Warrior

He was young for his type of cancer - squamous cell carcinoma of the larynx. I can't remember if he was a smoker or not, I don't think it matters, because those little details tend to deceive us into judging whether a patient "deserves" their cancer or not, and no one deserves a diagnosis of cancer. His tumor fell into the "organ preservation" limb of treatment, and he underwent weeks of grueling radiation and chemotherapy with his wife steadfastly by his side. The first few scans came back clean, then a year or so after treatment - recurrence. The cancer would prove to be a formidable enemy.

"Salvage laryngectomy" is the term we use when our first treatment has failed for voice box cancer and the ultimate decision is to be more aggressive and wield cold steel and hot cautery against our opponent. I think in some ways the term is quite poignant. It implies a battle of sorts raging within the body - treatments and human will versus the scourge of the malignancy infiltrating the tissues. Poetic interruptions aside, it meant the patient lost his ability to speak when we removed his larynx in an attempt to also in turn remove the cancer. Once again, a period of reprieve and healing. He became artful in speaking with the electrolarynx, attacking this new challenge the way he had all other challenges before then. But once again, the cancer returned with a ferocity, infiltrating the skin around where his airway now exited from his neck.

"Peristomal recurrence" is the term we use when the cancer returns in such a location. In general, it is considered a very poor prognostic sign. The type of sign where all you have to do is utter the term and those knowledgable to the lingo simply nod their head sadly, understanding that you're implying the chance cure is essentially zero.

And so it went on, another round of chemotherapy. More radiation. More chemotherapy. Experimental regimens that were so new or different they weren't even clinical trials yet. He lost a lot of weight. Nausea. A tube was placed through his skin into his stomach. His tumor grew larger. He was hospitalized. His tumor grew larger. He had bleeding. He spent time in the ICU. His tumor grew larger. He had abdominal pain. That earned him a surgery, and more pain, only to find that the cancer had further metastasized. His tumor grew larger. He would spend the last few months of his life in the hospital, until one night he quietly passed.

The unfortunate fact is that half of head & neck cancer patients in an academic institution will succumb to their cancer. His story, however, struck a chord with me.

Our team was frustrated with his care. We had tried many times to lay out prognosis to him, to arrange end of life care, to make him comfortable. But he would always talk about the next round of treatment. He would always talk about the day when his cancer would be gone for good. In fact, up until the end, he talked quite a bit. About his favorite football team and the upcoming season. About his rec sports league and the joy he got from the competition. He struck he as the scrappy small guy you hated to compete against but always wanted on your team. Ultimately, he always equated palliative care with quitting no matter how how we tried to frame the conversation. We, the team of residents caring for him, had trouble with transferring our own opinions onto his life. We saw the last few months spent in the hospital as time wasted, unnecessary pain and suffering. (And wasted healthcare dollars if you work in Washington). Some would paint his case as a failure of our medical system to navigate end of life care. Every day as we passed through his room we were left with a dampening of our spirits, a daily reminder of our own mortality, and the futility of our care at times. He was the other, more real, 50% of head & neck cancer patients.

I think when it comes down to it, he derived value and meaning from the fight. And I think he measured the worth of his life in the end by how hard he fought. He was a warrior. He outlived prediction after prediction. 6 months to live. 3 months to live. 1 month to live. He tolerated an inhumane amount of painful and debilitating treatments. He demonstrated the tenacity of human will.

And ultimately, I can't help but admire his story. In the end, I think, it was a good death. A death befitting a warrior.

Sid Meier's Hospital

So I'm on Plastic Surgery this month. Excuse me, Plastic & RECONSTRUCTIVE Surgery. Though I think it's fair to say the department here earns that title as they do a fair bit of reconstruction amongst the stripperplasties and wrinkles-be-gonesies. It's strange being back on an academic surgical service after a break of over 3 months, but refreshing at the same time as the duties of the medical student on said services of academia (list updating, prerounding, hastily presenting, obscure pimping) are warm and familiar to me. Like a well worn sweatshirt or something. But the hours still suck.

We had a really interesting person on the census the past while - the whole package, interesting medical case and interesting personality. The guy was tackled by a buddy of his and broke a rib. Being the regular dust-on-the-boots American that he is, he didn't come to the ED but rather was just going to deal with the pain. Problem was, he was a nice guy, and since bad things only happen to nice guys, the rib pierced his pleura and soon enough he was in the hospital whether he liked it or not with a rip roaring empyema. One lobectomy, a lat flap, and a couple chest tubes later, he found himself parked on the floor slowly biding his time until he was given the blessings of the great doctors to go home. The healing was slow and he was nearing 2 months on service when I rotated on.

Of course he felt well enough, and rather than bore himself with watching his chest tube output, every day when we rolled through the room in the clusterfuck that is surgery rounds, he would be clicking away on his laptop, engrossed in a computer game. Now despite my rugged and masculine exterior, I am quite the computer nerd. Growing up in the glory days of DOS, I spent many an hour of my youth tinkering away at the computer keyboard with classics such as X-Wing, Doom, and Mechwarrior. Like like many things of youth, these hobbies have slowly been eroded away by the responsibilities of growing up. So on rounds we were much more focused on said chest tubes than what was on the computer screen.

Finally, after a few days on service, the chief resident glances up from the patient's incision and asks "Are you playing Civilization???"

The junior looks up from the chart to add "Hey, I love Civilization."

Intern: "What version? I haven't played 5 yet."

From my n=1 experience, I can now say that all medical students and residents have played Civilization. I'm not sure what that says about our demographic, but the computer nerd in me grinned internally.

Sure enough, this past weekend we were rounding with the attending on call, and our fearless world leader slash conquerer was getting ready to be discharged home. We roll into the room and there he is, clicking away at his laptop like always. He's excited to go home. We make small talk. Finally, the attending was bent over glancing at the site of the last chest tube, when she comments "Is that Civilization? I love that game!"

Somewhere, Sid Meier is smiling.

These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.

Empathy, Tragedy, and Progress

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

"The Look."

