Month: February 2021

Sunday and Monday with the trauma service team. They don’t expect much from students this week because they know that we’re thinking about the exams that start on Tuesday. Ted, my chief, tells instructs me, “You can go study in the student lounge. We’ll let you know if anything interesting pops up.”

There are only 183 UWorld surgery questions. It takes about five minutes per question, each of which has five possible answers, to pick an answer and then read the explanations associated with each possible answer. I have studied all but 44. M4s and previous clases recommended getting through the Internal Medicine gastrointestinal and pulmonology questions as well because they all overlap with the Surgery SHELF exam. Surgeon Sally and Christian Charlie both finished the 113 GI and 123 pulmonology questions on top of the surgery questions.

In the ED, we have a skinny 26-year-old patient who was in a head-on collision. He is in no apparent distress, with some minor hip pain that is well controlled on 5 micrograms fentanyl. An x-ray shows a femoral head (top of femur) fracture extending into the acetabulum (hip bone). Was he drinking? He replies in a muted, monotone voice: “No.” Use any drugs? “I’ve used meth and heroin in the past. I wasn’t using anything.” Nurses keep telling him how amazing it is he came out with only minor injuries after a 65 mph crash, but he doesn’t perk up.

What do you do for a living? “I worked in a mechanic shop, but I’m between jobs. I lost my job two weeks ago.” He shrugs. “It’s whatever.” Ted joins me in the ED, recognizes the last name, and we admit the patient to our service (“trauma”), and consult orthopaedic trauma service. Our job is mostly coordination with more specialized services.

We are placing orders in the ED when the patient’s father and mother arrive. The father is a well-respected doctor in the hospital. Out in the hallway, the parents report that their sonhas been diagnosed with schizophrenia and major depressive disorder, but refuses to seek help for the past two years. “He’ll live with us for a few weeks, then we won’t see him for moths. He currently lives out of his car.. He’ll keep a job for a few weeks to get money for drugs, then quit.” We go back in and ask about his psychiatric history. He admits that he purposefully drove across the yellow lines into traffic. (The mother and back-seat child in the other car were not seriously injured and had been taken to a hospital without Level 1 Trauma certification.)

We place him on suicide precautions (1-1 sitter, paper gowns) and consult psychiatry. A classmate on the psychiatry service shows up. We interview the patient together. He reports that he has no active suicidal ideation since he drove into the oncoming car. The job of an inpatient psychiatrist is to determine whether the patient needs to be admitted to the psych after being medically cleared by the primary team. Even a patient who tried to kill himself 24 hours prior does not meet criteria without active suicidal ideation. Therefore, he will be referred to follow up with a different psychiatrist in an outpatient clinic two weeks later. It is the patient’s responsibility to call and make the appointment and then show up. Everyone knows that this won’t happen, but nobody takes ownership of the patient’s mental health and, even if the patient did take the necessary initiative there would be no continuity of care.

He undergoes surgery that evening for his hip. We also get a consult for radiation oncology. Why? Fractures that involve the acetabulum have a high risk of developing impingement as remodeling creates spurs into the hip joint. To prevent this, there are two options, a two week course of strong NSAID, or radiation to the hip joint to stop remodeling. He undergoes radiation the following day.

Tuesday is the simulated patient exam, starting with with mesenteric ischemia (poor circulation to the small bowel). I walk in to a screaming 60-year-old. The challenge is to perform a physical exam while she is squirming on the bed in pain. After the encounter, I’m writing a note and able to view the PMHx (medical history). The diagnosis becomes clear after reading about the two previous heart attacks and paroxysmal atrial fibrillation. The second patient has classic cholecystitis (inflammation of the gallbladder). The patient reports nausea, vomiting and RUQ abdominal pain. When I ask her to take a deep breath while applying pressure under her right ribs, she jumps off the table (positive Murphy’s sign). She also fits the “Fat, forty, female and fertile” saying for gallbladder pathology. 

