On becoming senior & Germanic terms that make us sound smarter than we really are

[Jan 28 08]

Ok, I know…

Some personal Geschtalt highlights this past week to better illustrate this arcane term:

• Asked to see a patient with pneumonia regarding changing his antibiotics, examined the gentleman, suggested to the doctor to consider speaking to the family about ceasing antibiotics and adopting palliative measures… the patient passed away that evening before either of my suggestions could be carried out.
• Consulted for fatigue, lethargy, decreased appetite in an elderly gentleman admitted to long term care. Patient seen and examined, when the nurse asked me what I thought of her patient, I said if gambling on diagnoses was ethical I’d put my money on cancer… Stage 4 Non-Small Cell Lung Cancer it was.
• Saw a patient in her 70s who was going to surgery to correct a hole in her bladder that had urine leaking into her abdomen. The surgeon told me it was either a tumour or Crohn’s. I politely raised Tuberculosis as something to include in the differential, he scoffed, she’s in isolation ;-)

Blair

A Series of Firsts [Oct 19 06]--It’s been a while since I last posted an entry on Big Medicine, but that is the nature of the Internal Medicine Residency. A program designed to immerse you (quite literally at times) in the art and science of medical diagnosis and management, occasionally letting you up long enough to realize how bloody exhausted you are while at the same time acknowledging that there isn’t a single other gig in the universe you’d rather have. It really is odd that way.

As is to be expected, the first three months of residency have been punctuated by ups and downs and more than my fair share of first time experiences. To give you a bit of a perspective from the eyes of an R1 (or Intern in some areas) I’d like to relay a few of these to you.

My First Day: July 3rd, Overnight in the Emergency Department doing Internal Medicine Consults. I arrived 30 minutes early as is my nature, and spent a good 15 minutes making sure everything was in order. Took some time to get used to my new long white coat, with its different pocket layout. I was paired overnight with a 2nd year resident, a colleague that I knew from the same medical school.

The contrast could not have been more evident. I was dressed in my pristinely bleached, still having the creases from the package, white coat. His was a stained and crumpled coat testifying to having paid his dues in the trenches of medicine. We took sign out and as we were about to tackle the box full of our work for the night I asked him if he had any pointers. Without missing a beat “Take your time on each case, have fun, and try not to kill anyone on your first night……. Oh and if you need me, I’ve got my pager”.

With that trite and yet totally reassuring pep talk under my belt I set forth into my night of firsts.

My first prescription was for an Insulin sliding scale. Perhaps fitting since as a kid I was fascinated early on by the discovery of Insulin. It was likely a combination of being proud of a Canadian discovery that saved countless lives and the fact that a seemingly crazy idea of taking extracts from a dog and giving it to a human being actually worked.

I moved on quickly to tackle my first case: Hypercalcemia; incidentally found in someone who came in for a cough. Hypercalcemia had always been my favorite electrolyte disturbance as a medical student (I’m an internist, give me some slack here), largely for the sheer elegance of its diagnostic workup and the relative ease with which it is managed. So I jumped into this case head first, requested the workup and in the end ended up with hyperparathyroidism, my first diagnosis.

The next day would be the shift with my first procedure. For most residents it consists of an IV insertion, Arterial Blood Gas or putting in a Foley.

Not me.
 

No Sir… My attending comes and tells me that we have a patient with a pleural effusion who needs to be tapped and that I should go prepare all the equipment. As I am gathering my supplies, preparing to stick a 14 Gauge Cathlon into a man’s chest I begin to wonder what the hell I am doing here.

Three days ago I was a medical student who would have never been asked to do this. What exactly happens at midnight on July 1st every year that we are all of a sudden competent and independent medical providers?

I spent longer than usual searching for that vacutainer as I reviewed the steps in my head. I had read about thoracentesis several times, I knew its indications, steps, and contraindications cold. I’d even seen two of them, which immediately conjured up chills as I thought of the See One, Do One, Teach One mantra our school employs. I’d also essentially done a nearly similar procedure before on the street as a treatment for a suspected tension pneumo, but this was different.

