Friday, June 24, 2005
I suppose internal medicine is a mixture of sad, happy and other.
In other news, I stopped by the 4th floor for a minute on my way in (you can read about that in a moment) and on my way to the elevator the innocuous blue light on the ceiling made me say, "Code!" I started running before I realized that I did not know where to go (although I know I can follow the lights) and it was not my day anyway. When I got upstairs to the call room, my senior and the two (brand new) interns were walking in. Apparently, the post-call team had just "dumped" their code beepers on the shelf before the call team had come in (bad form). My team was in the room and at 07:02, just two minutes into their first day of internship, they had to respond to their first code! Since the fourth floor is the surgery floor, there were a ton of well-trained docs already in the room taking care of business by the time my team made it down, so they just came back up. That's often how codes during the day work.
On the happy side, one of my older patients (an 81 yo Indian woman) who was seen before by our service (although not by me) had gone to a temporary nursing home while waiting for surgery to repair her mitral valve. She received very poor care there and was readmitted to our service for some good old TLC. We nursed her back to health and got her ready for her upcoming surgery. Her family is very involved with her care so I go to know her two daughters and her son, who is a pediatrician. She did not speak a lot of English, but enough to get by: one morning while I was doing my daily exam she said something to her daughter who told me that I was now her grandson. Needless to say, it was a good was to endear herself, but I was already vested in her care because she is just to nice. He had her procedure yesterday and I had planned to view it and had the "okay" from the surgeon, but because I was working with other patients I did not get to go with her right away. When I finally did go to the OR, the charge-nurse would not allow me to go in. I did stop by the thoracic surgery ICU (TICU) this morning to see how she was doing and I was surprised to see her intubated. Then I realized that everyone was intubated. She gave me a little smile, but I could tell she was not comfortable and not happy. The procedure did go very well and she is doing quite well, which is great. I'm looking forward to seeing her off of the ventilator. I saw one of the daughters when I stopped by on my way out. We hugged and talked about how her mom was doing--that's when I found out that it went well. Since, according to her daughter, I'm the only doctor that makes her mom smile, I'm going to make it a point to drop in each day. Not that I wouldn't have anyway.
On the sad side, my young man with cancer had something really wrong with his intestines yesterday. We tried to place a nasal-gastric tube to suck out some of the gas from his intestines because it was causing him a tremendous amount of pain, but, because we could not put him in the correct position (due to the pain) we could not get the tube placed. One of the fellows tried after we had tried and she was not able to get it placed either. Later last night, he passed away last night in the hospital. We had hoped to get him to hospice in flint this morning so he could see some of the other members of his family that could not make the trip down to the U. Supposedly, when he passed, he was comfortable and not in a lot of pain--we had started a morphine drip which hopefully helped. I'm still a little numb about the whole thing, but feels are brewing in the background. I suppose I had been preparing myself since his first day especially because I did not think he was going to make it through the first night. But, I could also tell his time was drawing closer as he started having more problems and pain.
Prolonging life or prolonging death. I suppose it is a very fine line between the two. All I know is that he did not want to go where he knew he would.
Ode to Johnny
Do not go gentle into that good night,
Youth burns and rave as eclipse hides day from sight,
rage, RAGE against the dying of the light.
Through fool's eye at their end ponder dark is right,
Because their desires no lighting they, but you,
Do not go gentle into that good night.
Good men, wave by wave try, crying how blight,
Their frail deeds might have danced in the darkened sight,
rage, RAGE against the dying of the light.
You, wild man, who caught and sang the sun in flight,
And learned, too late, you grieved it on its way,
Do not go gentle into that good night.
Grave man, near death, you see with blinding sight
Blind eyes that blaze like meteors and be saved,
rage, RAGE against the dying of the light.
You, my friend, there on the sad height,
Have blessing you now with your fierce tears, I pray.
Do not go gentle into that good night.
rage, RAGE against the dying of the light.
In other news, I stopped by the 4th floor for a minute on my way in (you can read about that in a moment) and on my way to the elevator the innocuous blue light on the ceiling made me say, "Code!" I started running before I realized that I did not know where to go (although I know I can follow the lights) and it was not my day anyway. When I got upstairs to the call room, my senior and the two (brand new) interns were walking in. Apparently, the post-call team had just "dumped" their code beepers on the shelf before the call team had come in (bad form). My team was in the room and at 07:02, just two minutes into their first day of internship, they had to respond to their first code! Since the fourth floor is the surgery floor, there were a ton of well-trained docs already in the room taking care of business by the time my team made it down, so they just came back up. That's often how codes during the day work.
