What that is exactly may slightly differ for each of us, but at its core it's likely the same: to die on our own terms in the conditions we wish to die in. Perhaps only after seeing death are we able to truly appreciate life and realize that death itself isn't the worst thing, but rather the conditions surrounding it. We have no control over death. But we often do have control - to a large extent - over the conditions in which we die.

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Pediatrics: Treating Disease, Safeguarding Health

Love is... The best medicine by ~hjstory on deviantART

Compared to either medicine or surgery, peds is yet another world in and of itself. Again, at it's core only the patient population differs from internal medicine. However, children are not just miniature adults. There are many unique diseases specific to kids, and this is true also of adults. Medicine manages disease and surgery fixes disease. But pediatrics treats disease and safeguards health.

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Treating Disease

Most diseases that affect children aren't chronic in nature and aren't due to lifestyle choices. Often, kids get sick at no real fault of their own. When a child gets pneumonia or gastroenteritis, you treat it and it goes away. These diseases aren't "fixed" as kids may get them again later, but they're not something chronic to be managed long-term, just nasty infections (kind of like getting a cold, only much much worse). Thus these diseases are treated.

That said, there are some chronic conditions that kids do have to deal with, most notably being asthma and ADHD - neither of which are results of lifestyle choices. Both of these are heavily monitored and managed by the child's pediatrician, and tweaks are constantly being made with the hope that the child may eventually come off medications altogether (usually in the distant-ish future of young adulthood). More troublesome diseases include Crohn's disease and ulcerative colitis, and these tend to be inherited.

Safeguarding Health

Pediatrics - particularly in outpatient peds - the pediatrician addresses the whole patient. This includes development, diet, exercise, school environment, home environment, exposures, stressors, etc. A pediatric patient is more than a collection of symptoms to be managed or fixed. A pediatric patient is a person in the context of his/her sociocultural environment. Really, this is nothing new or different compared to internal medicine, however, there is a much greater emphasis on this in peds. Pediatricians are well aware that habits (good or bad) developed early on have long-lasting implications throughout life. Thus they endeavor to instill good habits into their patients and their patients' families. As such, pediatrics attempts to safeguard health.

This notion appeals to me on so many levels. When I was on medicine, I saw a patient who was so obese that she got stuck in a CT scanner. I saw another patient who was even more obese, so much so that she was unable to even roll over on the hospital bed, much less walk (it was a wonder how they even got her in the hospital doors). But I see the kids of these patients and they are normal - not obese, maybe slightly overweight, but by all other accounts normal. And I ask myself, "How do those kids in less than 2 decades' time become their parents? Or aunts? Or uncles?" Pediatrics has the unique position of being able to intervene when intervention has the greatest potential impact.

To achieve this requires two key things: education and an emphasis on health, not disease. I read an article (here) where a medicine resident goes through a cardiology rotation and encounters a patient who was "non-compliant" in taking her medications. Apparently no one had educated the patient on her cardiac disease and the importance of taking her meds, they just assumed someone in the past had done so. That moment of clarity revealed a gap in which educating the patient, rather than assuming, would've resulted in better compliance. I read another inspirational article (here) that elaborates on why "being a good doctor is more than writing prescriptions." One of the physician's roles in the community is to inspire better health, not just attend to the sick - important and critical though that is. In pediatrics I see this role in public health played out most prominently. One sees it in vaccines, in telling parents what are good food choices for kids, stressing the importance of exercise, etc.

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Pediatricians work just as hard as medicine doctors or surgeons. The difference, to me, is in how they care for their patients. There is much less managing of disease. There is usually little fixing of disease. But there's a lot of treating of disease and on top of that, there is the role of public health in safeguarding health. There's something more holistic about pediatrics that I had not seen in prior rotations, and it may have been the first time that I treated every one of my patients as a person first and a patient second.

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