As part of our internal medicine rotation, we were required to spend 5 weeks at a hospital out in the community. The hospital I was sent to was a fairly large medical center with close to 500 licensed beds, and part of my hospital was a large tower of a structure dedicated as the "cancer center". The problem with the cancer center is that it was built as an addition to the hospital, which meant to get access to the beds within the tower, you had to go up to the 3rd floor of the regular hospital, through this back hallway attached to the corner stairwell, go through a tiny side door, which brought you to a back elevator shaft. You then went up the curiously slow elevator, through a set of double doors, then up another set of stairs, just to get to the beds in the tower. As a result, the tower had been nicknamed the "Death Star", because every time a code or rapid response was called in the tower it took several minutes to respond simply by virtue of its reclusive location. While rotating at the site, I worked with a senior resident who took the code pager very, very seriously. Whether it was a code blue or a rapid response, we. were. running.

One day on short call, we had an afternoon where the code pager would not shut up. As a result, we were running all over the hospital to various locations within the hospital, always at an aggressive jog with my 30 pound white coat flapping around me and sweat beading on my forehead. All the codes that morning ended up being fairly well controlled situations... a patient in the post-op area of the day surgery who got too much narcotic, a code blue called on a patient already in the cath lab, a patient who had an an RRT called simply because the attending wanted a stat ECG. We had just finished up our 5th code of the morning when the code pager started blaring again, this time for a patient in the Death Star. "Crap." my senior muttered, and off we took, up to corner stairwell, down the back hallway, through the tiny side door, to the elevator. Wait for it. Wait for it. Wait for it. Up the elevator. Through the double doors. Up the stairwell. Down another hallway.

When we arrived the scene was fairly chaotic. An elderly woman was sitting tensely up in bed. Nursing staff was trying, quite unsuccessfully, to get an ABG, and blood was spotted all over her arm and hospital gown. The ECG showed new-onset a-fib and the patient was satting 70% on 12 liters of oxygen through a rebreather mask. But what struck me most profoundly was the look on the poor woman's face. She had what we called "the look": sitting rigidly upright, arms locked with hands grasping onto her sheets, desperately trying to breath with eyes wide and an expression of impending doom on her face.

There's only a few things that give someone "the look," and in an elderly bed-ridden hospital patient, we knew even before the labs came back that she had thrown a clot to her lungs. She was wheeled down the hallway, down the elevator, through the lobby, up another set of elevators, and into the ICU. Luckily, she did quite well and survived her PE with only a scare. The Death Star had been defeated that day. But I'll forever be imprinted with that look she had the moment we walked through the door. It's one of those indelible moments that are sprinkled throughout the third year of medical school - when what you learn in textbooks manifests itself in a living, breathing human being tenuously placed in front of you.

Happily exhausted.

There's a lot of mystique surrounding the internal medicine rotation in the third year of medical school. Besides the fact that your IM core clerkship grade is considered one of those "important things" for residency, its also the rotation that best integrates the various informations you crammed into your head during the pre-clinical years. Some say its where you learn to "think like a doctor" or "be a doctor." While my IM clerkship has not turned out to be nearly as dramatic as some would make it out to be, I have seen myself making small but significant strides on being able to capably diagnose and manage patients in the acute setting. I'm on week 6 of 10, and so far it's been exhausting, but incredibly rewarding.

It's amazing how many different experiences you can pick up in a short period of time, and how patient's stories are intertwined within all of it. Some are humorous, some are sad, some are powerful.
The little old lady found wandering the streets at 3am looking for her favorite starbucks, pleasantly delirious due to a UTI.
The woman admitted with herpes zoster ophthalmicus, who always wants you to linger just a little longer when pre-rounding, and you can tell she is lonely.
The patient who has a syncopal episode while masturbating.
The woman who has never smoked a single cigarette in her life, who dies from lung cancer.
The woman with sickle cell who is allergic to opiates, forced to endure the pain of her acute crises with only tylenol, who handles herself with awe-inspiring stoicism.
The 22 year old asthmatic, who can't afford an inhaler because he spends all his money on heroin.
The man with end-stage liver disease who can't get a transplant because he can't kick the bottle.
The 600 lb man, bed-ridden for over a year, who stands for the first time, and the attending shakes your hand and says "strong work, without your help, I don't think he would have ever left the hospital."
The patient with a-fib who passes suddenly in the middle of the night.
The woman who comes in with difficulty swallowing and leaves with a terminal cancer diagnosis.

It's humbling that these experiences are considered my "education." But I don't think I've ever appreciated or enjoyed medical school more than now. Its funny that it happened on this rotation, because internal medicine can sometimes (often) be much too rhetorical and slow paced for me. But there's something to be said about the principles of internal medicine being the foundation of how medicine is practiced, regardless of specialty. And I think my experiences on this rotation have allowed me to cross another one of those thresholds of clinical competency. I found as I was getting my feet wet in third year, I was often so concerned with not screwing up that the nuances of clinical medicine whisked right by me. I was so concerned with not missing anything in my history, I missed connecting with my patient. I was so concerned with my notes being perfect, I didn't stop and think about what I was looking for in my physical exam, or why certain things were in the plan. But as you gain competency in those skills, you learn to enjoy the process as much as the result. Medicine becomes less of a checklist and more of a visceral experience. And it becomes much more fun in the process.

So tomorrow, my alarm will go off at 4:30am. And I'll groan, because I'm exhausted. But then, I'll get up, and I'll smile. Because I get to do this for a living. How awesome is that?

Snap, Crackle, Pop.

One of the difficult things about learning the art of the physical exam early in medical school is learning to differentiate pathology from normal. I remember when we first were instructed on the lung exam. We learned about these ambiguous terms... rales, rhonchi, egophony, stridor, tactile fremitus. I learned that you could have crackles in your lungs, and set about listening to the lungs on all my patients very closely. And I discovered a funny thing. Vesicular (aka normal) breath sounds can sound kinda-crackley if you listen close enough. All my patients started having crackles. I asked a doc I was working with one day "What do crackles sound like? Because it sounds to me like all my damn patients have crackles."