On the road you stick a needle in the chest of an acutely ill patient with the intention that if you don’t, they will die. Here I have a relatively well, stable guy who just needs some fluid taken off so we can make a diagnosis, slightly different stakes.

As I prepared my patient for the procedure I explained to him what I’ll be doing and the most amazing part for me is that he didn’t ask that question that EVERY R1 dreads: “You’ve done this before, right?”. As I continued with my longer than normal disinfection of the skin my attending gave me that look as if to say “Blair, Less stalling and more sticking of large bore needle into chest”.

Without delay I froze the skin and gently nudged my catheter into his pleural space. Perspiration had collated my mask to my face and my heartbeat remained in the nice maximal range until I saw that flash of amber coloured liquid in my syringe.

I believe at that very instant several people in attendance took a collective sigh of relief. I plugged the vacutainer and proceeded to take off about a litre of fluid. I explained that he might cough towards the end, a common event as the lung begins to re-expand.

As I passed on this golden tidbit he coughed rather violently and thrust back into my drainage apparatus. The fluid quickly changed from amber to grossly red. I muttered a few choice words that were about parallel with my breath, then removed the setup and applied pressure. My attending thought it was pleural irritation or a small vessel. I spent the rest of the day thinking I’d perforated his pulmonary artery or some part of his heart. All that night, as I couldn’t sleep, I dreaded coming in the next day to hear that he had gone to the ICU, the OR or worse yet the Eternal Care Unit as a result of my procedure.

At that time it became readily clear to me just how easily a physician can harm his patient, how I can take a relatively healthy person and quickly change their status. The patient did just fine, it was likely what my attending thought, but still that was a stat dose of humility and for the first time Primum Non Nocere was more than an easy way to sound smart by speaking Latin.

My first continuity of care took place about a month into residency. I was on the ward and was surprised to see a familiar face admitted onto our service. The patient I had seen bleeding in her washroom in my last column had survived to admission on the medical service. Proving once again, that when it comes to an individual patient the only statistic that matters is 50:50, it’ll happen or it won’t.

She was in a palliative stage of her liver disease, entering into and out of delirium as is so typical of hepatic encephalopathy. I had several discussions with her husband who was at her bedside, nearly round the clock. We talked about the course of her disease, how it was affecting him and what we could offer to take care of both his wife and his needs. For the first time I could say that I really had my own patient.

As a medic I worked in that snapshot of acute care; assess and stabilize, do the best I could to make that brief time with them as comfortable as possible. I always regretted not being able to have a certain degree of follow up. Sure you’d occasionally hear about the big cases, the cardiac arrest you brought back or that stabbing to the neck who you kept alive by tamponading their neck vessels with your gloved hand, but you never knew the rest.

Now I get to see and follow disease, get a real sense of what my interventions are doing and also support my patients and their family for more than 30 minutes. One Saturday morning that I was on call she didn’t wake up. I declared her, did the paperwork and called the husband. Continuity of care means dealing with all elements of the cycle.

Thus far there have been many similar moments to those I related to you above. Some nights are easier than others, some cases more straightforward and others that we never really do get a handle on. I’ve had the pleasure of working with health care providers from all backgrounds and levels, with different methods of training and approaches to patient care. Yet in spite of all this diversity, from the newest first-aider to the most grizzled veteran medic, from the newest nurse or greenest resident to the nurse who remembers the chief of surgery as a resident, there is one common theme amongst them. That unflinching desire to render assistance in whatever capacity possible to their fellow man.

There is one experience as a resident that proved this fact beyond a shadow of a doubt, my first Code Orange.

I was on the pulmonary service that day, hunkering in the ER’s isolation room reviewing my third rule-out TB consultation of the morning with the attending. Bedecked in our gowns, gloves and N95 masks my EMS pager buzzed with a message from a colleague watching TV that there had been a shooting at Dawson College. As we exited the negative pressure room and removed those infernal masks the code orange was called, preparing our hospital for an external disaster.

