Lessons outside the Hospital

Too many times in medicine, we see patients with overbearing families that question everything we do and can't seem to give us room to work. Some family members even become emotional, angry, and confrontational when they don't understand what's going on. I probably had my share of exasperation with people like these, until I found myself in their shoes for a different, yet similar scenario.

This afternoon I was at an airport in Philadelphia (where I'd been apartment hunting) with my dad to catch a flight back to DFW. My dad had accidentally left his license at home and as a result had no photo ID on him. The security people who questioned him about his identity were, to put it nicely, not very friendly. They kept asking him how he was able to get a boarding pass without a photo ID, even though he explained that he bought the ticket online and got the pass at the self check-in which did not require a photo ID (just a credit card). Despite that, they kept asking him how he got his boarding pass without a photo ID. I was standing off to the side watching quietly, and I was getting tired of the way the guards were talking to my dad. Were they being hard on him because he was Asian and spoke with an accent? Finally I couldn't take it anymore and blurted out, "We went through the self checkout line!" as if that would explain everything. Not surprisingly, they ignored my little outburst.

What was surprising was when another guard standing nearby (he was a young guy) asked me if I was okay (I must have looked really pissed off). "I'm fine," I said, "I just don't like the way he (my dad) is being questioned, that's all." He asked if there was anything he could do to help, and I said no, but told him that my dad had no photo ID on him and was being interrogated. The guard said that while it did seem like the other guards were being aggressive, they were just doing their job and trying to make sure that my dad was who he said he was. When I saw one guard on the phone, the nicer guard said that he was calling some security company to verify my dad's identity, and everything would only take a few minutes to clear up. He asked if we had a flight to catch, and I said that our flight wasn't due for several more hours, so a few minutes' wait wouldn't hurt. At this point my dad and I were allowed to proceed to the security gate, where my dad had to be patted down for weapons (they sure take things seriously in Philly). Afterwards when I grumbled to my dad about the whole process, he was way more understanding about the whole matter. "It's the government," he said simply.

I then realized that just now, I'd become one of "those" people, the family members who let their emotions get the better of them and make the jobs of the doctors (or in this case, the security guards) more difficult. I don't usually lose my temper on complete strangers, and this was a first for me. *sigh* The things we realize about ourselves when we're stressed. You'd think being a medical student/future doctor would teach me to be calm in any situation, but now I know that's not the case, especially where family is concerned. The guards may have thought they were doing their job, but I saw them as antagonizers giving my dad a hard time (even if he didn't think so). I'm very protective of the people I care about, and at that moment, I was pissed.

Enter the other guard. Somehow, he could tell I was upset, and he made the effort to find out why and explain the interrogation procedures to me so that I'd understand what was going on. And in the end, that was all I needed to hear. Just like in medicine, sometimes patients' families just need a little reassurance now and then, which is why it's important for us as future doctors to be more understanding of them and educate them whenever possible. My one regret is that I never got to thank the guard for his help. This experience has really opened my eyes, and I hope I can learn from it to be a more compassionate physician once I graduate.

Pulm: Winding Down

Today was technically the last day of my pulmonary rotation (and medical school) since Dr. JS doesn't work tomorrow and I only have to attend Grand Rounds before going back home. Dr. JS made a point of saying I was his last student ever (unless something happens to our school president or unless the Clin Med office decides to send students to Tyler anyway), which seemed kind of sad. Once again I was relieved to be graduating at a time when our school politics was not very stable. Dr. VT, the doctor in charge of the rotation, went over exam questions with us in place of Pulmonary conference this morning, and afterwards Kate told us all about what was going on down at the school as she knew it. *sigh* Again, glad to get away.

Lisa took tomorrow off and left within an hour or so after lunch, but I agreed to go out to eat with Kate, Danny, and Amber at a Mexican restaurant called Mercado's. I already ate the microwave dinner at my house so when we got to the restaurant I snacked on chips and salsa and ordered a margarita. It was a nice way to celebrate the end of medical school. I mentioned that I'd brought my violin to Tyler (and actually played on two occasions as well), so the others asked if they could hear me play. We hung out in my cabin for about 1-2 hours just listening to my violin and chatting about things music-related. I learned that Kate and Amber had great voices when they sung along to "Nearer My God to Thee;" I wish Danny could have recorded them singing. Violin in the background, voices in the foreground...it was beautiful making music together like that. I never thought I'd get the chance to do something like this again.