Eventually, I had a patient with real crackles, and like anything else with the physical exam, once you listen and touch enough normal patients the pathology begins to jump out at you. But this story isn't about that patient. It's about a patient I saw earlier this week, a 65 year old man with chronic kidney disease and congestive heart failure who presented with shortness of breath. He was actually my first patient I've seen with 3+ pitting edema, I damn near lost the entirety of my index finger into his left shin. But this story is about crackles, and I noticed a certain quality to his voice as I was talking to him in the exam room. No hoarseness or changes in phonation. But it sounded like someone had just poured themselves a bowl of rice krispies and set it in the corner. The snap, crackle, pop became more audible with each labored breath he took. For some reason, the moment brought me back to my early days of listening to the lungs, waiting for total silence and listening intently, hoping to catch a crackle or two in passing. And here I had a patient sitting in front of me with so much fluid brimming out of his lungs that I didn't even have to place a stethoscope on him to hear the crackles.

Sadly, in this economy, I'm not sure Kelloggs is looking for any new spokespersons anytime soon.

Coin Flip

So I was in clinic the other day, and the next two patients on the schedule looked like this:

10:45am - 21 yo male - abdominal pain
11:00am - 28 yo female - abdominal pain

Hrmmm... which one of these is the appendicitis? The doc I'm working with decides to leave it up to a coin flip on which one I see and which one he sees. Heads, I get the 21 yo dude. Tails, the 28 yo dudette.

Heads.

Cool, 21 year old guy with new onset abdominal pain is about 'classic' for appendicitis as you get. I knock, enter the room, and the exchange does something like this (abridged for everyone's sake):

Nice to meet you, Mr. Abdominal Pain Dude, tell me what's going on.
"My stomach's hurting."
How long has it been hurting?
"Oh a while."
A while as in several days? Several weeks? Months?
"It started at 9 pm last Tuesday, I was sitting on the couch eating french fries and watching Biggest Loser."

...I could see in a hurry that this conversation was hurtling out of control into the "awkward patient encounters" category...

Can you point to where it hurts?
*points to RUQ*
Does it hurt anywhere else?
"My back hurts all the time, and spine pain. And my jaw has been hurting recently. Is that related? I also have nerve sensitivity, like if you touch me here, it hurts. See? That hurts. So don't touch me."
Any nausea or vomiting?
"Well I just throw up sometimes. So I don't know."
Hrmmm, interesting. Have you thrown up since this pain started?
"Oh yeah. In fact, I think I could throw up on your face right now."
Any change in your stool? Diarrhea or constipation?
"I always have diarrhea."
Also interesting. Any other symptoms?

...I see the patient take a deep breath in preparation to respond. This is not a good sign...

"My neck hurts, and my hips hurt when I walk. Is that related? And can I get injections today? My anxiety is really bad recently and I'm out of xanax, can I get a refill? My therapist says I need a refill. I'm also out of my vicodin. I've had a fever of 98.9 all week, and I feel really sweaty. I lost weight but then gained it back. I have to get up to pee sometimes at night but I think thats all the water I drink right before bed. My grandpa had colon cancer... oh my god is this colon cancer? I'm also pretty sure I have fibromyalgia. But that doesn't cause stomach pain, right? Could this be herpes? I'm pretty sure I have herpes. I've been tested 6 times and they were all negative but could this be it? I read on google once that herpes can attack your liver. But I'm pretty sure this is gallstones. Can I get them taken out?"

Long story short, I had no clue what to say after that, and felt that asking too many questions more would just further convolute the picture. Physical exam (yes, he ended up letting me touch him) was very benign, with maybe some very mild tenderness to palpation in the RUQ. We ordered up a chem10 (because, hey, he was right, herpesvirus can cause a fulminant hepatitis, despite the fact that he was not bright yellow) which showed a mild bump in alk phos and total bili. RUQ ultrasound found some very small gallstones. Whether they were the etiology of his abdominal pain or an incidental finding, who knows. He left with a GI referral. But no xanax refill.

Oh, and the 28 yo woman at 11:00 ended up having classic appendicitis.

Marty and Me

One of the most overused cliches in medicine is the oft referenced: "When you hear hoofbeats, think horses, not zebras."

It's a valid reasoning in which to guide one's thought processes. After all, common things are common, uncommon things... aren't. But part of the responsibility of a physician also is to provide comfort and reassurance. It's our job to think "worst case scenario," to work up patients for those conditions, and provide reassurance when evidence is sufficient to quell our suspicions. Another common phrase in medicine is "until proven otherwise." Vaginal bleeding in a postmenopausal woman is cancer until proven otherwise. Acute onset of dyspnea or hypoxemia is a pulmonary embolism until proven otherwise. Severe epistaxis in an adolescent is a nasopharyngeal angiofibroma until proven otherwise. I recently had two patient who elucidated just how true this axiom can be.

A 62 year old woman presented with lateral chest pain of two weeks duration. On physical exam, her pain seemed very musculoskeletal in nature. Pain to palpation, pain on deep inspiration and with sneezing/cough, etc. The horse in this situation is a simple intercostal muscle strain. Regardless, we ordered a chest xray which showed ambiguous opacification of her right lower lung. It just didn't quite add up with the lack of any pulmonary symptoms. So, congresspersons and escalating health costs be damned, we decided we couldn't quite be comfortable with just writing things off, and sent the patient off with a referral for a CT scan and instructions for prn ibuprofen and heat. We saw her back today. The CT scan showed findings pathognomonic for lung cancer. Turns out, her pain was musculoskeletal in nature, as the cancer had begun to invade into her 8th rib. It had also spread to her spine. Zebra. Ironically, the patient returned to say that the heat and ibuprofen had really helped with the pain. If it wasn't for the CT, she would have been sent on her way with the belief that it was all just an intercostal muscle strain, while the cancer continued to grow in her chest.

A 22 year old woman presents with a painful unilateral cervical lymphadenopathy which had been present for 1 month. The horse in this situation is some form of infectious etiology: mononucleosis, cat-scratch fever, occasionally HIV (though this didn't jive with her history). She had been to several urgent care centers, and, going with horses instead of zebras, prescribed two antibiotic regimens, with no improvement of her symptoms. There was still a high likelihood her neck mass was viral in etiology, but we ordered a chest xray "just in case." It ended up showing an extensive mediastinal mass. One biopsy later, the diagnosis returned nodular sclerosing Hodgkin's. Zebra. Luckily, her prognosis is excellent and the delay in diagnosis likely will have no significant effect on her therapy. But it is never easy telling a previously healthy 22 year old that they have cancer, and there is a certain level of embarrassment that it took 5 visits to a physician to reach a diagnosis.