Within minutes the whole hospital came to life. The ER was cleared of any patient who could tolerate the move and the emergency cart was wheeled up with all the additional supplies one could possibly have to use. There was an influx of nurses, pharmacists, unit agents, technicians and physicians of all varieties… some who came in early for a shift or just on their own accord, after hearing the news. Others quickly closed in the OR or interrupted rounds in the ICU to be ready to lend a hand. Amidst the countless bodies in the ER patiently waiting for the influx of patients, people were not wondering how this could happen, nor musing as to how many shooters there were or what video game they played. Each and every person was uniquely focused on making sure that the patients who would come in that door would get the best care our hospital could offer.

Throughout this crisis I stood in the nursing station and watched. Far enough away not to interrupt, but close enough to lend a hand if asked. At a colleague’s request and a throwback to my dispatching days, I kept my eye on the phone from the ambulance service that would announce incoming patients. Mostly though, I watched what was truly an unforgettable sight. We ended up getting 2 non-critical patients, each of whom was likely seen by 10 specialists within the first 5 minutes (take THAT golden hour).

Despite the paucity of patients that day, I can honestly say that amidst one of the darkest hours of my fine city’s history I was able to find one of my proudest moments as a member of the healthcare community.

To all those who answer the call: Cheers and Good on ya!
 

Cycles [Jun 28 06]--I’d like to take you back to a time in your life.

In the time leading up to the day you are filled with a sense of excitement, anticipation, fear and perhaps even a little dread. Your daily activities are occasionally permeated by visions of what that day will be like.

The night before you try to get a good night’s sleep, but your mind is racing and thoughts are flitting. You awake over an hour before you set your alarm, check to see if anyone else is up and saunter to the kitchen to pass the time with cheerios and milk. After what seems like an eternity of watching the numbers on the stove’s clock turn you are joined in the kitchen. The subsequent activities are a mere blur as people scurry about making last minute changes amidst harrowed requests to “please hurry up”.

Yes… I’m referring to that day we all remember so fondly, the first day of school.

This time may be more remote for some than others, but the feelings associated with it are so universal and strong that I don’t really feel the need to describe them further. As I sit now one week removed from the start of my residency these feelings are brewing again deep within me and truly the similarity between these two occurrences is uncanny.

The night before my first day I will lay out my new hospital clothing, be sure I have socks that match and fill my “schoolbag” with all of my supplies. I’ll go to bed early with good intentions and undoubtedly spend the better part of the night tossing and turning with excitement and a good healthy dose of self-doubt. I’ll awake early in the morning, completely unrefreshed after three furtive hours of sleep. This fact does not bode well for someone doing the first night shift, but I suppose it is a professional reality for the next several years. Gone is the bowl of Cheerios, replaced instead by the travel mug full of coffee and whatever leavened product is easily available in the kitchen. I’ll walk myself to the bus and arrive at the hospital, well in advance of the orientation session and choose to mill about outside rather than be the first to enter the classroom.

I’ll wait until someone breaks the ice by entering or more likely an administrator pops their head out to beckon the nervous gathering crowd inside. We’ll sign the attendance sheet and grab an envelope with our names on it, possibly even containing a “Hello my name is….” sticker!! I’ll scan the class looking for a familiar face and be sure to sit next to them and not really make an attempt to engage the new foreign faces in conversation.

Our chatter will be silenced by the entry of the attendings and chief residents. One by one they’ll go over the rules of the hospital, give introductions and as in grade school point out one of the more important facts, the location of the restrooms (though hopefully now we don’t need to ask for permission, nor go in pairs). We’ll sit eagerly awaiting the first recess break, with that fruit roll-up or prepackaged pudding now also replaced by a cup of coffee, and resume our banter.

I get a chill down my spine every time I think about this… in some ways, I really do miss grade school, with its glue sticks, coloured pencils, Velcro shoes and school nurses to take care of you… ok fine, I’ll kind of have the latter now.

