Category: Medical School

July 2019. I meet the SICU team at 6:00 am for handoff. The 35-year-old PGY3 “upper level” surgical resident is in charge of our team (he worked a Navy desk job before going to medical school), which includes a visiting fourth-year medical student (on an “AI”; see the end of Year 3) and two Critical Care fellows, one from internal medicine (Pulm/Crit) and one from emergency medicine. Both are already physicians, but are under our PGY3. We meet our attending, a cerebral 6’5″ trauma surgeon balancing male-pattern baldness with a thick brown beard. He doesn’t seem to have slept for years due to a combination of 24-hour calls, a 13-month-old child with a wife recently returned to her nursing job, and constantly refreshed waves of ignorant and incompetent students and staff, for which his patience is now limited: “Why would you give the patient 250mL for a fluid bolus? That’s like 75 mL intravascular. The response is worthless information. If you think the patient is volume-depleted, give volume.” 

Patients include trauma (car accidents, shootings, etc.), high risk operations, operations gone awry (e.g., perforation, anastomotic leak, etc.), and neurosurgical patients (e.g., brain bleeds, aneurysm clipping, and tumor resections). The nurses say this is the only real ICU, compared to the cardiac care unit (“CCU”) and the medical intensive care unit (“MICU”).

Tuesday is a typical day in the SICU. I get in at 5:30 am to review my three patients’ morning labs and any overnight events. I then head up for 6:00 am handoff from the night team in a conference room. We “run the list” going through each patient using the Epic handoff note that has free text bulleted information about each patient and a “To Do” list. The exhausted night team disbands, while our day team assigns each patient to a team member (students don’t count). We pre-round on our patients until the attending gets in at 8:30 am to start rounds. There are 18 patients on our census in the two-floor SICU. We are part of the 24/7 ICU team that manages the patient independent of the surgeon who actually performed the operation. This structure is referred to as a “closed” ICU.

Rounds last from 8:30 am to 1:30 pm. We do system-based rounds. I summarize the patient. “19-year-old Jehovah’s Witness presenting as MVC [motor vehicle collision]. He has bilateral leg injuries and a right proximal humeral fracture. Orthopedics is following and plan to take him to the OR for a left BKA [below-the-knee amputation] today. They splinted the right ankle for an unstable tibial fracture that will need surgical intervention at a later date. Overnight, the final read on the CT shows a submassive pulmonary embolism.” Then I go through each system:

• Neuro: he is on fentanyl 50 mcg/hr for pain.
• Respiratory: normal pulmonary function, ABG shows pH of 7.35 and CO2 of 40.
• Cardiovascular: he has not required any pressors, he remains tachycardic in the 120s. His CT shows he has a pulmonary embolism in a right pulmonary segmental artery. Echo shows no right ventricular strain. Do you think we should anticoagulant him given his blood loss? 
• Hemoglobin is 6.2 down from admission of 11 (normal is above 12. If not for his religion, we would have transfused him. The family says he would prefer to die rather than receive a blood unit.)
• Hematology: we already discussed his hemoglobin. Orthopedics is okay with taking him for the operation at this level. White count is normal at 8. 
• Infectious Disease: no antibiotics or signs of infection.

The resident or fellow would take over the presentation if I miss anything important, but hasn’t needed to. Nonetheless, there are interruptions. Desperate to impress (he’ll be applying here for a residency), the visiting medical student jumps in frequently and tries to get the last word.

We have some extra time in the afternoon, so one the Pulm/Critical Care fellow teaches me and the AI on different pressors and ventilator settings. 

Wednesday at 3:00 pm, we get a 70-year-old admission. He was driving (without a seat belt) and was “T-boned” by a meth head. Both came to the ED around 2:00 pm, but the meth head was quickly discharged. The trauma team met the patient in the ED’s trauma bay, and although he had a positive FAST (focused assessment with sonography) exam for a small amount of free fluid in abdomen, they elected to defer exploratory laparotomy. Like all trauma patients, he was “pan-scanned,” (head-to-toe CT scan) which was similarly indeterminate for serious abdominal problems.

[Editor: the multi-thousand dollar imaging bill to Medicare will not be indeterminate.]

He was sent to the SICU for observation. Around 4:30 pm, he became hypotensive in the 50/30s and responded to 1L bolus and pressors. Throughout he was alert and conversant. Our attending explained we needed to explore his abdomen. The patient vehemently declined. We stepped out to allow his son and daughter-in-law to talk it over. We once again explained the need for the surgery. Around 10 minutes later, he called us back in and consented to the operation. I asked the trauma surgeon if I could scrub in. I ran ahead of the patient transport as I changed out of my dress clothes and into my scrubs. Lesson: no doctor gets anything done wearing dress clothes.

