Happy Chinese New Year!

Year of the Snake 2013 by ~WeijiC on deviantART

新年快乐！  恭喜发财！  身体健康！！

Happy Chinese New Year!  Tis the Year of the Snake.  I can't believe it's been like 4 months since I last posted.  So much has happened that I need to get caught up on!  Alas I'm on my surgical sub-internship and so hours are long, free time is limited (and what free time I do have I'm often too tired to care about posting stuff, haha).

But hopefully I'll get things caught up by the end of this month? . . .  Wishful thinking perhaps, but hey, it's a new year!!  :-P

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Anesthesiology: Vigil over Sleep

Falling Asleep by *tune4jack on deviantART

The ancient Greeks believed that the god of sleep and the god of death are brothers.  In anesthesiology, this isn't really too far from the truth.  Anesthesia is much more nuanced and complicated than simply putting a patient to sleep during surgery.  The science of anesthesiology has been honed over the decades to a delicate art, and is now one of the most regulated and safest branches of medicine.

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There are several distinct steps in anesthesiology:

1.  Pre-op: The anesthesiologist reviews the patient's medical record prior to surgery.  They will meet the patient and assess their airway (mouth and throat) as well as veins for IV access.

2.  Induction: The anesthesiologist induces sleep in the patient through one of several methods.  The most common are IV induction with propofol or inhalation induction with sevoflurane.  Once the patient is induced, the patient is typically intubated to protect his airway, paralyzed so the patient won't move during surgery, and given pain medication.  Throughout all of this, the anesthesiologist monitors the patient's vital signs closely and additional IV access may be obtained.

3.  Maintenance: The anesthesiologist maintains the patient under anesthesia usually with an inhalation agent (e.g. sevoflurane).  Vital signs are monitored for response to pain and surgical stimulus so medication can be given accordingly.  Breathing is monitored because it must be actively maintained by a machine while the patient's paralyzed.

4.  Wake-up: At the end of surgery, the anesthesiologist must reverse everything done to the patient (except the pain medication).  The patient's paralytic is reversed, anesthetic agents are turned off, and the patient slowly wakes up.  Vital signs are close monitored to assess the stage of anesthesia the patient is in, as extubating (removing the intubation tube) too early could be dangerous.

5.  Post-op: The anesthesiologist follows the patient to the post-op area and monitors for a few minutes during hand-off to the nurses, making sure the patient breathes adequately and pain is under adequate control.

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Most people go into anesthesiology because they enjoy 1.) procedures, 2.) taking care of patients in an acute setting, 3.) don't want to deal with the patient's chronic/social issues.  A select group of anesthesiologists pursue a chronic pain fellowship, turning heads on much of what likely drew them to anesthesia in the first place.

I've had the privilege of observing acute and chronic pain services in pediatric patients.  This particular acute pain service controls all PCAs (patient controlled analgesia) and epidurals in the hospital, and are the ones who wean patients off IV narcotics and transition them to oral narcotics and then wean them off altogether.

The chronic pain service was a different world entirely.  Each visit took up to 90 minutes and is conducted with a psychologist.  Pain is addressed in a multi-factorial manner - approaching it from a psychological, behavioral, and medical perspective.  A treatment plan may include CBT (cognitive behavioral therapy) to learn coping mechanisms to deal with/mentally lessen the pain, rehab exercises, and pain medication (rarely are narcotics actually given).

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Even though I will not be going into anesthesiology, the things and thought processes I learned will only make me a better overall physician.

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Infectious Diseases: Diagnosticians of the Weird

DISEASES by ~scythemantis on deviantART

Infectious diseases (henceforth called "ID") is one of three hospital services that is consulted when nothing else makes sense, the other two being rheumatology and immunology.  I was specifically on the pediatric ID service and, time and time again, I've seen these three services consulted on a patient when the primary care team scratches their heads and throws up their hands in frustration.

I came into medical school with a strong interest in ID, having just completed a year (out of two) of a Master's in Public Health in a Hospital & Molecular Epidemiology sub-program focusing on microbiology and disease transmission.  It's a fascinating field with strong ties to public and global health.  I think what attracts me most to ID is that you still have to know a little about everything.  Infections don't just affect one organ or a couple organs, it can involve any part of the body and so you really need to know enough about everything that's going on.  The ID attendings I've worked with are some of the most brilliant (even terrifyingly so) physicians I've ever met.

ID is mainly an inpatient consult service, and is thus consulted by the primary care team to help diagnose and treat things that may have an infectious etiology.  There are several things to know about how the ID team thinks:

Trends: ID is all about trends - trends in fever, inflammatory markers (CRP, ESR, etc), cultures, wound healing, etc.  Trends allow an ID team to see if the patient is suddenly doing worse or conversely responding to treatment.  Trends can also clue in an ID team as to whether the patient has something infectious or not in the first place.