Since I last contributed not too much has happened. I had some dental surgery, read books that I personally wanted to read for the first time in quite a while, did a whole bunch of shifts back on the ambulance and I attended my medical school convocation.

It would be far too easy to quickly gloss over my medical school graduation and that is something that I’d like to point out. It is disheartening, though not surprising that the rich historical nature of this ceremony has fallen to the wayside. In its current incarnation convocation ceremonies are one huge big commercialized photo opportunity. Professors get all fancy in their academic robes, the graduands don their cap, gown and hood all because these are what is needed for the picture. You know the one that will be hung on the wall or kept in grandma’s wallet to be broken out when she speaks about how proud she is of you to her friends at the hairdresser. Now I’m not naïve enough to think that this disregard for the historic or traditional nature of a ceremony is unique to the convocation process. It’s a generalized trend of our generation, perhaps most popularly known in the commercialization of Christmas. Yet there is a difference. Just about everyone knows the story of Christmas and what that holiday is supposed to represent, many just choose to ignore it and focus their celebration in other more personal manners, be it conspicuous consumption or just plain family together time.

Convocation on the other hand is one step closer to extinction in that just about nobody who partakes in it knows the historical and symbolic nature of the ceremony. If you were to ask my fellow graduates about the regalia we were wearing you’d likely get responses such as: “They’re just what we wear at graduation”, “Its pretty cool….”, “I think they look great” (I do agree with the last comment, and frankly intend to wear a full academic regalia, complete with doctoral hood and cap at least once in my medical career on rounds…. But that isn’t the point here). We have forgotten the origins of universities amidst the medieval trade guilds. We don’t recognize the convocation as the gathering of the guild of master teachers before their soon to be colleagues. We choose to throw it up in the air haphazardly, rather than take the time to realize that the biretta or square academic cap has the exact same shape as the master mason’s mortar board. Few with a Bachelor’s degree know this term alludes to the apprentice of a small land owner and equally few physicians know the term Doctor, literally means to teach.

So convocation now is about dressing funny, enduring speeches, walking across stage to get your degree and posing for countless pictures. I suppose this is the way we now choose to mark this important change in our lives, but one can’t help be just a little bit discouraged at this loss of history.

I’m going to end this piece with a story from a recent EMS shift of mine, that really reinforced in me the importance of pre-hospital care and I don’t mean clinical intervention.

I was working the day shift with a relatively new, but quite competent partner. The tones dropped for a 82 y/o F with potentially life threatening hemorrhage. I through our truck in gear and coaxed our venerable turbo diesel to give me at least one more good run. We pulled up to the building, grabbed our gear and headed into the apartment. We were greeted at the door by the clearly anxious husband of our patient who in a hurriedly, albeit jittery manner pointed us into the washroom. The floor was covered in fresh bright red blood, that per the patient was rectal in origin. In the tight confines of the bathroom my partner gloved up and set about his assessment as I took the husband aside for more information. As I held his hand, the tattoo on his forearm indicated to me that he had survived far more than 60 years of marriage. I looked him in the eye and told him that we’d take the best possible care of his wife and proceeded to gather a history to try and piece this all together. He answered politely and concisely, as if he’d done this far too many times before, though the flow of our conversation was interrupted several times by his apologies to me for being so nervous. I learned that his wife had idiopathic cirrhosis and had been in and out of hospital several times, a quick look at her medication list showed Pantoloc and Propranolol leading me to suspect she had likely bled before. I thanked him for his help and asked him to prepare everything we would need for the trip to the hospital and returned to help my partner with our patient. She was pale, anxious and her significant oedema and floridly ascitic abdomen attested to her diagnosis. My partner reported a strong bounding pulse at 120 with a pressure of 140/80…(The body’s ability for compensation truly is mind blowing) The most striking feature of the physical exam though, was her eyes. She had that look that every EMT knows all too well. The longing, but silent gaze asking “Am I going to die?”. On this my partner deferred to me. In an instant I flashed to my time on the transplant service, mentally recalled the mortality of a GI rebleed in cirrhotic patients, factored in her vital signs and knew the answer. I calmly and thoroughly explained to her what was going on and the need for her to be evaluated and treated quickly in the hospital and seeing which team was on the transport crew, reassured her that she would be in good hands. To which she replied “I already was”. I gave a quick report and they knew full well this was a patient to load and go. As they were loading her into the ambulance we again looked at her eyes. This time there was a degree of resolve/acceptance, but more important to us was the absence of anxiety. Her husband thanked us profusely and apologetically as I helped him into the front seat of the transport unit.