The SHELF exam consisted of 110 questions over 2.5 hours. Questions were mostly second order. They would present a patient, and you would have to determine the initial management step for this diagnosis. Examples:

1. A patient with sudden onset of abdominal pain and vomiting presents to the ED. Pain localized midway between umbilicus and RLQ. Should the patient under surgery, CT scan or ultrasound? (Older docs would be content with a clinical diagnosis of appendicitis, but the board wants CT confirmation.)
2. What is the work up of an elderly patient with painless jaundice? CT scan or an endoscopic retrograde cholangio-pancreatography (ERCP, a procedure where a scope is placed down the esophagus into the stomach and duodenum; contrast dye is injected into the biliary tree under live x-ray to evaluate for any stricture or gallstone obstruction)?
3. Should you give antibiotics or undergo surgery for uncomplicated diverticulitis?
4. Patient with air-fluid levels on abdominal x-ray. Surgery or aggressive bowel prep?
5. What is the most likely loss of function for a midshaft humeral fracture? Axillary or Median nerve palsy?

I got 79 percent right. The mean across all medical schools is 74 (standard deviation: 8), but these are averaged without regard to rotation order. Surgery, Pediatrics, and Internal Medicine are known as the most challenging SHELF exams. Studying more wouldn’t have helped much. Recommendation: study the indications for exploratory laparotomy, management of appendicitis, and cholecystitis.

My Step 1 score is back. As the exam questions are changed, it takes a few months before any scores can be calculated. I get 237, disappointing because my last two practice scores were 245 and 252. (Passing is 194, mean across all medical schools is 229 with a standard deviation of 20.) Starting with the questions and practice exams earlier in the year would have helped. The best strategy seems to have been starting the UWorld questions in August and resetting the program to go through them again during the study period. Jane didn’t do that, but she made it through all of the UWorld questions and snagged a dermatology-worthy 249. Our Dean of Student Affairs is ecstatic with the class average score of 239.

[Editor: The 237 should be fine for dermatology if our author/hero checks the “Related to Elizabeth Warren in the Remnant DNA Tribe” box!]

Statistics for the week… Study: hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with Mischievous Mary, Lanky Luke and Geezer George.

The rest of the book: http://fifthchance.com/MedicalSchool2020

Full post, including comments

After a Sunday reprieve, Monday begins two back-to-back trauma alerts that force us to cut rounds short.

A 16-year-old 220 lb. 6’6″ African American high school football star flipped an ATV during a morning ride. As he is transported onto the trauma bed, he repeatedly screams, “I can’t move my legs!”. He has no movement or sensation in either of his legs. A CT shows numerous vertebral fractures. Most likely complete transection of thoracic spinal cord. Neurosurgery is consulted. Nothing to do now but wait. The attending: “We won’t know final outcome until about 48 hours when spinal shock resolves.”

He spends two weeks in the hospital working with physical and occupational therapy. He is paralyzed in both legs. He becomes agitated and aggressive with the therapists, calming down only when his mother and brother are present (there is never a visit from the father and we are trained not to ask). His football team visits after one week in the hospital. After one week, he is ready for rehabilitation, but the social worker struggles to find a good child rehab facility that will accept our state’s Medicaid insurance. My attending: “He would be a fantastic candidate for a few out-of-state adolescent rehab facilities, but I doubt this state’s Medicaid will cover them.” I am reminded by the young paraplegic who was admitted last week for a Stage IV decubitus ulcer (to soft tissue or bone) and sepsis rule out. If he does not take care of himself, this will also be his eventual fate. 

The next trauma alert arrives while the 16-year-old is in the CT scanner. An 18-year-old presents with a gunshot wound to the right leg. He appears stable, with intact pulses and sensation in the lower extremity. EMS reports that he was running away from a gang shootout (our patient is African American; perhaps he got on the wrong side of our active Hispanic gang, MS-13). Somehow the bullet missed all vital structures, just piercing muscle and fat. The attending comments: “The cardinal rule of trauma is that only the good die. If you are a productive member of society, paying taxes, a respectable member in the community, father of three, then that bullet will have bounced off the femur into the abdomen ripping up the pancreas, and piercing the lung. If the patient is a gangbanger, then it’ll just miss everything. The good die young.” I throw a suture in the entry wound, and we admit the patient to the floor. (I heard a news story about the gang battle during the drive home.)

We continue rounds where I meet an overnight MVC admission from yesterday. He is a suboxone clinic patient (monthly group therapy for opioid abusers ending in the dispensing of opioids) and is anxious to avoid being stereotyped as an addict. His trauma from the car accident was not severe, but the ED gave him tons of pain meds to overcome his years of tolerance for opioids.