I think the most telling thing I've taken away from these experiences is how important the differential diagnosis remains in clinical practice. Most common symptoms can be attributed to the relatively benign conditions that afflict the gross majority of the general population. But it is important to always consider what else can be consistent with a clinical picture that is truly dangerous, as just because a condition is rare does not mean it cannot be affecting the patient sitting in front of you. Bacterial pharyngitis is common and fairly benign. A retropharyngeal abscess is not, and can often present identically. It is the responsibility of the clinician to use their clinical judgment and work up a patient to the point that they can confidently feel the patient is safe in the context of their illness.

After all, just one day, you may come across a zebra in downtown New York.

Friday Night Lights

So I happen to be attending med school in the same city I grew up in. There's a lot of advantages to the situation: I know the area really well, the city "feels" like home, I'm close to friends and family, in-state tuition, etc. There's also the annoyances that come from returning to your hometown. Namely, running into old acquaintances, especially high school classmates, everywhere from the deodorant aisle at Safeway to the self-help section at Borders (you to!?!). Now, these aren't the good friends from the old days - those I've actually kept in touch with over the years and still make plans with from time to time. These are the people you see in a crowd, recognize the face and try to place their name, and before you can think of it they jump you with with the "Heeeeyyyy how are yoooouuuuu? What are you uppppp to? *awkward pause*" before you can make a quick getaway. At first these spontaneous encounters were kind of fun, namely because my younger self got to pull the "I'm in medical school card" (Yeah. I know. You don't have to tell me.) But after a while it becomes an annoyance more than anything. That being said, there's one place I never expected to bump into an old high school friend.

I was on trauma call on Friday night and going through my usual routine. Which means I was in the cafeteria at 10 at night, justifying to myself that I should get the ham and cheese sandwich and fries instead of the halibut and grilled veggies because "You deserve it. You're on call." Before I could contribute to my future coronary artery disease, the trauma pager goes off and I hand the delicious ham and cheese sandwich back to the cook and shrug, mumbling "Sorry. Trauma." I do my best doctor walk (you know, the walk where you don't look like you're running but you're tearing down the hallway on pace for a 4.0 40) down to the ER and work my way over to Trauma Bay 3. Ten minutes later the action starts as the paramedics wheel in the patient in a c-collar. My role is the lower extremity exam so I work on peeling away the patient's trauma-sheered pant legs, feeling for pulses, checking capillary refill, etc. The presentation of the patient begins.

"25 year old male was swimming with friends in the river. Dove off a rock and misjudged the depth of the water. Landed head first into shallow depth and immediately lost use of all extremities."

I examine the legs in front of me for lacerations, abrasions and such. The ED resident begins to talk to the patient.

"Sir, can you hear me?"

"Yeah," the patient replies.

"Can you tell me your name?"

"Mike." The appointed scribe sets out her form and begins to write in the elucidated info. "What's your last name, Mike?"

"Jergens."

Mike Jergens*. The two names snap together in my mind and I immediately glance up to the patient's face poking out above the c-collar. He had a beard now, but there was no mistaking his face. This was the same Mike I sweat and bled with during countless hours of football practice back in high school. He was a linebacker, I was a cornerback, and we spent more than a few hours shooting the sh*t in the huddle back in the day. I think back to my last vivid memory of him - also a Friday night, 7 years ago. We were walking off the football field my senior year, knocked out of the state playoffs in the quarterfinals in a royal butt-kicking from our local rival. He had cried that night in the locker room. I suddenly had the urge to cry myself.

I somehow pull myself together enough to help finish the triage and he is sent off to imaging. It would find that he had a C6-7 fracture dislocation. His cord was compromised. He was taken to the OR the next day.

Mike would eventually regain some motor use of his upper extremities. He had a long hospital stay with a rocky course including a ventilator-associated pneumonia. He was eventually discharged home 4 weeks later with a trach, facing a long road ahead I cannot even begin to fathom.

I never let him know I was there in that trauma bay. I tried to muster the courage several times to go visit him in his ICU bed, but the best I could do was to post a message on the website that had been erected for friends to send well-wishes and prayers. I still don't know what kept me from stepping into that room, but I carry a certain amount of guilt knowing that we now face such divergent paths in life. If anything, it has certainly helped me to gain perspective on how precipitous our lives can be and how quickly they can change. The minor annoyances in life, such as being "forced" to make small talk with an old acquaintance, are suddenly seen as blessings instead. An opportunity to see and know that that person is well. It's a strange world we live in.

As if to emphasize this point, the next night on trauma a patient in his early twenties was life-flighted in with nearly the exact same injury. He had dove into the river off a large boulder. Misjudged the depth. Landed head first in shallow water. But he escaped with only a hairline skull fracture.

It's a strange, strange world we live in.

* = Name obviously changed to protect his identity.

MedZag's First Night on Surgery

If there's one thing you can count on during your surgery rotation, it's that you'll have at least one occurrence a week where you will stop, survey what is going on in the room, and think in your head "what the f**k is going on in this room?!?" The residents take a certain amount of glee in finding ways to induce nausea and/or vomiting in the new, cute and cuddly little medical students on service. So of course on the first day of our rotation, with the knowledge they will be soon gaining some fledgling MS3s on service, the residents on my team saved all their *ahem* hands-on *ahem* floor work for the day for evening rounds when we would be joining them.