On the happy side, one of my older patients (an 81 yo Indian woman) who was seen before by our service (although not by me) had gone to a temporary nursing home while waiting for surgery to repair her mitral valve. She received very poor care there and was readmitted to our service for some good old TLC. We nursed her back to health and got her ready for her upcoming surgery. Her family is very involved with her care so I go to know her two daughters and her son, who is a pediatrician. She did not speak a lot of English, but enough to get by: one morning while I was doing my daily exam she said something to her daughter who told me that I was now her grandson. Needless to say, it was a good was to endear herself, but I was already vested in her care because she is just to nice. He had her procedure yesterday and I had planned to view it and had the "okay" from the surgeon, but because I was working with other patients I did not get to go with her right away. When I finally did go to the OR, the charge-nurse would not allow me to go in. I did stop by the thoracic surgery ICU (TICU) this morning to see how she was doing and I was surprised to see her intubated. Then I realized that everyone was intubated. She gave me a little smile, but I could tell she was not comfortable and not happy. The procedure did go very well and she is doing quite well, which is great. I'm looking forward to seeing her off of the ventilator. I saw one of the daughters when I stopped by on my way out. We hugged and talked about how her mom was doing--that's when I found out that it went well. Since, according to her daughter, I'm the only doctor that makes her mom smile, I'm going to make it a point to drop in each day. Not that I wouldn't have anyway.
On the sad side, my young man with cancer had something really wrong with his intestines yesterday. We tried to place a nasal-gastric tube to suck out some of the gas from his intestines because it was causing him a tremendous amount of pain, but, because we could not put him in the correct position (due to the pain) we could not get the tube placed. One of the fellows tried after we had tried and she was not able to get it placed either. Later last night, he passed away last night in the hospital. We had hoped to get him to hospice in flint this morning so he could see some of the other members of his family that could not make the trip down to the U. Supposedly, when he passed, he was comfortable and not in a lot of pain--we had started a morphine drip which hopefully helped. I'm still a little numb about the whole thing, but feels are brewing in the background. I suppose I had been preparing myself since his first day especially because I did not think he was going to make it through the first night. But, I could also tell his time was drawing closer as he started having more problems and pain.
Prolonging life or prolonging death. I suppose it is a very fine line between the two. All I know is that he did not want to go where he knew he would.
Ode to Johnny
Do not go gentle into that good night,
Youth burns and rave as eclipse hides day from sight,
rage, RAGE against the dying of the light.
Through fool's eye at their end ponder dark is right,
Because their desires no lighting they, but you,
Do not go gentle into that good night.
Good men, wave by wave try, crying how blight,
Their frail deeds might have danced in the darkened sight,
rage, RAGE against the dying of the light.
You, wild man, who caught and sang the sun in flight,
And learned, too late, you grieved it on its way,
Do not go gentle into that good night.
Grave man, near death, you see with blinding sight
Blind eyes that blaze like meteors and be saved,
rage, RAGE against the dying of the light.
You, my friend, there on the sad height,
Have blessing you now with your fierce tears, I pray.
Do not go gentle into that good night.
rage, RAGE against the dying of the light.
Tuesday, June 21, 2005
Last call (Sat-Sun) was very interesting, at least technically. We had three codes on two people. The first person was successfully socked back into a normal rhythm. Then, unfortunately he experienced what is called electromechanical dissociation about 30 minutes later. We performed chest compressions for over an hour (about half of which the gentleman was conscious) before he was finally declared. There were three of us taking turns doing the compressions and it was the first time I had ever done them. It was surprisingly similar to the resuscitation Annie dummies they use with one small exception. When I started, there was a snap under my palm which I announced. The group replied, "that's how you know you're doing it right!" My instinct is to compress a little fast, which is WAY better than a little slow. During the code, a trans-thoracic ultrasound echo was performed because he had a good looking EKG but no one could get a pulse. Sure enough, the echo showed a quivering heart with no contractions.
The third code came right at midnight. It was a younger woman who was doing well just 5 minutes before her heart suddenly stopped. We did compressions on her for about 15 minutes and her heart started back up while I was performing my second or third set. I know she lived through the night and no one was really sure why her heart had stopped other than maybe due to aspiration some vomit. (She had vomited about 1/2 a gal before we got there.)
Yesterday, the oncologist and the team had to tell my young man with cancer that there was not anything we could do at the moment. There is a chemotherapy that will stop the tumor from growing, but his liver had not recovered enough to receive it. We discussed having him go home for hospice and check his liver in about a week to see if it as improved sufficiently to start the chemo. The cardio-thoracic surgeons were not will to debulk the tumor since his health is in such bad shape already including the kidney and liver failure. And, just to make matters worse, we found out that the cancer had mets to his bone marrow which means even if he could have the chemo, he could never be cured. Very "heavy" and rough news to deliver. I suspect he will be discharged tomorrow or the day after. The intern working with me on this case delivered the news and I must say he did as good a job as I could have imagined. That certainly is an aspect of medicine for which I was not fully prepared. You think about and you try to get yourself "ready" but really, you cannot. It does certainly keep you grounded when things go wrong. And my advice (not meant to be flippant): if you think you feel a mass in your skin, don't wait! Go to the doctor.
I'll be on call again tomorrow, so I'm gonna' hit the sack now so I'll be well rested. I'm planning on watching the surgery of my one of my other patients (an 81 year old Indian woman with a flailed (damaged) mitral valve). She calls me her grandson--as I'm the only doctor that actually makes her feel better.
