Another nightmare

Another mass shooting last weekend, this time in Las Vegas. Funnily enough, I had originally planned to go to Vegas this weekend. My bf had even asked for a day off from work so that we could spend a 3-day weekend together. But due to various circumstances, we elected not to go to Vegas after all. Thank goodness for that, as I don't think I would have been comfortable making the trip after the shooting outside Mandalay Bay. Having stayed at the Delano twice for SHM meetings, I was very familiar with the area around Mandalay Bay, including the venue where the shooting took place. And I couldn't help but wonder, what if something like this happened to me?

In my mind I saw myself lying in an ICU bed, on a ventilator, unresponsive to all stimuli, my head covered in bandages from a bullet to the head. Massive brain damage with no hope of recovery. I saw my parents at my side, then my sister and brother-in-law, and my boyfriend. Everyone is crying. My niece and nephew are too young to visit an ICU and I would not want them to see me like that anyway. I see my mother wailing, the way she cried when my maternal grandparents died. I see my father trying to keep his emotions in check, but even he cannot stop the tears from flowing down his cheeks. I see a representative from TOSA standing outside my room, preparing to talk to my family about organ donation. I had listed myself as an organ donor on my driver's license, and I have spoken to my parents about how I would want to be an organ donor if I died. I'd like to think that they would honor my wishes. In my mind I can also see my loved ones saying goodbye to me for the last time, but the mental image of this has brought me to tears myself.

This is not a far stretch of the imagination. Ever since our hospital became a trauma center, I've seen firsthand what humans can do to each other. A man who murdered his girlfriend in a nearby town became our patient when he turned the gun on himself and shot himself in the head. He did not survive, but before he died, TOSA was able to ensure that his organs would be harvested  and donated to others in need. I wonder who granted permission to harvest his organs. Did his parents agree to it as a way of making up for the life that their son took away? Who knows.

All I know is that I never want my family to experience the scenario I outlined above. We should not have to live in fear that violence will take our lives away, but lately this seems to be more likely a reality. And that's very sad.

Not taking life for granted

A lot of craziness happened this weekend. First a young singer from "The Voice" got shot to death, and now the mass shooting at a club in Orlando where 50+ people died. It just goes to show that no matter where you live in the world, no place is truly safe.

I learned early on that life can be cut short at any time. In my med school class alone, one classmate was killed by her husband, another died of cancer, and yet another is fighting cancer now, diagnosed with lymphoma around the same time she gave birth to her first child.  Hopefully she will do well with her treatments. And the patients I see, some go from healthy to dead within days, or even weeks. One memorable patient was an elderly dentist who came to the hospital because people told him he looked "yellow." He was diagnosed with pancreatic cancer, and less than 2 days later, he was dead after he developed a GI bleed and aspirated. It was extremely quick, and if there was any consolation to his family, it was that he didn't have to go through the prolonged pain and suffering that most patients do. He was healthy for all but 2 days of his life. Not a bad way to live and die. 

Then there are the dreams. I rarely remember my dreams after waking up, but there have been a few times in life where I'll be struck by a sense of deja vu and think, "I feel like I've been through this before." But I do remember my dreams about death, only because they were so vivid and disconcerting. There was one dream where I'm lying in bed dictating my will, and another where I'm looking down at my body, and I don't recognize myself because I'm so thin and emaciated from cancer. The latter dream left me shaken after I woke up, and it still scares me to think about it.

This is why I try to live in the moment. Why I have no trouble spoiling myself after a long day at work, or splurging on a new pair of shoes that I really don't need, or traveling long distances to visit my family and friends. I don't want to have too many regrets when I die, and when I die, I want to feel like I'd lived a life well lived.

Blast from the past

A few days ago, I had a near-encounter with my childhood bully.

When I was around 7-9 years old, I got picked on a lot in [language] school because I was one of the youngest kids in my class, and I was an easy target for my classmates. The ringleader was a guy about 2 years older than me and his father was the principal, so he probably got away with a lot of stuff. I won't go into detail what happened back then, but it usually ended up with me in tears (I cried easily as a kid). It was a miserable time of my life, and to this day I tend to avoid anything related to that particular church (and maybe church in general) because it was not a safe place for me at a time when I needed (and did not get) extra support.