Case #1 was a patient we called Boss. Ms. Boss was the first patient I saw on my surgery service. Now keep in mind, I had just rotated off pediatrics, where I was used to seeing adorable kids all day. Sure, they may have been covered in poop, or really sick, or doing their due vigilance to prevent atelectasis by screaming for 23 hours a day, but they were still kids, and I freakin love kids. So we roll into The Boss' hospital room here I am confronted with a 350 pound elderly woman lying in her bed as Jerry Springer blasted from her television set. Our resident instructs myself and my fellow med student to glove up as it was time to change The Boss' wound. He peels back the dressing to reveal no wound but rather a massive gaping hole. You see, Ms. Boss had had a previous ventral hernia repair with a mesh. She got discharged to her nursing facility and the mesh subsequently got infected - necessitating removal of said mesh and all surrounding infected tissue. What was left was a 14" crater in her abdomen, with loops of bowel showing through a thin layer of tissue at the base. The tissue was still infected and I was immediately struck with the smell of... sherbert ice cream. Needless to say no sherbert ice cream was consumed this past month. So we get the supplies together and the resident gets to packing the "wound" with xeroform and two packs of kerlex. As I watch the resident place gauze on the exposed bowel, I step back for just long enough to think to myself: "what the f**k is going on in this room?!?"

Later on in rounds we come to a patient who the team had come to call Mr. Rabbit, for reasons which HIPAA will not allow me to explain but unfortunately not due to resembling a rabbit in appearance or size. Mr. Rabbit has originally presented to the ER with what was originally diagnosed as a rip-roaring case of panniculitis. As Mr. Rabbit was homeless and weighed in at a hefty 628 lbs, there was obviously quite a bit of pannus to become infected. He was taken to the OR where they found that while yes, his pannus was infected, it was actually due to a large sack of herniated bowel which was eroding into the skin. His hernia was reduced and he got a non-cosmetic panniculectomy (aka tummy tuck). The weight of his excised pannus: 78 lbs. So we reach Mr. Rabbit on rounds, now a svelte 550 lbs, who was beginning to show signs of a wound infection: rubor, dolor, calor, tumor (you have to say these in as dramatic a voice as possible). The team decides its time to open the wound to let it drain, a staple of proper wound care on surgery. The protocol for opening an infected wound is to (1) open, (2) assess drainage, then (3) follow the pocket of infection to get a sense of how large it is and where it tracts. For small wounds, this can be done with a wooden q-tip. For larger wounds, a gloved finger is often necessary. Our resident gloves up, removes the necessary staples, and begins to follow the pocket of infection. More and more pus begins to pour out of his abdomen. Despite his newfound surgically-enhanced physique, Mr. Rabbit still had quite a bit of subcutaneous fat, and before we know it, the resident has his entire hand, up past the wrist, inside the patient's infected incision. I stand back, take the scene in, and think... well you already know what I think.

The Bee Gees, Storage Closets, and Medical Education: A Thursday

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

It was my last day in the PICU and last day on pediatrics. I had come in at my usual time of 5:30 to pre-round on my patients. One I had carried for a week and was very familiar with and the other was a little boy with an epidural for who most of the heavy lifting had been done overnight. 7:30 came, I presented my last 2 patients, and rounds flew by, finishing ahead of time mostly due to our light census. It was looking like it was going to be a light last day, and that I would have time to fit in some much-needed studying for my shelf exam the next day. It was 8:30am and I had just settled down with a paper on PRVC ventilation when the voice on the overhead speaker system chimed on: "Code 99, 9th floor, room 4. Code 99, 9th floor, room 4."

The PICU chief takes off running down the hallway, the team a few meters behind. We arrive up at the code in under a minute, finding ourselves the first responders due to the fact that most of the attendings and residents in the hospital were a building over in morning report. Our team would be running this code.

A code in real life is nothing like in the television shows (big surprise). It is a much more controlled chaos. There isn't any yelling, pounding on chests, doctors screaming "don't quit on me! DON'T QUIT ON ME!," or any of the other stereotypes that people think of when you say the words "code blue." We had actually had a mock code for the residents and students with a sim-patient the week before - our institution is big on assigned roles and closed loop communication. So I settled into my role of information gatherer and runner: finding the patient's most recent labs in her chart, getting ice to cool the patient's body, running blood gases down to the PICU, etc.

The patient was a 3 year old little girl who was actually set to be discharged later in the day. She had nephrotic syndrome and had spent half a day in the PICU earlier in the week with some mild pulmonary edema. Her labs looked completely normal and she hadn't had any issues besides intermittent hypertension. While her parents were showering her that morning in her hospital room, getting her clean for the ride home, she suddenly collapsed and became unresponsive. Within 4 minutes of that moment she was receiving chest compressions from the PICU chief.

137 minutes of chest compressions, 8 boluses of epinepherine, 4 boluses of atropine, 4 boluses of bicarbonate, 3 doses of calcium, 3 cardioversions, 2 boluses of ibutilide, 2 IO lines, and a bolus of insulin later, there still wasn't a pulse. Since she was a previously healthy child and was remarkably stable during the course of her hospital stay and had started getting chest compressions so soon after her event, the decision was made to get her down to the PICU and put her on ECMO (cardiopulmonary bypass) in hopes that giving the heart a break would allow it to snap back into rhythm. She was wheeled down the hallway with my resident straddling her on the bed, continuing to give compressions.

Down in the PICU, her room was converted into a field OR, and the cardiothoracic surgeons arrive to prepare to get her on ECMO. I am standing outside the room, looking for more opportunities to help and absorbing the controlled chaos, when the chief turns to me and says:

"MedZag, why don't you relieve David from compressions. He needs a break and I think it would be a good experience for you."

My adrenals dump a massive load of catecholamines into my system. I somehow find a way to utter "Yes, sir."

During our "Transition to Clerkship Week" at the beginning of MS3, we were forced to re-certify in our healthcare provider BLS (basic life support) training. Which basically entailed kneeing on the hard ground in dress clothes for 2 hours doing practice compressions on blue plastic mannequins which looked like they got misplaced from the set of I, Robot. There was no way I could predict that in 6 short weeks, my mannequin would suddenly morph into this brown-haired little girl.

I gown and glove up and go and relieve the fellow doing compressions. I was determined to do everything exactly correct - probably a delusional desire in the given circumstances, but I became fixated on a study I remember reading where residents and medical students who were instructed to do chest compressions to the beat of the Bee Gee's "Stayin' Alive" were much more likely to hit to target heart rate.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

The surgeons incise in her neck and begin to dissect down to the carotid artery, a difficult prospect as with every thrust of my palm down into the little girl's ribcage, her neck jerks and blood flies into the air.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

I become fascinated by how strong her ribcage is. Sweat begins to bead on my forehead, my respirations steadily quicken, and my arms begin to burn as the lactate accumulates in my muscle tissues.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

This little girl was going to make it. She was supposed to go home today. This will be a fantastic experience to look back upon. I had images of the thank you card the PICU will receive when she starts first grade - the little girl grinning in a photo, missing her front baby teeth. The little girl who nearly died but now has her entire life, a full and rich life, to look forward to.