The third code came right at midnight. It was a younger woman who was doing well just 5 minutes before her heart suddenly stopped. We did compressions on her for about 15 minutes and her heart started back up while I was performing my second or third set. I know she lived through the night and no one was really sure why her heart had stopped other than maybe due to aspiration some vomit. (She had vomited about 1/2 a gal before we got there.)
Yesterday, the oncologist and the team had to tell my young man with cancer that there was not anything we could do at the moment. There is a chemotherapy that will stop the tumor from growing, but his liver had not recovered enough to receive it. We discussed having him go home for hospice and check his liver in about a week to see if it as improved sufficiently to start the chemo. The cardio-thoracic surgeons were not will to debulk the tumor since his health is in such bad shape already including the kidney and liver failure. And, just to make matters worse, we found out that the cancer had mets to his bone marrow which means even if he could have the chemo, he could never be cured. Very "heavy" and rough news to deliver. I suspect he will be discharged tomorrow or the day after. The intern working with me on this case delivered the news and I must say he did as good a job as I could have imagined. That certainly is an aspect of medicine for which I was not fully prepared. You think about and you try to get yourself "ready" but really, you cannot. It does certainly keep you grounded when things go wrong. And my advice (not meant to be flippant): if you think you feel a mass in your skin, don't wait! Go to the doctor.
I'll be on call again tomorrow, so I'm gonna' hit the sack now so I'll be well rested. I'm planning on watching the surgery of my one of my other patients (an 81 year old Indian woman with a flailed (damaged) mitral valve). She calls me her grandson--as I'm the only doctor that actually makes her feel better.
Friday, June 17, 2005
It's a sad day and tomorrow will be even sadder. Although I will not have to do it personally I will be there: Tomorrow, we will tell the family and the 25 year old man that he has an incurable cancer in his heart. We think it started in his thigh and, unfortunately, he allowed it to grow to be a 4 inch diameter mass before seeking medical attention--it only took 3 months for it to grow to that size. It metastisized to his heart--specifically his right ventricle. It is possible that the surgeons can debulk the mass and give him a little more time, but, because the cancer has metastisized, he is not a candidate for heart transplant. Also, his general medical condition is so critical that the surgeons may not perform the procedure at all.
I knew that some day I would be involved with this, but I did not think it would be this kind of problem in a person so young.
Since the news has not been broken to the family. I will save this post and publish it later.
I knew that some day I would be involved with this, but I did not think it would be this kind of problem in a person so young.
Since the news has not been broken to the family. I will save this post and publish it later.
Sunday, June 12, 2005
Spent the day off with my loving wife. I had call Friday-Saturday and it was busy. But, I got 1h of sleep out of the 37h shift. I did spread the healing touch! Nothing like a little imperic antibiotics (ABX) to keep someone from dying after a femoral cath. I only had to fight with the docs overnight to get them to her. Withing 5 hours after starting the ABX, she started looking MUCH better. Tomorrow I'll find out if I was actually right or if she was just going to get better on her own. (But, to my eyes, she was getting worse, not better, until we started the ABX. Thus, I'm sticking with my story no matter what the cultures say!) Hmmm, I suppose I can actually go look and SEE what the cultures said. If I write more, then you'll know I was right. ;)
Sunday, June 05, 2005
Maybe there's a little confusion over my next block. It actually starts tomorrow. For some reason, we're not quite on a perfect monthly schedule. Cardiology (or cards for short) will be a Q4 rotation and I will have call my first night--although it was suggested to me that I may be sent home that first night because I won't really know anything, but I'm not counting on it. I will have to try a little harder to get some sleep during call because it will be twice as often as my month at the VA and I won't have 16 hours available to sleep after each call.
Since this weekend was switch weekend, we had it "off." Which means I have had two weekends in a row off. My dad, for some reason, takes issue with this. :-) A group of us went canoeing down the Huron yesterday, which was pretty fun, although it was a bit too shallow at times. Also, there was a transfer point where you had to pick the canoe up out of the water and walk it down some stairs to the actual river. That was not too much fun! But, overall we had a good time. Maybe there will be some pics to post. (Just like I need to do with Hawaii.) Oh well, as time gets more precious, you have to cut something out.
ML and I will go have sushi-brunch at our favorite local sushi place in a little bit. Yummy! It's our Sunday ritual. That is, when I have Sunday's off.
Since this weekend was switch weekend, we had it "off." Which means I have had two weekends in a row off. My dad, for some reason, takes issue with this. :-) A group of us went canoeing down the Huron yesterday, which was pretty fun, although it was a bit too shallow at times. Also, there was a transfer point where you had to pick the canoe up out of the water and walk it down some stairs to the actual river. That was not too much fun! But, overall we had a good time. Maybe there will be some pics to post. (Just like I need to do with Hawaii.) Oh well, as time gets more precious, you have to cut something out.
ML and I will go have sushi-brunch at our favorite local sushi place in a little bit. Yummy! It's our Sunday ritual. That is, when I have Sunday's off.