Pulm: Rain, Rain, Go Away

Dr. JS doesn't have clinic on Fridays, so after lecture I met him at his office so we could round on our lone TB patient. He was scheduled to have a bone marrow aspiration this morning, but we were able to talk to him before that and learned that he was finally about to cough up some sputum for a sputum sample. We don't even wear the masks when we go to his room now; Dr. JS seemed pretty confident that he was no longer contagious.

Amber, Danny, and I were free to go after Grand Rounds, but it was raining outside, HARD. After discussing it amongst ourselves, the three of us decided to make a run for the cabins. I slipped in the grass at one point but it wasn't enough to stop me from getting to my cabin. I waited about 30 minutes for the rain to slacken before driving back home.

Pulm: Damn Birds...

Argh...for some reason last night a group of birds set up roost in a tree outside our cabin and chirped at each other ALL FREAKING NIGHT. Lisa and I lay down at about 11:30 pm, but I did not actually fall asleep until sometime between 2 and 3 a.m. I spent a good chunk of that time trying to sleep and also thinking of ways to get rid of those birds (i.e. throwing stones, spraying them with a hose). Those things had better not be singing all night is all I'm saying.

I paid another visit to our TB patient this morning after the pulmonary conference, and he commented on how much he'd love to go outside since he's been cooped in his room since he's been here. It really WAS beautiful and sunny outside. While talking to him, I realized that no one had told him yet that he was due to get a bone marrow biopsy tomorrow, and when he asked about his pancytopenia, I had to play stupid. It was not my duty to tell him that someone was going to stick a needle in him and drain him of some marrow (it was the hematologist's)

There was one patient today whose case was really sad. She was a 75-year-old woman with mild dementia who was recently hospitalized for pneumonia. In the hospital, both a CXR and a chest CT revealed a huge mass in her left lung, and it practically screamed lung cancer (especially since she had a long history of smoking). She was also a Longhorn fan and had her doubts about Dr. JS b/c he graduated from A&M, so the nurse stuck a Post-It to her chart that read: "To all Aggies: Patient is a Longhorn." Dr. JS burst out laughing when he saw the note, which came at a pretty inopportune time b/c he was in the middle of telling the patient's husband how dire her prognosis was. Given her poor health and dementia, everyone agreed that chemo and surgery were not the best option for her, and that palliative care was the best option. The patient seemed to understand what was going on, and as the couple left the office they were holding hands and trying to keep from crying. =(

Pulm: Interesting patients

After morning report (7:30 a.m.!), everyone went to clinic. I had nothing to do (Dr. JS hadn't shown up yet) when Danny came over and said that Dr. V, the ID doc, had an interesting case for med students to see. So I went to the room and Dr. V asked the patient to hold out his hands. Both palms were covered with a diffuse rash that the patient said was non-painful, and Dr. V said, "He also has them on the soles of his feet." Well, if that wasn't a huge giveaway of what this patient had I don't know what it was. When I left the room, Danny asked me what I thought it was, and I said, "Secondary syphilis." "Really?" he asked; he hadn't seen secondary syphilis before, whereas I saw a case of it at JPS. When Dr. V came out of the room, we discussed potential differentials, including erythema multiforme. "What's a common cause of erythema multiforme?" he asked, and we said drug reactions. "Which drug is most common?" was the next question. Danny didn't know, but I remembered it was Bactrim, which the patient was taking b/c he had advanced HIV. But...the localized rash to the palms and soles was very characteristic of secondary syphilis. The patient, however, had a negative RPR. "Why is that?" asked Dr. V. I thought the answer was obvious; he had HIV so his immune system never had antibodies against the syphilis. At any rate it was good learning experience and teaching case.

I had some pretty interesting patients in the clinic today. One man (his wife was the patient, who had an elevated left hemidiaphragm after her phrenic nerve was injured during open heart surgery; both were in their late 80s/early 90s) was wearing an interesting yet beautiful pair of boots, and someone asked him what they were made of. "Ostrich," he said proudly. Another patient asked if he could get his sleep study done before next month because after that, "I'm gonna go kill me a bear." Dr. JS asked where he was going to go shoot a bear, and he said, "Montana." I asked if he was planning to eat the bear or skin it when he was done with it, and he said if he got a bear he was going to have it made into a rug. =( I'm glad I'm not a bear in Montana.