We grew up, and while the bully and I still had mutual friends (and the same music teacher), we never really crossed paths again after junior high. One of my friends developed a crush on him at a region meet; I was quick to talk her out of it. I'd heard he'd gone out of state for college, but in my 4th year of undergrad, I ran into his mother on a plane on the way home from a med school interview. She then proceeded to tell me how her son was attending a prestigious medical school and was doing very well for himself, emphasizing his interest in research (which I personally did not care for). When I told her which medical school I got accepted to, she immediately cut me down, saying it was a horrible school and that I should withdraw my acceptance. Wow, really?

Flash forward nine years to 2014. My medical education complete, I was starting my 3rd year as a hospitalist when I learned that the bully had also begun practicing medicine in the same city as me.  My PCP belongs to a multispecialty clinic which sends regular email updates on any new hires; imagine my surprise when I opened an email which announced that the bully was joining the clinic as a medicine subspecialist! "You've got to be kidding!" I muttered out loud. Several other doctors in the vicinity asked what had happened. Not wanting to go into detail, I just said that one of my least favorite people will be practicing medicine across town. Some of the male docs immediately assumed that the bully was an ex-boyfriend; that's a laughable idea.

At that time, I wondered what would happen if I did run into the bully again. Would he even remember who I was? Was he ever sorry? Does it even matter, 20+ years later? We're all adults now, and people change. I can definitely say I'm no longer the crybaby that got picked on almost every week; in fact, people tell me that as far as first impressions go, I can be pretty cold until I warm up to you. Interestingly, not long after I saw that email, I had a dream in which the bully and I talked things over (don't recall exactly what), and at the end he said he was sorry. After that, I decided that I would no longer let him cast a shadow over me. Though we may live in the same city, the chances of us crossing paths was very low, and I put him out of my mind.

Then, while visiting my family over Thanksgiving, I recognized the bully's father when we went to one of our favorite restaurants for lunch. My dad recognized him, too, and while those two stopped to exchange greetings, I proceeded to my table without saying hello. I wondered if the bully was there, too, and suddenly I dreaded the thought of having to come face to face with him. Was that my inner child rearing her head? My dad returned to the table and told me that he saw and shook hands with the bully, and said that I should be polite and say hello, too.

I did say hello to his father, but when I saw anyone who even looked remotely like the bully in the buffet line, I turned my head and made myself invisible. Because even though it's been 20+ years, I had no desire to acknowledge his presence or speak to him. "Hate" is too strong a word as I do not waste time thinking about him and he is not worthy of whatever hatred I may possess; however, I think I can certainly say I dislike him for how his bullying affected me in the long run. Maybe I was a coward for avoiding him, but he has no place in my life, and I prefer to keep it that way.

Of course, there's still a slim chance that I'll cross paths with him again. And if it happens, I hope I'll be able to leave childhood hurts aside, and show that I've truly changed for the better.

Dangerous Skies

I used to never be afraid of flying but with all the recent airline disasters in the past year (most recently the recent deliberate crash of Germanwings 9525 into the French Alps), I can't help feel a bit anxious every time I set foot on a plane now. The latest reports suggest that the co-pilot of the Germanwings flight had a medical condition (depression?) that deemed him unfit to fly, yet his employers knew nothing about it. If his condition was really that serious, did his physician have a duty to report this if working meant putting other people's lives at risk?

I had a similar case approximately 2 years ago when I admitted an airline pilot to the hospital after he had a seizure during a marathon. His CT head was negative and he later got an MRI, but he left AMA before the results came back. He'd believed that dehydration was the cause of his seizure (he did have AKI but felt better after getting fluids) and saw no need to stay in the hospital. Usually when people leave AMA we don't follow up on their results, but the following day I looked up his MRI report and saw that he had a brain mass. I asked my partners what to do, and they said to call him and his PCP so that he could self-report to his employers that he could not work.