"Ah, ha, ha, ha, stayin alive, stayin alive. Ah, ha, ha, ha, stayin alive, stayin alive."

Bypass in on. Her body is once again receiving fully oxygenated blood. Chest x-ray shows everything is properly in place. Her heart regains a rhythm. Sinus. But 45 seconds later it fades. Asystole.

A repeat echocardiogram would eventually show a massive saddle embolus in her pulmonary arteries. You can't get blood to the body if blood can't get to the left heart. MRI and clinical exam showed absence of all reflexes and fixed, dilated pupils. There would be no first grade photograph.

I was in the room for the conference with the patients. Our chief explained what had happened. The scene felt surreal.

When stepping out of the room, one of the residents broke down in tears. The chief stares off into space. His words resonate in my head.

"Hope and pray that you never have to do that enough in your career that you get as good at it as I have."

Bypass was stopped 2 hours later. Within minutes, the brown-haired little girl, who should have been home watching cartoons, had passed on.

I was sent home to study for my shelf exam. I sat starting at my question book, but no studying would be happening that night. I logged onto the EMR and looked at her chart again. I looked at her echo again. I read the note I had written on her earlier in the week when she had been in the PICU. We had been instilled with the proper fear of a saddle embolus during our first two years of med school, but this was the first time I had seen one clinically and wanted to make sure all the information about the situation was seared into my brain. But mostly I simply sat there. And thought. I couldn't shake the feeling of guilt clawing at my stomach. This will be one of those centennial moments of my medical training: the first time I actively participated in a code, the first time I performed CPR on a patient, the first time I witnessed a truly horrific conference with parents, the first time I saw a member of the team collapse in tears, the first time I watched a patient die without forewarning. This was an important day in my medical career. But it is a sadistic reality that my education requires bad things to happen to good people.

So, to the patients of that little brown-haired girl: Thank you. Through your tragedy, I gained valuable experience that one day may perhaps enable me to save someone else's life. And know that I would gladly exchange all that experience for a picture of your daughter, clutching her pink backpack, grinning with her missing front teeth, on her way to start the first grade.

Tough week.

Death count for my PICU rotation: 4 and climbing...

Worst by far was the mother who found her 15 year old daughter down in her room. EMS resuscitated but her pupils became fixed during transport and she was brain dead by the time she got to the PICU. Her cerebral perfusion scan was eerie for the complete and total absence of all blood flow. It was like someone went in and performed a total lobectomy, the cutoff was so precise. Tox screen negative, all lab work negative, no signs of trauma, asphyxiation, etc. We have no idea why this perfectly healthy girl was suddenly found essentially dead.

There are true tragedies in this world.

Waste Management

There's a protocol around here for how you attack an infant with a fever of unknown source (FUS). Basically, the justification is that since babies can't tell you they're sick, and are at risk of serious infections, every one of them gets a full sepsis workup. Blood culture, urine culture, lumbar puncture, CSF culture, and a cherry on top - and then they get parked in the hospital while those cultures cook in the lab.

While I was on my general peds inpatient stint, we averaged around 5 of these a week; almost every day we have another "rule out sepsis" touchdown in our ward. They begin to blend together - a day or so history of fever, maybe some lethargy or poor feeding, occasionally some sniffles or a change in stool. The cultures always come back negative, of course, and if the bigwigs on Washington saw my life as a 30min episode of reality TV, they would be up in arms bemoaning the "Waste of healthcare dollars! Defensive medicine! Rabble rabble rabble!"

My last FUS was a little different, however. He also had the classic history - 2-3 day history of fever hovering around 101, not feeding as well, a little fussy. But mom didn't take him to the doctor. After all, its just a little temp. Babies get sick, it happens. Until she was holding him and watched his eyes roll back in his head as he stopped breathing and turned blue. EMS got him resuscitated, and that's when I met him in the PICU, after the damage had been done. That moment little baby turned blue, his body could no longer compensate from the bacteria and cytokine storm raging in his body. Brain MRI showed diffuse bilateral watershed infarcts; he was brain dead. Blood cultures taken in the ED grew gram negative bacteria.

That's the crazy thing about all this preventative medicine, rule out sepsis, empiric treatment mumbo jumbo. It lulls you into complacency until that moment it blindsides you. One of the classic lessons of medicine is "learning diligence"; to never settle with an innocent diagnosis until you have ruled out the dangerous ones. It's often a lesson learned the hard way. Would the money spent ruling out sepsis on that one kid have been worth all the money spent on the other kids ruling out sepsis? I bet you his mom would have said so.

The worst part of all about this case is that his blood ended up growing out Haemophilus influenzae type B. A bug he SHOULD have been vaccinated against. But mom was afraid of vaccines.

As one of the residents macabrely put it: "At least he never got autism."

You go Jenny McCarthy!

"Wow, I had no idea med school was so bad for you."

Medicine is full of ridiculous moments. To me, and my extremely sarcastic sense of humor, its one of the many (or few) areas of medicine that remain dear to me.

Queue Situation #1:
Patient Zzzz comes in for his routine physical (good for him!). He has had no significant medical issues, but his wife has a primary complaint, among many, that her husband snores so much that it seriously disturbs her sleep. The patient has gained 40 pounds in the past 2 years and is about 70 pounds overweight. He is pre-hypertensive. He complains of lethargy. He eats poorly and doesn't exercise.

Patient Zzzz: "So what can I do about the snoring? Isn't there some drug out there that can help me?"
MedZag/Preceptor: "We can install a noisy machine in your bedroom to help you sleep better. But your wife will likely complain just as much, and counteract said effects of restful sleep. Try exercising and losing weight."