As prehospital providers we go on countless runs where all we seem to offer is transport, vital signs and perhaps some oxygen and we question what our role is. This symptom is commonly associated with the “I'm just an EMT syndrome”. Sure it is nice to spike a line or push lasix, but that doesn’t replace nor negate the paramount importance of pre-hospital emergency CARE. The importance of the work done by the personnel in this field cannot be understated. I don’t know if this patient survived once she was hospitalized, but I do have a sneaking suspicion that the time we took to treat her as a person went a whole lot farther to her overall well being than a bag of saline would have. People ask me why as a doctor I still feel the need to work in a limited scope first response service. The effect we can have in these situations is unparalleled anywhere else in medicine. While religion may be the opiate of the masses, most prehospital workers would take a mainline of calls like these any day of the week.

I realize that my entry today was really three smaller and seemingly disjointed pieces. Yet when you look at all three on a broader scale, it is kind of fascinating to see the trend of cycles. In spite of the stochastic nature of our universe and the freedom of human self-determination, some things just happen again and again…

I’ll check back sometime after my first day of school as a teacher.
 

On the jingling of 'change' [May 12 06]--I’m sitting now at the end of medical school and on the cusp of my residency. Truly an impressive time of transformation. As I sign contracts and insurance forms, it quickly becomes apparent to me the responsibilities that I am about to assume.

I no longer get to use the well-worn answer “That I’m Just a Medical Student” when answering patient’s questions. No, now I need to introduce myself as Doctor Schwartz and fight that urge to use those finger air quotes as I say doctor. I can sign my own orders for Tylenol™, perform procedures, fill out mountains of paperwork and work 30 hr shifts all on my own.

Yet, in spite of all these awe inspiring changes, right now, the one I am perhaps most looking forward to is being able to finally wear a full length white coat.

You see, as if the endless scut, and running around doing others bidding wasn’t enough, we medical students were imposed one final subjugation: The Short Coat. It looks impressively like the standard white coat, with the final indignity of ending just below your butt. I'm sure there is some perfectly good historical reasoning for this decision, but one can’t help but ponder some ulterior and perhaps unsavory motives. All the same, it certainly does make for an interesting look as the ward team meanders about on its rounds.

The wizened attending in the lead, making small talk with the chief/senior resident amidst forced laughter all adorned in their long white coats. This group is followed by the junior residents, also adorned in the venerated long coat, out of earshot from the lead party whilst torn between straining to hear what was being discussed in front and carrying on their own banter about lack of sleep or poor progress of contractual negotiations. Lastly there are the medical students, easily discerned in the short coat, scurrying along at a frantic pace, hoping that the guffaws from up front are not in reference to their recent miscue and scouring the floors to pick up ANYTHING someone from in front may have inadvertently dropped.

I’ve witnessed this scene from within and as an innocent bystander and I can never help but to think of a medieval army. Led on by the horse mounted knights and their lord, followed by the well trained and venerable armored foot soldiers and at the rear are the efficient, methodical but defenseless and largely expendable archers.

The white coat is certainly a hot topic in the medical community, with physicians divided as to whether we should in fact still be wearing them. The theories surrounding the origin of this garb are diverse. Some claiming that by adopting the traditional garb of the “scientist”, physicians were attempting to portray the scientific nature of their craft and separate themselves from the numerous charlatans of the day.