I called the patient at home and gave him his MRI results, telling him that he needed to schedule an appointment with his PCP so that he could arrange followup with a neurosurgeon. I further told him that he could not fly anymore and needed to tell his employers so. Then I faxed a letter to his PCP explaining what had happened, then called the PCP the next day to confirm that he'd gotten the letter.I was somewhat amused when the CMO of our hospital called me about a day after I spoke with the patient's PCP telling me I needed to notify his employers immediately of his diagnosis so that he can't fly. "Already done," I told him, and couldn't help but feel satisfied that I was one step ahead of him.

Within a month of diagnosis, the pt had his brain mass resected and was diagnosed with stage IV GBM. What happened afterwards I don't know, only that the craniotomy left him debilitated and he required extensive PT and OT before he could undergo XRT. I doubt he will ever pilot a plane again, but at least we were able to stop him before he potentially had a seizure mid-flight, and no lives had to be put at risk. Who can say what was going on in Andreas Lubitz's mind when he chose to fly the plane into the Alps. Committing suicide is selfish enough, but why take 149 other lives with you? Nothing about this case makes sense to me. I shouldn't have to wonder if my pilot is of sound mind and body before I board a flight; that should be a given.

Hospital Under Siege

Yesterday a cardiothoracic surgeon at Brigham and Women's was shot in cold blood on a routine day at work by the son of a patient whom he'd treated. We don't know the whole story yet; apparently there were complications and the patient (the shooter's mother) had died. No one likes to think that this could happen at their hospital, and yet it did happen, and at one of the nation's most prestigious hospitals no less. Needless to say it's shaken me (and several coworkers) to the core.

The concept of doctors getting attacked at hospitals is not a new one. I still remember the episode of ER where a schizophrenic patient stabbed two doctors, one of whom died and the other ended up addicted to narcotics. Then there was that episode of Grey's Anatomy where the disgruntled husband of a patient who'd died went on a shooting spree at the hospital in revenge. He, too, was targeting doctors, specifically the doctors involved in the care of his wife, and killed many people.  I remember watching that episode while on call in residency, and my classmates and I briefly discussed where the best places to hide were in our hospital. And yet when an earthquake struck the East Coast and the very room where we were relaxing began to shake, none of us knew what to do. We just sat where we were watching the closet door sway back and forth, wondering whether to evacuate or wait it out.

It did cross my mind once or twice to wonder where the safest place in the hospital would be if there were a shooter in the hospital. To reach another floor, you'd have to use the staircases; you need a hospital badge to get from floor to floor and if the shooter did try to enter a staircase, he's essentially trapped there without a badge. The physician's call room is code protected, but that's not safe either. Some of the nurses know the code and could be forced to give it up under duress. Not to mention once you're in there, there's no escape. The shooter could just shoot through the glass even if I did hide under the table or behind the couch. Then of course there's the random empty patient's room, but no matter how much I think about it, there really isn't a safe place in the hospital.

Then the next question: flee or fight? I'll be the first to say I'm a coward when it comes to confrontations, that when I see a ball flying toward me I'd duck before I'd try to catch the ball in mid air. And yet, I'd like to think that if it really came down to it, I'd fight back if I had to. It's not like I have zero training in self defense. I've been taking kickboxing classes for over a year; I know my kicks are more powerful than my punches, I know where to press my thumb into someone's throat to cut off their airway, and I know where to aim to bring someone to their knees. But what good is that against a gun, which could snuff out my life in an instant, as it did the life of Dr. Mike Davidson?

It's sobering to think that any one of us, if we pissed off a patient too much, could end up dead, injured or worse. I have no intention of letting fear take over my life, but I will be vigilant just in case.

Influenza

I cannot believe how insanely busy things have been since December. The influenza (and especially H1N1) epidemic has been horrible. I got my first H1N1 patient in early December, a 40-year-old woman with no history aside from smoking 2 packs of cigarettes a day who came in with full-blown ARDS and hypoxia.  She said both she and her husband had flu symptoms, but while he recovered, she did not, and ended up being hospitalized at a small country hospital for presumed pneumonia that did not respond to antibiotics. She got transferred to our hospital when it was clear she wasn't getting better. When I presented her to the pulmonologist, describing her symptoms (high fever, shortness of breath, some hemoptysis), he shook his head and said, "That's classic (for H1N1)." When I asked my patient if she would consent to being intubated, she gave me the thumbs-up, then proceeded to spend the next 10+ days on a ventilator. Fortunately, she was one of the lucky ones, and she was able to go home on Christmas Eve.