The trauma surgeon working the night shift is Dr. Cruella, the young universally-feared 39-year-old with whom I worked in Year 3, Week 4 (a spleen was thrown). The PGY3 is trembling: “She holds herself to extreme standards, and expects the same from others.” I remember her as a great teacher so long as she doesn’t think you will write her up for a non-PC joke. She allows me to make the first incision. The resident then takes over while the attending and I hold retraction to open up the fascia. Once open, the resident and attending explore the abdomen in an organized fashion while I hold retraction with the large “Rich” retractor. We suck about 1L of blood from the abdomen, which does not suggest a large artery bleed. “The liver looks good, no contusion.” She then looks at the spleen. “It looks ischemic [not getting sufficient oxygenation from blood flow].” We open up the gastrocolic ligament to enter the lesser sac where we can see the deeper abdominal organs. Blood fills this area and takes several minutes to suction and absorb with “lap pads”. We finally see a swirl of bright red blood amid the darker old blood. “Suction where we are exploring, not where you see fluid. Give it to [the resident].” The resident takes the suction and jabs it where the swirl is. “Guess we’re doing a splenectomy,” says our attending, and asks for a silk suture to close the artery.  After they gain control of the artery by suturing it proximal and distal to the injury, we apply two Kelly clamps to each ligament connecting the spleen.

The resident cuts the ligament in between the Kelly clamps with Mayo scissors, and ties silk sutures on the ends of the ligaments. This time the spleen is not thrown, but rather gently passed from the attending to me to the surg tech. We then finish the exploration of the abdomen. There are several hematomas in the mesentery of the small bowel, but nothing bleeding. We then notice a “bucket handle injury” of the colon. In blunt trauma, the deceleration force causes the bowel to shear off its mesentery, a fatty sheet with blood vessels connecting the bowel to the aorta. I can put my entire hand through the bucket handle injury. We then notice blood pooling at the base of the mesentery. The entire middle colic vein was transected. The hole abruptly stops at the middle colic artery on the right hand border (i.e., a bit more force and the artery wouldn’t have been strong enough to hold the colon). The pancreas is also injured, so we “paint” (cauterize) the pancreas that is bleeding, and place a drain, and pray. Dr. Cruella: “Never mess with the pancreas. We just have to pray it doesn’t get mad.” She asks, “What’s the cardinal rule of surgery?” I answer: “Never mess with the pancreas.”

We perform a transverse colon resection (removal of 8 inches of colon, out of a total of roughly 60) using a staple device. The attending and resident discuss if they should perform a “primary anastomosis” (connecting the two cut ends together). She asks the anesthesiologist, “How has the patient been doing?” The anesthesiologist explains he had come off pressors for 30 minutes after the four units prbc (packed red blood cell units) and 1 unit FFP (fresh frozen plasma), but recently went back on them. “Damn it. No anastomosis,” says Dr. Cruella. Instead of closing the abdomen, we put a series of plastic liners and foam connected to a vacuum device (“wound vac”) in the midline incision. We leave the bowel in “discontinuity” for a “take back” procedure tomorrow once he is resuscitated. I leave the hospital at 10:00 pm.

The next day I ask to scrub in on the re-exploration operation with a fresh-out-of-fellowship trauma surgeon. We remove the wound vac and don’t find any missed injuries. The pancreas appears quiet. Unfortunately, he is not stable and therefore we cannot reconnect his colon. We perform a colostomy with the proximal transverse colon and leave the distal colon as a large “rectal stump”. The attending explains, “He could not handle an anastomotic leak. This is damage control.” After his surgery, he is unhappy, but understands he is alive. He is exhausted and resigned to his new reality. It is conceivable that the colon can be reconnected six months from now, given sufficient health and nourishment.

Aside from the colostomy, this patient seems to have a good chance of recovering his life before the trauma. He has no neurological damage.

Unfortunately, however, when I come in on Thursday morning, the night team informs me that at 2:00 am he vomited a large volume of “coffee-ground emesis.” We order an EGD (esophagogastroduodenoscopy) to evaluate for active bleeding. The test is negative for a bleeding ulcer, but he goes into respiratory distress at around 2:00 pm. He is reintubated and once again requires pressors. He likely aspirated gastric fluid into his lungs. We start him on broad-spectrum antibiotics. I discover he also has a superficial surgical site infection. The PGY3 jokes, “Seems like you are the common link to both procedures. I hope you didn’t cause it.” Saturday, he is still intubated, requiring lower dose pressors. His bowels still have not woken up with no output from the colostomy. He hasn’t eaten in 5 days. If this doesn’t change, we’ll have to start him on TPN [total parenteral nutrition, all nutritional needs are given through IV because the bowels are not working]. I leave Saturday night, a little dispirited for my Sunday day off.