He has not had a bowel movement in three days so we explain we need to transition him from scheduled Q6H (every six hours) to “as needed” narcotics. We propose scheduled acetaminophen and NSAIDs (e.g., Advil) with breakthrough Toradol for pain control. “Oh I don’t want that stuff. NSAIDs are bad for you.”

The rest of the week is uneventful except for another ATV accident, this time in a 14-year-old. She has a Colles fracture (fracture of distal radius from falling onto outstretched hand), and a few abrasions. We also have two elderly ground falls requiring hip surgery: trochanteric fracture requiring pin, and femoral neck fracture requiring hip replacement. 

I had expected two weeks of running all around the hospital in response to urgent pages and watching dramatic life-saving surgeries. Instead, despite the best efforts of our local gangs, drug abusers, seat belt scoffers, ATV enthusiasts, and motorcycle riders, it was mostly waiting around. We had more “trauma” during the week of nights (Year 3, Week 3). Much of “trauma” turned out to be social work, e.g., predicting who would be a motivated candidate for inpatient rehab and persuading insurance companies that OT/PT will be effective. Patients may occupy a bed for a week receiving no significant care while the social worker enrolls the patient in Medicaid and then negotiates with Medicaid regarding the new beneficiary.

Summary of two weeks of trauma: I learned the ABCs (Airway, Breathing, Circulation) for initial trauma evaluation and some fracture management. Work started just after 6:00 am and I was usually gone by 4:30 pm. The emergency surgery service option probably would have been more educational due to its higher caseload.

Saturday: Jane’s sister is at the hospital until 10:00 pm, well past her 7:30 pm scheduled shift conclusion, and stops by our house on her way home. “An 18-wheeler going 65 mph hit three highway workers, father, his son, and the son’s best friend. The father dies on impact, the 30-year-old son is medevaced to our hospital, and the best friend is medevaced to an outside facility because our ICU is full. Now, keep in mind about 30 minutes before he shows up, we get a self-inflicted GSW [gunshot wound] to the chest resulting in a massive pulmonary contusion and injury to the IMA [inferior mesenteric artery, supplying the colon]. He had shot his girlfriend who had died in the trauma bay. So we have one patient who is bleeding out into his chest and abdomen, and [Dr. Cruella] comes running in and performs a bedside thoracotomy [opening of the sternum and ribs] and x-lap [exploratory laparotomy] on the GSW. Meanwhile, we are coding the 30-year-old as he goes in and out for 30 minutes of VFib [ventricular fibrillation, serious cardiac arrhythmia]. His wife is crying holding their one-year-old daughter. Dr. Cruella is running between the GSW and the highway worker. We finally get both patients stabilized. He is brain-dead, but everyone except Dr. Cruella is in denial. We perform two nuclear perfusion scans before the wife accepts.

“Time of death is called. My CNA [certified nurse assistant] and I then have to deal with post-mortem poops before the family comes in. And let me tell you, post-mortem poops are the worst. Everything comes out. Worse than C diff [clostridium difficile infection of colon]. I tell my CNA to watch out as we turn him. As we’re dealing with this, three gigantic birds, maybe vultures or something, fly right up to the window. It was the freakiest out-of-this-world experience ever, like a sign from God. [coworker nurse]’s jaw dropped. Was that the three souls leaving this world?

“After we cleaned the room and changed the sheets, my coworker and I offer to get a handprint for the daughter. The wife thanks us. We then realize he has a huge cast on his hand. We try prying it off, then ask if a footprint would suffice. We then don’t have enough ink in the ICU so we’re struggling to just get a toe print. We eventually find some from upstairs. The family comes in to say their farewell before we remove him from life support. They stay in the room for more than an hour.”

Statistics for the week… Study: 12 hours. Sleep: 6 hours/night; Fun: 0 nights. Jane and I grab a beer Friday evening, and then study the weekend away before exams.

Full post, including comments

After sleeping all day Friday and Saturday, I am nearly recovered from a week of night surgery and it is time to start a two-week trauma rotation. Morning report starts at 6:30 am with M&M (morbidity and mortality).