Another of my patients, a 68 year old man who was still climbing on roofs working as a carpenter, came to the hospital c/o a 1 week history of cough, fever, sore throat and generalized aches. Because he only had hyperlipidemia, we initially treated him for community acquired pneumonia. The next day, I walked into his room and said, "Hello, Mr. ___, how are you doing---whoa!" The reason for the exclamation? There was a LARGE hunk of bloody mucus sitting in a basin that he'd been spitting into. With my other H1N1 patient fresh on my mind, I called pulm immediately. Sure enough, he had H1N1, and he ended up on a Rotaprone bed for at least a week. Eventually, however, he recovered, though he's now so debilitated, both physically and mentally, that he got discharged to a nursing home after a 1 month hospitalization. Of course, it could have been worse. He could have died.

Fever. Cough. Hypoxia. Hemoptysis. "Fluffy" chest X-ray. Anytime I see 3 or more of these characteristics in the same patient, I immediately think H1N1 until proven otherwise. And even then, sometimes the H1N1 PCR is negative. Doesn't matter; if it acts like H1N1, we treat it like H1N1. I had two patients who tested negative for H1N1 but had the classic presentation. Both were spared intubation, fortunately; one guy recovered enough to go home after a week, while another remains in the hospital 3 weeks later on high F1O2. It's amazing how the same virus affects different people in different ways. When I walked through the ICU, I was struck by how young some of the intubated patients were. One thing they had in common: they didn't get their flu shot this year.

In our hospital, most of our sickest patients were women in their 30s-60s, often overweight, diabetic, or worse, pregnant. We've had 3 pregnant H1N1 patients come through our ICU. The first was a 30-year-old who denied being pregnant on 2 separate occasions; only after she was intubated did her family inform us that she was, in fact, pregnant. A stat ultrasound showed she was 31 weeks along, and because she was so unstable (and on a Rotaprone to boot), her ICU room was turned into a makeshift OR and she had an emergency C-section. Her baby survived, though she did not; she was transferred to another hospital on ECMO several days later and ended up dying. The second pregnant patient was only about 25 weeks along; they put her on ECMO and got to the other hospital, don't know how she did. The third, a woman in her 40s and 25 weeks pregnant with her 5th child, initially got admitted for DKA but almost immediately became septic while in the ED. The baby was delivered via emergent C-section but did not survive. The patient lasted about 3-4 days maxed on 5 pressors before she, too, succumbed. The last case in particular was very tragic, as the H1N1 hit that poor woman hard and fast, and her family lost both her and her child.

The news recently something along the lines of how 9 people so far have died of the flu in our city alone this year; I think the number is probably much greater. Even the pulmonologists said that this winter has been the worst H1N1 they'd seen, even worse than 2009. As a result, our hospital beds are almost always full, there's almost never room in the ICU and IMC because so many people are on the vent, and the doctors are overworked and overwhelmed. Me included.

One of these days, I got to start taking care of me. Otherwise, I don't know how long I can keep doing this.

Judgment and Faith in Medicine

 One of the challenges of being a physician is making decisions with regards to a patient's care and well being. The decisions we make are oftentimes derived from both our training and the lessons we learn in residency and in the workplace. And sometimes the choices we make are not easy.
Two nights ago I was asked to admit a patient who had a syncopal episode in front of his daughter, got intubated at an outside hospital, and then transferred to my hospital for stroke workup and management. By the time he arrived at the ER and I got to see him, he was wide awake, following commands, and able to respond to simple questions by nodding or shaking his head. His chest X-ray was clear, and his ABG looked great. He looked like someone who could be extubated on the spot, and his RN agreed he looked like he could "fly," the term we use for patients who do well post extubation. The question: since the patient was in the ER, who makes the call regarding extubation?