Patient Zzzz: "So what about feeling tired these days? Isn't there some drug that can boost my metabolism?"
MedZag/Preceptor: "Well there's always methamphetamines. But if you're opposed to injecting your medications, or smoking them off of a knife, you can try exercising and losing weight."

Patient Zzzz: "My blood pressure has never been high. Why all of a sudden? Isn't there some drug you can give me to bring it down?"
MedZag/Preceptor: "If it stays elevated or continues to climb up, yes. In the meantime, you can try exercising and losing weight."

Patient Zzzz: "Wow, I had no idea gaining weight was so bad for you."
*MedZag smacks face with Phizer clipboard*


Queue Situation #2:
It's 11:37am. MedZag is in one of those wonderful "small groups" that medical school curriculum directors have some strange fetish with these days. Topic of the day: reading radiological images of the chest. After slogging through your typical lobar pneumonia, bronchiolar pneumonia, and miliary cocciciomycosis pneumonia (ok, maybe not so typical), we reach the highlight image of the day. The small group facilitator clicks his snazzy InFocus clicker and a spiral CT chest image comes onto the screen. The group gets to work analyzing the image. Mediastinum... clear. Outside the lungs... clear. Lurking in the lower right lobe is a fascinating bright "opacity." The group diligently examines said "opacity," and discerns that it is a cavitary invasive lesion of the bronchus. It was invasive. It was big. And the local lymph nodes were enlarged and bright. Likely diagnosis: squamos cell carinoma of the lung, a nasty lung cancer highly associated with smoking. We discussed his prognosis, which was poor. We talked about how bronchus epithelial metaplasia from smoking insult can lead to the development of SQCC. The group excitedly gives its diagnosis to the facilitator.

Facilitator: "Well duh. You all forgot the most important finding on the CT scan. Can anyone tell me what it is?"
Group: *best stoned pufferfish impression possible*
Facilitator: "Look in the upper right corner of the image."

There, sitting on the upper right corner over the CT cross-sectional slice, was a section through the pack of cigarettes sitting in the patient's front left pocket. Yup, here we are reading this poor guy's catscan, talking about how screwed he was from years of smoking, and the dude went into the scanner with the smokes still in his front pocket.


"Wow, I had no idea smoking was so bad for you."

Ah, medicine.

Ruminations on idiotitis.

Probably one of my favorite structures in the human body is the uvula. Maybe it comes from my childhood love of stalactites (nerd alert!), but there's something endearing about that little ball of mucosa hanging suspended from the back of your throat.

Little, that is, until it gets infected.

In one of the more bizarre medical presentations I have ever been around, a patient came in 3 days after having his uvula pierced. That's right, he pierced his uvula. Even more amazing, this sort of thing actually came up with a google image search.

Exhibit A:

On examination, his uvula had swollen nearly to the size of a golf ball and was at risk of closing off his airway. And stuck in the middle of it, like a hula hoop around John Daly, was his newly acquired uvula bling.

We checked his epiglottis, and that seemed to be golden, so he wasn't at immediate risk of asphyxiation and this was almost certainly a case of a non-sterile piercing. The #1 etiology of bacterial uvulitis is group A strep, but since this was due to direct trauma by an instrument we weren't sure what it was, so we took a culture and put him on some amoxicillin and told him to follow up in 3 days. But as a parting gift, the PCP also gave him an epi pen and told him to inject his uvula if he felt like he could no longer breathe, and that should buy him time to get to an ED.

Yup. If he felt like he couldn't breathe, and was panicking, he was supposed to take this pen, put it him his mouth, and inject the back of his throat. His eyes got pretty big as the doc told him that one. If he was looking for a little "badass factor" with his new throat ornament, I think he got a little more than he bargained for. But hey, every guy on a certain level has to wish he could do his own little personal re-enactment of the scene in The Rock where Nicholas Cage injects himself to save his life. I should have given him some green flares for dramatic effect.

Maybe I should convince myself I'm going to win the lottery.

Another story from preceptorship. A patient came to clinic last year convinced he had lung cancer. He was a previous smoker (1 pack/day for 10 years), but had no symptoms, no family history, no other risk factors, in his 40s, nada, zip, zilch. So the doc ordered a blood panel, guy was healthy as a horse, and sent him on his way. He couldn't even elucidate why the patient was suddenly convinced he had cancer.

Got a call from radiology at the local community hospital this week. The guy had presented to the ED with acute chest pain. Chest xray revealed multiple metastases in his lungs.

As the french say: déveine.

Say ah.

Patient is a 12 year old boy with a sore throat. Neighbor boy had strep throat the week before and the patient was exposed at a birthday party. Mom brings him in wondering if he has strep.

History includes a 12 hour fever (no thermometer used) two days prior which disappeared overnight. No headaches, chills, or malaise. Chief complaint is odynophagia. No mucous drip, stuffy nose, ear pain, or cough. Patient is afebrile and on examination has no tonsillar exudate, no erythema of the posterior pharynx. Tympanic membranes clear bilaterally. Only remarkable finding was petechiae of the soft palate.

Preceptor: "Mr. MedZag, what would you say is the likelihood of this child having strep?"

MedZag: "I'd say 20-30%. The fever course was too short, currently afebrile, no tosillar exudate or enlarged lymph nodes."

Preceptor: "WRONG! With the presence of petechiae on the soft palate, I would place his likelihood at over 80%. I might make you print the antibiotics prescription."

Fast forward 15 minutes. Strep test comes back... negative. Score one for the medical student.

The CENTOR score is criteria used to evaulate the pre-test risk of GABHS phayngitis. The patient is given a point for filling any of the following criteria:
:: Febrile (Temp >100F)
:: No cough
:: Swollen anterior lymph nodes
:: Tonsillar exudate/swelling
:: Age 3-14

Little Billy scored a 3 on the CENTOR score, which puts his pre-test probability at... drumroll please... 28-35%. Hey, 5% off ain't bad.

Can I get my marrow in gunmetal silver?

$350,000.

That's a lot of money. That will buy you a lot of cool things. For example:















A Rolls Royce Phantom


















A Necklace















A Yacht















A Nice House

And most importantly, it will buy you this:










A Bone Marrow Transplant.