Lisa and I went to the gym this evening and did an aerobics class. See, we are working out! =P

Pulm: New Attending

Because Dr. JS (new preceptor) didn't start clinic until 1:00 pm, I was able to drive to Tyler this morning (after telling my dad to go to see his doctor since he's been coughing for a week). I still haven't finished filling out my paperwork for Drexel but did submit my offer letter today (among other things). I saw a few patients with Dr. JS, but it wasn't long before he fell over an hour behind schedule. I did meet one patient who had Fuchs' dystrophy (hereditary corneal dystrophy that eventually results in blindness), but she recently got an epithelial cell transplant down at TMC and has regained some of the sight in her left eye. Yet another patient had a lung removed in 1985 due to lung cancer, and he's still going strong. Amazing. During clinic, Dr. JS got a page about a new TB patient and told me to go do an H&P on him. The patient was a 45-year-old man originally from Grenada (he still has a Caribbean accent) who was diagnosed with TB in September but even on 3 anti-TB meds his hilar lymphadenopathy and infiltrate-laden lungs did not improve. He had never given a sputum samble and his notes were disorganized so Dr. JS and I had no idea how he got diagnosed with TB in the first place. By this time it was past 5:30 pm, so Dr. JS told me to go through all the notes from the other hospital and then dictate my H&P. Easier said than done. I ended up having to put the notes in order before I learned that the TB was diagnosed after a bronchoscopy revealed AFB-positive stains. And my dictating skills suck; I haven't had to dictate anything since Tanner week in family medicine which was well over a year ago. The transcriptionist is going to have a field day when she hears my stammering...

Pulm: Good Thursday

This morning I met Dr. Ozzie and Andrea down at the ICU again, and our patient is not doing too well. His vent settings haven't changed; the nurses attempted to drop his FiO2 from 40% to 30% but he didn't tolerate it. His neuro signs are still abnormal and he's minimally responsive. The only time he really showed a good response was when his childhood friend and pastor came to visit; when that happened, his eyes were open and he was looking around the room. Almost seems too good to be true, but when Andrea asked him to trace her finger with his eyes, he couldn't do it. An EEG done on his brain showed "slowing activity," indicating that while the patient is not brain dead, his chances of survival off the vent are not good. The patient's brother and sister would be visiting today, and Dr. Ozzie planned to talk to them and tell them about the prognosis. In some downtime, Dr. Ozzie sat down with Andrea and me and went over the lectures he gave earlier in the week since Andrea wasn't present for all of them. She also didn't have the PPTs like the students did, so I made her a copy of my slides as a reference.

There was a Tumor Board in the afternoon with fettucine alfredo (Lisa and I lamented not going to the gym yesterday after getting this carb-full lunch) before we returned to clinic. There was originally an ICU lecture planned for 1:30 pm, but that got moved to 3:00, and then 4:00, because Dr. T (who's in charge of the students) was seeing walk-in patients. That was fine, since Andrea and I got to see some pretty cool pulm cases like bronchiectasis and pulmonary eosinophila (VERY hazy on CXR). I also submitted my clinical question assignment to Dr. Ozzie at the end of the day (fortunately he was still at the clinic since I stayed up until nearly 1:00 a.m. looking up that assignment), and he read through it to make sure it was acceptable. Basically we had to ask ourselves a question and see how long it took to answer, so I questioned whether IPF could be better treated with immunosuppressants combined with steroids compared to steroids alone. The answer: no concrete evidence that one is better than the other.

We got Good Friday off, so after lecture the five of us returned to our cars and took off for a long weekend =)

Pulm: The IJ

This morning I met with Andrea and Dr. Ozzie in the ICU to see our lone ICU patient: a 66-year-old man who developed cardiac arrest and V-fib with a delay in CPR (but he got defibrillated, fortunately). He was intubated but not sedated, and though he reacted to pain, his neurologic signs were somewhat abnormal. Both Babinski reflexes were positive, and his eyes were sluggish and fairly non-reactive to head rotation. He also needed a central line (IJ), so Andrea got to do that while I watched. The ultrasound machine was malfunctioning for a while but Dr. Ozzie refused to do the IJ until it was fixed. This is a far cry from JPS, where central lines are done blind without the aid of an ultrasound, but this patient had a lot of fat around his neck and clavicles so in his case an ultrasound was necessary. Fortunately we got the ultrasound plugged in, but the IJ was still not without its difficulties. The patient was unconscious, but not sedated, so during the procedure he'd sometimes move his arms, legs, and head. I had to slide my hands under the sterile field in order to keep his hand down. It took a few sticks to get the vein, but Andrea got the job done. Better her than me; I've only done subclavian lines.