“Ted,” a burly, soft-spoken 6’4″ 32-year-old PGY4 resident described by Surgeon Sara as a teddy bear, is presenting a trauma case on a MVC (motor vehicle collision) patient in hemorrhagic shock from abdominal bleeding. The case was chosen because the team deployed an aortic balloon to maintain blood flow to the brain before exploratory laparotomy. Ted wants the entire surgery team to be familiar with the proper uses and indications for an aortic balloon. The attendings reduce Teddy to blubbering as they grill him on management of this patient. My former chief comments as we walk up the stairs: “[Teddy] was stumbling, but he was answering all questions right.” After M&M, we head up to the floor to round on our twenty trauma patients, fifteen of which are fractures following falls, ten from alcohol and five from old age.

I am assigned a 21-year-old patient beginning her second in the hospital following an MVC that resulted in an epidural hematoma (bleeding in the skull) and multiple fractures. She was driving back from work at Subway when a drunk driver hit her head-on at about 45 miles per hour. She was ejected from the car. Most of the ICU team did not expect her to recover any brain function. She has become somewhat of a miracle on the floor as she has regained consciousness, primitive motor function, but is cognitively at the level of a 5-year-old. She underwent emergent craniotomy by neurosurgery to release intracranial pressure from the epidural hematoma. She has a wound vac (sponge-packed wound hooked up to a continuous vacuum) on her scalp from the craniotomy site and a tracheostomy tube that can be capped to allow her to speak. The trach does not bother her as much as the spine brace that is needed for several weeks due to her cervical and thoracic vertebra fractures. Her 45-year-old mother stays quiet in the back as we pile into the room.

(The drunk driver was placed in the ICU bed next to her and passed away a few weeks ago.)

Rounds last about two hours as we go room to room for each trauma patient. I meet my 38-year-old attending. At barely 5’4″ she is known to put chills in medical students and residents alike. She is also Jane’s role model in surgery.

(We met her in Year 1, Week 17, starting a meeting of a “women in surgery” interest group:

There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction. Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.

)

Dr. Cruella says that we deal with “bullshit” faux trauma (e.g., drunk person falls and is screened for head injury) rather than transfer patients to the internal medicine service or orthopedic service, as was conventional at the hospital where she trained. Her theory is that this relates to enhanced revenue if a trauma note is dropped into Epic. After rounds, we head to the OR for a rib plating (one plate per broken rib) on a 60-year-old alcoholic who was run over by a car after he passed out in the middle of a road. Eleven ribs were broken, but miraculously he suffered only a mild lung contusion. 

Dr. Cruella hasn’t used this brand of rib plates, so the manufacturer’s rep is here to teach her how to use the drill and deploy the plate. After she gets the hang of the equipment, she asks about my background. She describes her experience as a resident. “This old guy in the ‘golden age of surgery’ used to sexually harass every female — med student, intern, resident, nurse, you name it — except the surgical techs. He would never mess with a surgical tech. I was writing a note as a second-year resident and he pulled down my scrub pants in front of the entire OR.” 

Had she ever been written up for unprofessional behavior? “I got written up for intimidating the blood bank personnel. I was doing a splenectomy and we needed blood urgently. We kept calling the blood bank and they said they would bring it down. I called two more times, and finally they tell me they need a form, which they could have told me right at the beginning. I had to speak with the Chair and attend anger management.” Like the movie?!? “No, it’s on the phone. Most surgeons have a monthly session.”

What’s the worst thing you’ve seen in the OR? “Well besides getting pantsed by my attending, watching a hotshot surgeon throw a spleen full force at the wall. It exploded with blood everywhere and on everyone’s face. That was pretty bad.” She jokes, “I’ve never done that, but I’ve wanted to!”

Has any surgeon gotten written up by a medical student? “At least once every year. Last year,  a medical student wrote a surgeon up for ‘throwing a scalpel at me’. There was no blade on it. Not sure what was going on, but it could have been just him tossing the scalpel to the student.”

The rib plating takes about 2 hours. I assist in retraction of the skin folds while the attending and chief attach the plates between the fractured rib fragments. At the end they allow me to place a chest tube on each side (it will be removed three days later after testing for leaks). Ted patiently teaches me his special “D” suture technique to anchor the tubes in place.

While rolling the patient back to the ICU, a nurse says, “Natural selection, it’s a real thing. You get drunk and pass out in a road, Nature is coming for you.”