$350,000. That's a mortgage to some people, but its also the mortgage on your life for people with leukemia and hematological diseases. Most insurance companies will cover some of it. Only the really good insurances cover all of it. And patients have worked out some really creative ways to raise the difference. Bake sales, fund raisers, church gatherings, newspaper ads, dances, concerts, you name it, it's been used to try to gain a cancer patient a second lease on life.

My preceptor's least favorite clinical encounter is when a patient comes in expecting to talk about their transplant, and instead has to talk dollars. Such is the reality in medicine where monetary value is assigned to human life. I was blissfully naive on the state of the health care system coming into medical school. During one of my admissions interviews, a physician asked me what I thought was the #1 problem with health care today. I replied, essentially, "Drug companies. Hiking those prices. Gotta cut 'em down."

*smacks forehead* It's a wonder I got accepted there.

But the more I learn, the more I learn there aren't easy answers. The system is broken and propagated by all members of it. Drug companies propagate it through advertising propaganda and skyrocketing drug prices, which are necessitated by the financial reality that they are just a few failed drug away from bankruptcy. Insurance companies propagate it by cutting corners (aka peoples' lives) to compensate for a drying up subscriber base as more people choose to hedge their bets and go insurance-less than pay unreasonable premiums (though I definitely have less sympathy for insurance companies). Patients propagate the system by expecting a level of care beyond which our economic model can support, refusing to budge in the voters booth when it comes to lowering their standards in order to raise the standards of the uninsured. And yes, physicians are culprits, having to walk the tightrope act between all parties, often having to compromise small aspects of their own personal beliefs in the name of the evil reality called "doctors don't make as much anymore, you got a family, and you're in a crapload of debt."

Last monday, we had to talk $350,000. A woman came into clinic with her 1 year old child - diagnosed with Hurler's Syndrome, a rapidly progressing genetic disorder which, if left untreated, kills its victims by the age of 5. A successful marrow transplant means a cure - even more so than kids with cancer can look forward to. The mom is in clinic and ready to talk transplant. Only problem is, the insurance doesn't add up. The policy is bizarre. It will pay for transport of the donor marrow to the hospital of transplant. But it won't pay for the HLA typing and searching required to find a donor. It will cover part of the cost of the stay during chemo and transplant, but not all of it. All in all, the mother's policy falls about $30,000 short of the full cost of transplant, and thats if the transplant goes without any complications - opportunistic infections, prolonged acute GVHD, and such. If such things happen the hospital bill can reach 7 figures, all on the mother's tab. The mother is not poor, so she fails to qualify for state aid. She is not rich, so $30,000 would essentially financially cripple her. My preceptor can do certain things behind the scenes to cut cost - ordering diagnostic tests from the endocrinologist so it doesn't count toward the transplant cost, using cord blood instead of a full marrow donor, etc, but we're talking fractions of total cost.

I found this case essentially profound for several reasons. (1) Hurler's syndrome is a ticking time bomb with rapid progression. In the time it takes to raise the difference, the poor child's bone, liver, and brain are slowly deteriorating, to the point where he may not tolerate the necessary chemo to produce ablation of the marrow, he may develop lifelong cognitive and orthopaedic disability (2) The transplant is a cut and dried cure. There is no risk of relapse, and we've gotten very good at managing transplant complications. (3) This is a 1 year old child. A child with a chance at a normal life, or just as easily a life riddled with hardship.

Like I said, there are no easy answers. And navigating the financial landscape of medicine is one of those areas we are simply expected to learn and find our way in. We can read articles and spout statistics, but ultimately it comes down to the human relationships we build with our patients and our oath to treat these patients to the best of our ability. It's hard to treat when your hands are in handcuffs. Every physician wishes they had an easy button to push to deal with these difficult situations, a money tree to go harvest to make everything better. But unfortunately the botanists are still working on that one.

Sorry for all the depressing posts lately. I guess thats a byproduct of rotating through a difficult specialty. But its the difficult cases that ultimately hold the truest lessons. I promise a couple more humorous posts soon. We start our last integrated class tomorrow, which will take me through mid-June and freedom. The light at the end of the tunnel is finally in sight.

Med School Poker

If there's one thing that every medical student knows, its that medical school is really just a bunch of humbling experiences all strewn together under the ruse of "education." Most people out there know that doctors are smart. And that they know lots of stuff. But I don't think anyone can truly realize how much there is to know and how much practicing physicians DO know as part of their daily functioning. I have studied day and night for 8 straight months and still am barely able to interact on a fairly elementary level. And just when you start to forget that and start to think you might actually be making progress on this whole doctor thing, bam, along come some attending wielding his massive sword of knowledge, striking you down from your high horse to go mingle again with the peasants.

Take for example today in clinic. I was talking with a pediatric hematologist about an interesting patient I was about to see with him - a 17 year old patient with Blackfan-Diamond Anemia. The typical first line of treatment for this disease (a erythroid progenitor disease that prevents red blood cells from properly maturing) is steroids in hopes of resuscitating the patient's own marrow's ability to pump out those cute little RBCs. So the physician was discussing the various steroid treatments they have tried on this patient and asks me "do you know what some common clinically pertinent adverse effects to steroids?" I proceeded to stare at him like a stoned pufferfish.

Now, deep in my brain somewhere, I actually know some "common clinically pertinent adverse effects of steroids." They include weight gain, hypertension, osteopenia, and psychosis. But like 99.9% of the things I've learned this year, they were stuffed into my tired and overfilled brain and subsequently left to dissolve back into this bizarre long term memory twilight zone where they come back to me during weird moments like when I'm watching Futurama on a Monday night (read: now), but never when I actually need them.

Massive Sword of Knowledge: 1
Me: 0

Of course, I currently hold the ultimate wild card: the totally awesome "I'm a first year" card. Play this card in any situation and the attending will smile with a fond reminiscence at you, reward you for demonstrating any shred of medical knowledge whatsoever, and then proceed to explain things to you at the level of a first grader. If you've been there, you know what its like, and its truly hilarious.

But like all good things, the totally awesome "I'm a first year" card will come to an end. In exactly 10 weeks (not like I'm counting) I will graduate from a cute little first year to a second year. And then I might be actually expected to know something.

Uh oh.