Causality: By its very nature, ID seeks to determine a discrete cause for a disease.  They will question the patient/family for any and all exposures to find some clue in the history for why they're even being consulted.  They will go to some length to obtain cultures from blood, cerebrospinal fluid (CSF), sputum, pus, biopsies, etc to determine what organism(s) grow out of it which may be causing disease.

Proper Coverage: ID is fastidious about the drugs it employs for treatment.  The fear and bane of ID is when a bug becomes resistant to treatment (e.g. MRSA and certain antibiotics).  They are infuriated when other services immediately go for the "big guns" - the stronger medications known to treat a microbe - because overuse breeds resistance.  They are also annoyed when other services switch antibiotics too quickly because they don't see an immediate effect or "double cover" the same organism.

A Motley Crew: The ID team can be a mix of people you may not initially expect.  Of course there is the ID physician, but in addition there may be an ID pharmacist who helps dose and regulate the use of antibiotics throughout the hospital as well as microbiology pathologists who look at the cultures for the ID team (and who answer more readily to the ID service than the rest of the hospital).

Know Your Consult: When you consult the ID team (or any consult service for that matter), make sure you have a good intelligent question and reason for consult.  It should never be, "We don't know what this is, the kid is having a fever, please figure it out for us!" or "We think it's this, are we using the right drug?"  Rather you need to make a convincing case why the ID team needs to be involved - also, this is partly why the ID team usually only sees the most severe and/or bizarre cases, haha.

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Ordinary and Exceptional

Fight For Your Life by *darkcalypso on deviantART

On my flight to Chicago to take my USMLE Step 2 CS exam, I sat next to a pre-med.  She saw me open my review book and asked, "Are you a doctor?"  To which my reply is, "I hope to be soon!"

At one point during our conversation while waiting for the plane to take off, she told me a story about how her mom had received a liver transplant.  She had been fine seeing other patients hooked up to lines and machines, but when it was her mom, it was far more difficult to see.  She remarked, "I think one of the hardest things for me when I get to med school is to not be too emotionally attached to certain situations."

To this I replied, "No, it's a good thing to hold on to your emotions."  Emotions are what make us human and is what draws some (hopefully many/most) of us to medicine.  It's surprisingly easy to detach oneself from a situation, that seeing exceptional situations over and over again make them ordinary - but it'll always remain exceptional for someone.  I believe the moment we lose that attachment, the moment we become cold and treat the patient as "just another patient" or a "bag of symptoms," that is the moment we lose our raison d'etre - if you will - for medicine.  It's not called "the art of medicine" for nothing, as the art represents the human side of care.

Once I arrived in Chicago, I was at a McDonald's getting coffee with my uncle when I eavesdropped on a nearby conversation.  A man sat down across from some friends by coincidence.  They asked him how his wife (I think) was doing.  He replied that she's probably alright, she probably didn't have a heart attack and was just released from the hospital, and that they did a big work-up involving an MRI.  The friends gave their sympathies.

A small part of me ran through that in a purely clinical and almost mechanical way.  But most of me stopped to consider how frightening it must've been for this person, their friends, and the patient herself.  This was an exceptional event.  But we in medicine see this kind of stuff often enough that it becomes normalized and even ordinary.  We sometimes become unphased by the gravity of the situation.  Is this necessarily bad?  No, as it helps us stay calm and collected under stressful situations.  But I don't think we should shrug off our emotions entirely, rather we need to acknowledge them openly.

In a moment of reflection and Zen, I think we in medicine should ask ourselves: are we more healer or are we more diagnostician (doubtless we should strive to be equal parts of both)?  Do we let exceptional events become ordinary?  Or do we, despite the ordinary-ness that exceptional events become for us, openly acknowledge that they are exceptional - perhaps the most exceptional - event for someone?

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Family Medicine: A Holistic Balance

Balance by *BlackJack0919 on deviantART

Family medicine is often thought of as a "jack of all trades, master of none" branch of medicine.  And this isn't false.  Family medicine generally can't manage multiple co-morbidities in an acute setting, nor can they do much more than simple in-office procedures, nor are they as aggressive about pediatric issues or being as detailed/complete as a pediatrician.  But family medicine offers something else: a holistic balance.  During my time with my family medicine preceptor I've seen many things - things that are a natural continuity of what began in outpatient pediatrics.

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Whole Family Care

It was common for my preceptor to see all family members, from the newborn to the child to the parents and even grandparents.  The family physician observes and understands the intimate family dynamics between each member and, at one time or another, hears all sides of the story.  He is then able to practice medicine within the context of the family, utilizing other members where possible if needed.

There is a back-edge to this sword.  Sometimes numerous family members are squeezed into the same exam room to be seen in rapid succession - the child for a cold, the father for back pain, the mother for headaches, the grandma for knee arthritis.  It can be chaotic and frustrating, but one learns to flow through these moments with a smile and an efficient plan.  And through it all, the family gains a deeper trust and respect for the family physician.