The rib plating ends at 1:00 pm. I wait in the medical student lounge for gold alerts, but there aren’t any, and get sent home around 4:00 pm.

The next days are similar. I round on my 21-year-old MVC recovering patient. I also check in on the rib plating, although there is a different service and attending that covers the ICU patients. This can be quite frustrating as many patients that we may do the initial trauma evaluation, and possible surgical intervention, will be transferred to the ICU team for further management until they are ready for downgrade to the PCU (progressive care unit) or “floor” (the most basic level of inpatient care).

Thursday morning: trauma alert for an overweight 28-year-old who fell while running from U.S. Marshalls. He was cornered on top of a two-story building, and decided to jump. Why is he not in handcuffs? “He wasn’t arrested,” explains the EMT. “That’s pretty common. Law enforcement will arrest him after he’s out of the hospital so that the Department of Corrections doesn’t have to pay for the trauma care.”

He arrives on a stretcher. We transfer him to a trauma bay bed, and begin the initial assessment. About 10 people are around him: three trauma nurses, a respiratory therapist, a scribe, an EM resident, a general surgery resident and intern. I grab my valuable trauma shears and cut off his clothes, while the intern evaluates for airway (he can speak), breathing (good air entry into both lungs), and circulation (good peripheral pulses). He has severe pain in both arms. Vitals are stable. We get a chest x-ray to ensure no rib fractures, and a mid humerus x-ray showing a closed, displaced fracture. His right arm has a mid-humerus fracture, and his left shoulder is anteriorly displaced. He also has an anteriorly dislocated shoulder. Ortho tells us via text they will put him on the case list for tomorrow.

Friday morning I pre-round on the patient. He is pensive. He asks, “How old are you?” and then shares some hard-earned lessons. “Make sure you choose the right woman, man. I got two baby girls, and their mom doesn’t care about them or me. But I am going to be a man and take care of them.” It seems that the drug dealing that led to the encounter with U.S. Marshals was motivated by a need to pay court-ordered child support in excess of his legitimately earned income. The orthopedics PGY2 comes into the room and I stay to see his examination. He tries to “reduce” (put back into place) his left dislocated shoulder. After three failed attempts with just a 50 microgram dose of fentanyl, he decides to just do the reduction during the operation while he is sedated. Orthopaedics take him for open reduction, internal fixation. He stays for seven more days working with PT/OT until he has some movement restored in both arms. Arguably disproving his theory that baby mama doesn’t care about him, she was his only visitor during this week.

Statistics for the week… Study: 8 hours. Sleep: 6 hours/night; Fun: 1 night. Dinner party with Lanky Luke, Sarcastic Samantha, Jane and me at Put-Together Pete’s apartment. Jane and I successfully made Tres Leche cake.

The rest of the book: http://fifthchance.com/MedicalSchool2020

Full post, including comments

How should one prepare for a week of nights on surgery? Class president: “I drank a pot of coffee, and stayed up as late I could on Friday.” Adrenaline Andrew: “I went out to bars on Friday. Kept me up later than if I had stayed in. Worked quite well in fact. If you’re trying to stay up as late as possible come out with us.” I elect to go out with several classmates to a few bars, get to bed at 2:00 am and sleep until 10:00 am. In retrospect, bar hopping was a mistake…

We start on Saturday at 5:30 pm in the surgeon’s lounge for handoff from the day teams, which include separate groups for colon, liver, plastics, urology, orthopaedics, cardiothoracic, ENT (maxillofacial), etc.. All of these groups’ patients will become the responsibility of the night team, which can decide to call a specialist back in for anything urgent. The night team also consults as necessary with the ED and other units, such as oncology.

Our team consists of a critical care fellowship-trained attending (“trauma surgeon”), a senior resident (PGY4-5), a mid-level (PGY2-3), an intern, my classmate Surgeon Sara and myself. The senior resident is a calm 31-year-old aspiring to follow in his father’s footsteps providing medicine in developing countries. Navy Nate, the PGY2 mid-level, is a snarky, brilliant 36-year-old who steered a desk for 9 years. “I should’ve probably should’ve stayed for another 11 years to retire with a pension. But medicine was my calling. I just couldn’t think of doing anything else except surgery. It’s the thrill.” His wife is a family medicine resident. Pregnant Patricia is the intern who immediately speeds off after handoff to run the “floor,” i.e., every floor in hospital with postoperative patients. The chief and I head down to the ED trauma room to wait for consults, while the attending, a 46-year-old tall pensive former philosophy major with a unkempt beard, slips away to his call room.