After work Kate and Amber invited Lisa, Danny, and me to join them for dinner at a restaurant called Bodacious BBQ. The sweet tea there was pretty good, and the five of us chatted about all topics ranging from our pets to our classmates. Then later in the evening Kate knocked on our door and asked if we wanted to play "sucker ball" with them. It's a game where you hold a racket with suction cups on one side and toss a ball back and forth with the goal of catching the ball with the suction cups. It was pretty addictive and Amber and I got pretty good with playing ambidextrously. Lisa came out to play a little later, but it was all a nice bit of fun. Danny didn't come outside at all, despite our laughter; he was probably sleeping.

Pulm: ICU time

This week Dr. Ozzie and I were joined by an FP intern, Andrea, who was doing her ICU rotation and would be with us for a week. Dr. Ozzie had originally scheduled a lecture on hemodynamic shock next week, but he moved it to this afternoon so that Andrea could hear the lecture, too. It fell on me to contact the other four to let them know of this sudden change in plans. All of us were present at noon for the shock lecture, and much to my dismay when we were going over the basics of shock I started spouting off wrong answers. *sigh* Not the best way to impress the attending.

Dr. Ozzie got 3-4 new admits, including one in the ICU, so after giving a lecture on mechanical ventilation he emphasized that he expected Andrea and me to really know our stuff. I saw two of the patients: one really nice 85-year-old lady with a lower lobe pneumonia and an equally pleasant 66-year-old guy with a COPD exacerbation and MRSA. After that Dr. Ozzie met up with me and asked me what orders I wanted to write for the patients. Wow, he really is trying to get me prepped for residency! Not that I minded; I don't want to be a total idiot when I start residency. I also spent an afternoon at the PFT lab to see PFTs done (it was assigned to us; I'd already seen PFT testing back at Baylor). The first patient was a girl with CF who knew exactly what to do (she'd had tons of PFTs in the past); without anyone telling her, she took the apparatus and blew into it. And when the tech told her what her FEV1 and other values were, she looked happy. "See, that's better than last week!" she said to her mom. The second patient I saw was a really healthy 85-year-old lady who had some trouble with the apparatus at first but eventually figured it out. I'm amazed by how generally healthy the elderly population in East Texas is; yesterday in clinic I saw a couple in their 80s who went country line dancing on a weekly basis. I hope I'm in that good shape if I live be that old.

Pulm: Change of Pace

Dr. Ozzie was gone for the rest of the week so instead I was assigned to Amber's preceptor, Dr. JS (with whom I'd be working for the last two weeks of my rotation here). Dr. JS works long clinic hours, and today he also had to see Dr. Ozzie's inpatients. When he told Amber to see the inpatients, I offered to go with her since I knew them fairly well (having followed them for two days). The first patient we saw was a pleasant Vietnamese patient with miliary TB who had been presented at the TB conference yesterday for treatment options since she also had Hep C (and INH is hepatotoxic). This was the first time I ever met her since Dr. Ozzie had not let me see her previously, but she was very sweet. She told us that she had no idea when or how she contracted TB, and she was all alone since she had no children and her husband passed away within a year or two ago, but she was determined to get well no matter what, even if she had to stay in the hospital for one year. We assured her that most likely would not be the case, but she would definitely be on medications for six months to a year. Amber and I were both wearing the N95 duckbill masks, but as we examined her I couldn't help but wonder what my chances were of accidentally inhaling air droplets that contained TB and seroconverting into TB positive from this rotation. My other two patients were about the same, so I wrote notes for all 3 before we attended noon conference.

Kate has lobbied for us to get Good Friday off, and all we have to do now is fill out paperwork and clear things with our preceptors and lecturers. Lisa and I watched the series finale of ER tonight, and we were shocked when a placenta accreta/uterine inversion was shown in gory detail after a woman gave birth to twins. You didn't actually SEE the uterus or placenta, just tons of blood spilling down the foot of the bed to the floor, but the effect was pretty darn real. Having delivered several babies during my obgyn rotation, I was aware of how much a woman bled during birth, and this TV delivery gave a new meaning to "huge blood loss." Needless to say the woman went into DIC and died, but seeing all that (fake) blood on TV...damn.