Holistic Medicine

Now, when I say "holistic medicine" I don't mean alternative/homeopathic medicine, that which is outside the realm of the mainstream evidence-based medicine.  When I say "holistic medicine," I mean medicine that takes care of multiple aspects of a person's health.  My family medicine preceptor has a saying, "I don't want to give you my medicines if I don't have to.  Let's work on this together and see what you can do first.  Sometimes medicine is necessary, but let's not go there right away."  With every new patient, he'd spend an hour talking to him/her about their life, their concerns, what they want out of my preceptor's care, and lifestyle modifications that can stave off my preceptor prescribing medications.

With many physical complaints, my family medicine preceptor worked with patients to identify the problem and find some home remedies - often in conjunction with medication - to help solve the issue.  He was particularly astute in asking about herbal supplements.  He never dismissed what the patients were taking, but did often caution them as to how some supplements may interact with the medications he prescribed them or how another brand of the same supplement may be more trustworthy.  At times, he even referred patients to complimentary medicine practices such as an acupuncturist.

Work-Life Balance

More so than most other physician I had met, my family medicine preceptor actively stressed the importance of work-life balance.  He often reminded me between clinic visits to take a drink of water or eat a snack or take a moment to sit and just breathe.  He was proud that the flexibility in his hectic schedule still offered him plenty of time at home with his family.  He emphasized the need for us, as health care providers, to maintain a healthy lifestyle and to be an example for our patients.

He had a saying that he often repeated to me, his nurses, and his patients: "Have a good day.  Or not.  The choice is yours."  For many patients he utilized that as a means of motivation to help them get back on their feet and move forward in taking care of their own health - that we have a choice in how we begin each day, that our attitude about health matters.  Whereas in outpatient pediatrics reassurance and education are paramount, in family medicine it would seem motivation and helping patients reach a kind of self-determination is key.

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I understand that there are about as many different family medicine practices as there are family medicine physicians.  And for that reason I count myself very lucky to have been paired with a preceptor whose life values and medical philosophy match so closely with my own - nay, are steps above and beyond what I have come to on my own thus far.

As I move forward with my career, I must continue to take his words to heart and remind myself to slow down once in a while and take care of myself, so that I may take better care of those who need me.

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Life & Death

Life by ~Isilmetriel on deviantART

What an odd juxtaposition.  It was the day of my friend's funeral, the friend I wrote about in my last post.  A part of me demanded that I be there for the funeral but alas I could not.  I was on call.  My last ob/gyn call.  The least I could do was ask my dad to go in my stead.

And on my last ob/gyn call, I delivered and caught two babies.  One of them was to a woman I had seen in clinic almost weekly for the last 3-4 weeks, so she knew me well and was more than comfortable with me delivering her son.

What an odd juxtaposition.  A good friend leaves the world as two little babies enter the world.  Life and death always engaged in a dance.

Backlog: 05-08-12

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And The Dreamer Shall Dream Eternally

Jared,

I don't know who made first contact, you or I.  But I recall that we met the very first day I moved next door to you.  We became friends almost instantly.  Though you were 1 year younger than me, I always considered you my peer and one of my closest friends.

I remember the days when we'd run around in our backyards, absorbed in our imaginary worlds.  From Power Rangers to alien worlds to simply a game of tag, we would sometimes play all afternoon until after the sun set.  I remember you coming by to this one window in the back of my house when I was stuck inside studying.  I'd crack open the window and we'd chat for over an hour; I now marveled that you had bothered to stand for that long.  I remember when your brother, Taylor, and I came back from school one day talking about the alien worlds we had conjured up in class.  You eagerly joined in and became a crucial fabric of that made-up universe.  That day was the birth of your unfinished trilogy, The Ascension.

When I moved to the other side of town after 7th grade, our friendship cooled but never disappeared.  Those were the days of dial-up internet and email was not yet ubiquitous.  Months would go by before we chatted or hung out again.  Whenever we got together, it felt as if no time had passed.  We remained friends for over 20 years, ever since that day I moved in next door to you right before kindergarten.  There's something to be said for that.  Even till recently, months would go by without a word from you but we'd somehow manage to find a way to catch up . . . eventually.

You have always been a dreamer.  You dreamed of faraway worlds and stories.  You dreamed of goals and aspirations.  You had more imagination and creativity than almost anyone else I know.  And you were making your dreams reality.  You were one of the few people who could, with a word, reignite my creativity and passion when I had become too busy with my daily hustle and bustle.  There's something to be said for that.

I had envisioned us growing old together as life-long friends.  I hoped to see you reach the pinnacle of your career, and complete The Ascension.  I hoped to sit with you in retirement, on a beach somewhere, reminiscing of days gone by.  Alas none of this was meant to be.  You are a dreamer, and now you shall dream eternally.

I will miss you.  I will always carry my memories of you with me.  I will carry your passion.  I will not forsake the imagination and creativity of our childhood.  You are, and will always be, one of my closest friends.

Me and Jared at Taylor's wedding.

Jared Adam Radtke

September 19, 1987 to May 1, 2012

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