Others take an elitist approach, that the donning of a pure white healer’s habit set a hierarchical boundary between the physician and patient as recommended by the medical ethos at the time. Still others are more practical and smock-like about it, why would you want to expose your clothing to the myriad of medical fluids that you encounter on a daily basis?

Whatever the origin, it certainly is a hot button issue with some branches, most notably psychiatry, leading the charge AWAY from the white coat and other disciplines leaving it to the individual physician to make the choice.

As a future resident, I am a member of the clan of those who do wear a white coat. Not because I think people need to be convinced of my scientific nature, nor my superiority or even to protect my clothing, because lord knows I don’t own anything worthy of protection. It is however, a functional decision. In spite of all the history and symbolism, for the average resident the white coat is a functional object and thus I present to you:

The Anatomy & Physiology of the White Coat.

Firstly, the white coat should be well fitted. Square on the shoulders with a loose flare towards the bottom. The latter is absolutely imperative as it permits the coat to billow out in an awe inspiring cape like manner as the physician rounds the corner into the hall en-route to an obviously important intervention. Then we have the accoutrements, often consisting of an ID card which serves to inform all who will take the time to read it that we do indeed work here. In addition to the ID card there are the pins, an attempt to express some sort of personality in the often bland medical machine. Some will go for the flashy waiter look and adorn every empty space with a button of some sorts. I choose to wear a small silver Maltese cross indicative of my membership in the Order of Saint John, but also because I love the confused looks from hospital staff as they try to figure out why a Jewish doctor is wearing a cross.

Then we have the pockets… oh the pockets!

The breast pocket is where we keep our pen light. It will fall out frequently & break, or be lost in the halls of the ward. It will never work on the rare occasion we actually need it, and yet, in spite of this we always buy another one. It is kept company by the pens, and much like a swordsmen has blades for every purpose, we too have a role for each pen. First there is the “throwaway”. Often a pen that we grabbed from somewhere, a cheap pen; perhaps picked up at a hotel or from some pharma rep. It is what we use for a quick signature, to jot down a note or two on rounds or when someone asks us to borrow a pen. Quick and dirty, it is akin to the dagger. Then we have the “writer”, the workhorse of the day. This is the pen we truly cherish, the one we purchased from the office supply store. We admire its grip, the manner in which it writes and its overall elegance. We use it to write orders, prescriptions, progress and admission notes. Like the old English Longsword it is our trusted companion and we would never go into battle without her. Some amongst us have the fortune of a “fancy pen”, perhaps a gift upon graduation or from a grateful patient. With names like Cross™ or Mont Blanc™ these are seldom seen out in the open, but like the ceremonial swords of the Queen’s Own, they do come out on special occasions.

Then we have the index cards. What once infused fear by its association with learning my multiplication tables has now morphed into the multi-purpose information recorder. Be it lab values, tests to check, patient information or the home phone number of that special someone they store them all. No coat pocket is complete without a stack of crisp white index cards and already used slightly grey ones strewn about.

Then there are the pocket guides. Varying colours and sizes covering a wide array of medical knowledge, from pharmacopea to anti-microbials and everything in between. These are the resident’s crutch, a tool to double check that he is not about to prescribe someone 10 times the lethal dose. Then there are the miscellaneous medical supplies: gloves, tape, gauze, tongue depressors, culture swabs, cathlons, vacutainers…etc, anything that a resident may need in the course of their day (and you thought paramedics had full pockets).

Then we have the large amounts of loose change. It would seem folly to include something that is a nuisance to many in a treatise on the white coat, but its importance can not be overemphasized. Some might say that AMEX is what nobody should leave home without, but remember the coffee machine at 03h00 doesn’t take credit.

I’m filled with both excitement and what I hope is a healthy apprehension about my upcoming transition. I know it won’t be an easy journey, but I have to admit that I just can’t wait to slip into that long coat and hit the wards. Just remember to listen for the jingle from the bottom of the coat pocket, and when you do hear it, smile quietly to yourself knowing that you are in good hands.

Be well and practice Big Medicine.