Our first ED consult is at 6:00 pm. Navy Nate sends Sara and me to interview the patient: “Hey, you have ten minutes to report back. Don’t look at the chart. What is the problem? Is this surgical or not? Ten minutes.”

Surgeon Sara and I struggle to navigate the packed ED, looking for “Bed 4”. The rooms have filled up and patients are on beds in the hallways. A 27-year-old nulliparous female is lying on a hallway bed curled up with her boyfriend, whose family is in the hospital for an MI (myocardial infarction). The energetic female presented for worsening abdominal pain over the past 5 days. She has a family history of Crohn disease (named for gastroenterologist Burrill Bernard Crohn). On physical exam she has significant tenderness on light touch in the lower abdominal quadrants.

After a discussion while walking back to the trauma bay, we present our findings. Sara does the HPI (history of present illness) and PMH (past medical history), while I present the physical exam and A/P (assessment and plan). “It’s unlikely to be appendicitis or ovarian torsion. The timeline does not fit. It could be PID or inflammatory bowel disease although she has no diarrhea.” The ED had ordered a CT, which Navy Nate studies. The radiologist report is in Epic: “Cannot rule out appendicitis” given the mild edema around the appendix. Nate: “Radiologists can be so useless sometimes, but this is a pretty unimpressive appendix. I agree the timeline does not fit with appendicitis.” As we look through her CT we begin to see other involvement of the gut, including striations in the rectum and small bowel. We admitted her for serial exams to see if she worsens, and put in inflammatory labs for IBD. 

(Appendicitis usually presents over 48 hours. Umbilical or epigastric abdominal pain transitions to nausea and vomiting followed by localized pain over “McBurney’s Point” (halfway between the umbilicus and the anterior superior iliac spine of the hip. The key is that after 48 hours, the patient becomes acute (fever, peritonitis) with either a free rupture or abscess formation.)

Trauma Alerts text messages pop up on our personal phones starting around 8:00 pm. First a 23-year-old MVA (motor vehicle accident). He is talking and does not appear to have any significant injuries, but 10 hospital workers will do a complete trauma evaluation nonetheless. There is a primary survey for airway, breathing, cardiac activity, active bleeding, then a secondary survey for spine fractures, and finally a trip to the CT scanner for a “Panscan”. 

Trauma Alert at 11 pm: 20-year-old African-American with multiple gunshot wounds and a tourniquet placed by the EMTs. He is having trouble breathing and blood pressure is dropping. A CXR shows a massive hemothorax (collection of blood in the space between the chest wall and the lung) in the right side. The intern places a chest tube guided by the attending. Immediately the patient improves, and we consult plastics for reconstruction of the median nerve.

The chief and I see a patient stabilized in a rural hospital and then flown to us for treatment of septic shock from decubitus ulcer. The 22-year-old was in a MVA three years ago resulting in a T10 transection. He cannot feel anything below his belly button. He is cared for by his aunt.  The senior resident and I help him rotate to his left side so we can see the pressure sore. I shine an iPhone light onto the wound. Pus oozes out of the necrotic tissue. I see spongy red bone of the ischial tuberosity. The wound grows every kind of bad bug: KPC, MRSA, VRE. We begin stabilization. “This how paraplegics die. It’s a slow nasty death. We’ll probably clear this episode up but we’ll never get ride of the underlying deep infection. And he’ll just develop another one. It’s sad to say, but this is what eventually happens to most paraplegics.”

Surgeon Sara and I all head to a consult for an 45-year-old 250 lb. male with RUQ (right upper quadrant) pain, tachycardia (rapid heart beat) with stable BP and O2 saturations.  When we report back, the Chief, midlevel, and attending are poring over the patient’s CT scan and labs. “How’s he doing?” “Bad, he has rebound tenderness, intense pain.” Labs showed slightly elevated bilirubin, but normal liver enzymes and Alk phosphate. We quickly got hooked on cholangitis even though the liver enzymes were not elevated. The attending arrives from his call room. The chief asks the attending, “See that inflammation around the entire duodenum, not just the gallbladder.” “Yep, that’s why I came down. Let’s get him to surgery.” (We still don’t know what is wrong with this buy, but it is time to explore.)