I initially spoke with the ER doc who admitted him, saying that he was awake and alert (which he was NOT when she saw him), and suggested that he could be extubated. Unfortunately for me she was dealing with an acute CVA at the same time, and after speaking briefly to my patient's family, she said that because she didn't know why he became unresponsive (drugs, MI, CVA, etc), she was not comfortable extubating him in the ED. As far as she was concerned, he would remain intubated until he got to the ICU, where she wouldn't have to deal with him anymore.

I saw things differently. Whenever I did MICU rotations in residency, one of our attendings always ran through a checklist on each patient to see whether or not the patient still needed to be in the MICU (if not, call them out) or, if they were intubated, whether they could be extubated. My patient was awake and alert, and his chest X-ray was normal. I didn't know why he passed out, but I thought that most likely he was intubated prematurely. I was nervous, too, about extubating him in the ER with the possibility that he would crump shortly afterwards, but no matter what I couldn't justify sending this man to the ICU on a ventilator to spend the night in a propofol-induced sleep , then consulting pulm-crit in the morning just to extubate him. In the end, I had to go on faith, and believe that this man would do well. Taking a deep breath, I wrote the order for RT to extubate him.

I stayed in the ER and kept a close eye on the patient as RT extubated him, and his SpO2 was 97% on room air! He was placed on nasal cannula and was able to answer a few questions for me, saying that the last thing he remembered was talking to his daughter. He was able to move all four extremities, and the house supervisor asked, "You still want him in the ICU?" Not anymore. He was admitted to our IMC instead, which was good b/c there were only 2 ICU beds left in the entire hospital. In fact, I later learned that he was discharged home today.

So what did I get from all this? I had thought that the ER doc was too "chicken" to make a call regarding extubation, but now that I think about it, this was uncharted territory for her, too. Not many people come to our emergency room already intubated only to be extubated while IN the emergency room. In fact, I don't know how many of my partners would have made the call to extubate in the emergency department. Was I being too daring for my own good? I reviewed the case with a pulm-crit attending, and he assured me I'd made the right call. Thank goodness. I just hope I continue to make the right decisions throughout my career.

Patient Confidentiality

Back when I was in residency, I had an HIV positive patient whose wife was unaware of his HIV status (apparently he didn't find out until AFTER they got married), and he refused to let anyone tell her. He'd tell his doctors that he was going to, but then never would. He would never want to answer any of our questions as long as his wife was in the room, even if it was for something non-HIV related, like how his chest pain was doing. To be fair, he took his HAART faithfully and his viral load was undetectable, but even as an intern the hypocrisy of the situation was not lost on me. He was one of the patients that no attending in the hospital wanted to accept just because he was an ass (that must be true only of teaching hospitals because in the real world we usually aren't supposed to refuse patients), and I wonder if his wife ever found out.

I'm now caring for another HIV patient whose parents don't know about his status. He'd developed a bad case of PCP, but before intubation he made it clear that his parents were not to know that he had HIV. I've seen his father fervently praying over him and wonder what sin he committed to acquire AIDS (most likely premarital sex with an infected male/female, given his age), and wonder how unforgiveable that truly would be to his parents.  I don't know what to say when his parents ask why he's not getting better and why his pneumonia just isn't going away. Can't exactly say, "Well, Mr. ___, your son doesn't really have much of an immune system because his CD4 count is one of the lowest I've ever seen in my career." Can't be judgmental when the guy's so sick, but I wonder what the end point is. If he should die, do I let his diagnosis go with him to the grave? The Tarasoff ruling allows us to break the shackles of confidentiality when there is intended harm towards another, but what am I supposed to say if this guy ends up dying and his mother asks why? The things we deal every day...

Fullmetal in the hospital

A few days ago while I was working in the ER, I was borrowing a nurse's computer to print out a patient's vitals when I spotted the name "Edward Elric" on the list of patients in that part of the ER. Almost immediately I burst out laughing. For anyone not familiar with anime, Edward Elric is the main character of a well known anime series called Fullmetal Alchemist. I've never seen FMA myself, but I've been to enough conventions to recognize the characters, not to mention I've seen Ed's voice actor Vic Mignogna at multiple cons and he's made no secret of the fact that Ed was one of his favorite characters to ever voice. I know the basic plot of the story, how Ed and his brother Al used alchemy to attempt to resurrect their dead mother, and in the process Ed lost an arm and leg and Al's soul got trapped in a suit of armor. I also know that there are a lot of themes in the series, i.e. the bond between brothers and how dangerous it is to play God with other's lives. One of these days I'll have to watch FMA, but for now, all that mattered was that there was someone calling himself Edward Elric in the ER, and apparently I was the only one who knew that name was a fake.