Sara: “I am surprised how much the surgeons use imaging before the radiologist gives the final report.”

We learn he is a habitual cocaine user and, in fact, had used cocaine just a few hours earlier. He has an acute angioedema attack requiring rapid intubation in the ED and a 10-minute trip upstairs to the OR. The resident opens him up. The belly is a mess, with damage that was not visible on the CT. The gastric juices was eroding away at the tissue in the belly. The attending and resident pass the bowel back forth (“running the mesentery”) to look for any perforations in the bowel blood supply. This all happens so fast, I have no idea what is happening. They then identify maybe a five millimeter hole in the stomach from a gastric ulcer perforation. Attending: “Probably from the cocaine. Not his lucky day. Angioedema and a perfed ulcer.”

Navy Nate: “I need you do a med reconciliation on this patient [a 35-year-old female who came in for a rule-out on appendicitis]. Her chart says she takes 30 medicines.” Sara and I have to hold back laughing as we go through each medication. I ask if she takes X dose for X medicaition X times a day and Sara would write down the answer. It takes us at least 35 minutes because she wouldn’t stop about her experience in nursing school.  By the time we finish, it’s time for morning handoff. We leave the hospital around 7:00 am.

Wednesday night is memorable. Around 9:00 pm, we get consulted for a 73-year-old Army combat (Vietnam) veteran with a six-month history of worsening fatigue, melanotic stools, anemia and a 15 lb weight loss . He presents to the ED this evening because of an acute abdomen. The ED places him on two pressors for unstable vitals and fentanyl.  When we arrive he appears quite comfortable, accompanied by his wife and daughter. Sara asks, “Have you gotten a colonoscopy.” He responds: “No I never thought it worth it to get colonoscopies. I am so active.” We get a CT that reveals a large mass in the colon with distal metastases to the liver and lung. 

I call the VA to request his medical records. The attending instructs me to request only H&Ps, labs and imaging, “No progress notes.” 100 pages come out of the fax machine. We find that he has gotten a “CT ab” (abdominal CT scan) with follow-up needle biopsies of the mass about two weeks ago, pathology results still pending. Our patient doesn’t know why he got the biopsy and is unaware that colon cancer was the most likely diagnosis.

We go into his alcove in the ED and meet his wife, daughter, and 12-year-old granddaughter. The attending explains that the cancer has grown large enough that it is obstructing the small bowel. The recent onset of pain is most likely from a small perforation in the bowel. The attending explains there are two options. We could take him back to the OR and try to repair the perforation. “It’s unlikely that will work because the bowel around it is also invaded with cancer. It will be difficult to find good bowel to close.” He emphasizes that this is not a long-term treatment. “You are going to die from this cancer. The other option is palliative care.” We tell them to think about the options and go back to the OR lounge to look more carefully at the imaging.

“There is no way we can operate on him,” the attending tells us. “He is unstable and the chance of success is so low. Everyone says they are a fighter. Well if you were a fighter you would have gotten a colonoscopy. No one is a fighter. It’s the disease. I had an uncle who died suddenly, my whole family was so shocked but I see this every day. No one knows what they would do if given three months to live. No one knows what they find meaningful in their life until life runs out.”

Surgeon Sara: “I am calling my parents first thing in the morning to tell my parents to get a colonoscopy. My mom has been hesitant, saying she eats a good diet.” I also call my parents to encourage them to get their colonoscopy. Sara and I still have an hour before a required lecture on postoperative management at 8:00 am. We visit the 73-year-old veteran. “We’re here not to answer questions, but to give you some questions to ask the colon specialist on the day team.”

He confides in us: “I’ve done everything on my own. I didn’t depend on anyone. What’s the word… Pride, that’s the word. Pride. I wont have no pride if I am a vegetable. Just last year I was building a foundation in my backyard, lifting 50 lb bags of concrete. I was so active less than a year ago. How can this be?”

Jane and I are two ships in the night. I get home around 9:00 am and she is already gone for her psychiatry clerkship at the state mental asylum. I call her as I walk back to the car. She’s had a rough week. She walks around with a massive keychain.. Every door, to hallways, stairs, etc. is locked

Full post, including comments