I saw "hallucinations" as the chief complaint, so it was entirely possible that this guy was psychotic and really did believe himself to be Edward Elric. However, he wasn't my patient and I wasn't about to violate any HIPAA laws by reading up on his file. So I did the next best thing and snagged one of the ER docs, telling him that the name "Edward Elric" was a fake one and that the ER social worker was going to have to try harder to learn his real identity. I even pulled up Ed's picture on my phone and showed it to him to prove that I wasn't crazy either. The ER doc laughed, saying that his patient didn't resemble Ed at all. He was also amused that it was thanks to my "inner nerd" that all this came to light. What can I say, it's not everyday that anime and medicine come together in my workplace. I later texted Kyle, a voice actor I befriended who'd also worked on FMA, to say that "Edward Elric" showed up in in the hospital (without going into too much detail); he thought that was pretty funny.

"Edward" was in the ER for at least 3 days waiting for a bed at a psych hospital, though by the second day, some of the ER docs had looked up FMA to learn about the real Edward Elric. "I heard you're the one who found out it wasn't his real name," said another doc. And apparently the ER docs were still talking about it over the weekend (I got those 2 days off) and my partners heard about it, too. I'm guessing he finally made it to a psych hospital; hopefully he'll get the help he needs and not fall into more delusions of grandeur.

Studer Training

Several months ago, my colleagues and I attended a mandatory meeting with a coach from the Studer Group, a group of physicians that educates other physicians about how to improve patient satisfaction and outcomes. It was four hours of teaching us how to demonstrate empathy toward our patients, ways of going "above and beyond" i.e. sitting down when talking to a patient, touching the patients, communicating, etc. Most of my colleagues thought it was a bunch of baloney; as for me, this was nothing that our med school hadn't already emphasized back in the day. I do try to sit down with my patients whenever I get the chance, I listen to their concerns, and I'm not afraid to lay a hand on their shoulder when they're crying. This I attribute to my med school training, not to the Studer Group.

Imagine my surprise (and dismay) today when the chief medical officer of the hospital poked his head into the physician's dictation room where I was writing my notes and asked if I had time to spare for him and a Studer coach (the same coach from above) to shadow me while I talk to my patients. I haven't had anyone shadow me since I was a med student, and I was sorry to say I couldn't recall much from the Studer training session. The CMO, Studer coach, and I saw 4 patients together: an osteomyelitis case, a chest pain, an A-flutter s/p ablation, and a new ESRD pt. I chose these patients b/c they were pretty straightforward and I had a pretty good relationship with them so the coach could see me at my best. The coach seemed pretty interested in where I trained, and asked where I thought my strengths were. I told him that I take time to listen to my patients, and that I make an effort to develop a relationship or rapport with them while they are under my care. I even gave some props to TCOM by saying our old motto, "Treat the patient, not the disease."

As for criticism, the coach said that I never once sat down while talking to my patients (the other chair was occupied and I didn't want to sit on the patients' beds), and he also commented that I rarely ever smiled. That's nothing new; I know my default facial expression is more of a frown than a smile. Still, I could see his point. One of the nephrologists at our hospital is extremely bubbly and friendly, and just seeing her makes me want to smile. Now I wonder what kind of disservice I've been giving my patients by not smiling when I walk through their door. And as for sitting down to talk to patients, they say sitting down gives patients the impression that our face-to-face time lasts longer than if we spoke with them while standing. That, thankfully, was one tidbit I remembered from the Studer training session, and the coach seemed pleased when I was able to recall it. Overall, he said I was doing pretty well, and that with a bit of tweaking, I can do even better.

Some of my partners wanted to hide when they heard that the Studer coach and CMO were walking around finding people to shadow, but I think everyone's going to get it eventually.