The most unusual patient of the week was a drug-free 40-year-old who had recently moved in with his mother. His father died five months ago, but he had been behaving normally and his family also seems normal. Last week, he applied an animal castration band to his testicles. They must have been on for at least 48 hours because they were completely necrotic when EMS brought him to the hospital. After he applied the castration band, he amputated his left hand with a circular saw, got on an ATV and drove around the forest using the remaining hand. He threw the left hand into the forest. The police were able to get him off the ATV and into the hospital. The sister was able to find the severed hand and bring it to the hospital. Our hand surgeon completed a hand replantation. We had to keep him intubated to prevent him from moving his hand, anchored with just two short metal pins and any tension would have destroyed the delicately reattached veins. His family was devastated and had no idea that he was

Full post, including comments

Night shift: midnight – 8:00 AM. My resident is a 28-year-old whiz kid with slicked-back hair. An ED nurse rooms our first patient and drops off the paperwork. She teases, “Have fun, he’s here for bugs!” My resident sends me in there alone. “Good luck!”

The 55-year-old is presenting from home complaining that there are bugs crawling all over him. He wants us to write a note agreeing with him, so he can sue his landlord. “The bugs are everywhere. They are crawling inside me now.” I ask him where they are. “Everywhere. See.” He pulls out a zip block bag with a q-tip with ear wax on it. “See the bug.” He denies any drug use except marijuana. He is so convinced that he is convincing. Searching for the bugs, I am almost as confused as he seems to be. 

I present to my attending and resident. Within a few words, my attending has already figured out the problem. She states, “MJ is laced with meth around here. These delusions can be so strong that nothing will change their mind. I’ve had people bring in zip-lock bags with tampons claiming there are bugs. I just hope there are not any bed bugs on him.” We go in to see him together, and try to explain that there are no bugs on him but he may have taken meth. We offer to do a UDS [urine drug screen].” He becomes combative. He storms out of the ED.

My attending summarizes, “EM would be amazing if not for the addicts and psychotics. They suck out your soul.”

[Editor: Maybe she would be happier practicing medicine in a country where the government-run health insurance system doesn’t purchase opioids in tractor trailer quantities?]

My resident asks me what I want to do. I respond that I am not sure. “Well, if you’re debating between EM (emergency medicine) and IM (internal medicine), it’s easy. If you like to perseverate on stuff that probably doesn’t matter and will get better with time, do IM.” He continues, “EM is for people who have ADHD and want to fix things quickly and do procedures. We deal with putting out the fire. I’m not going to be great at everything, but we get the job done. We do eye procedures and central lines. We’re not as good at eye stuff as the opthamologist and we’re not as good at central lines as the intensivist. I had to put in a suprapubic catheter to drain 3 liters of urine [the bladder ordinarily holds no more than 0.5 liters]. I’ve never done that so I looked up the procedure steps and watched it on youtube. I got the job done.”

After a slow few hours, a neighboring resident comes over to our pod and asks if I want to do a lumbar puncture (LP)? A 45-year-old female presented with a several-week history of worsening headaches, gait disturbances, and visual changes. Neurology evaluated and is concerned about the possibility of a rare encephalitis. Neurology is busy so they asked if the ED wanted to perform the LP. After we consent the patient, the attending and resident help me prep the patient and numb her up with lidocaine. We lay her on her left side and ask her to bend over, thereby flexing her spine to open up the lumbar vertebrae. I insert a long spinal needle into her back, slightly off midline, while aspirating on the plunger. I keep hitting bone. After 3 attempts, the resident takes over and also struggles. The attending gets it on the second attempt. “That was hard, she must have some bad arthritis.”

After the last clinical day of M3 year, our entire class gathers in the medical school lecture hall for the M4 lottery. We are each assigned a number and go in order selecting M4 rotations. Straight-Shooter Sally is stressed because she would like to do “Acting Internships” at other institutions. “If I get the wrong order, I won’t be prepared when I have to do my AI.” (For example, someone interested in a cardiology AI would try to do the cardiology rotation at the home institution just prior.)

Statistics for the week… Study: 12 hours. Sleep: 7 hours/night; Fun: 2 nights. House party at Buff Bri’s house to celebrate the conclusion of M3 year. Sarcastic Samantha talks about her job distributing new admissions among the hospitalists.. She explains, “I have to fight with the hospitalists. They act like children. When we get a new heart failure exacerbation in the ED, they whine, ‘Why is it my turn?’ Because you haven’t taken one all week.”

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

Full post, including comments

The second week of EM. As soon as I put my bags down for the second shift (2:00 PM to 10:00 PM) at the physician/nurses station, a code blue is called over the loudspeaker – “Code Blue, Triage.” My PYG3 resident, a 30-year-old mountain biking enthusiast yearning for his upcoming Montana life after graduation in a few short months, waves for me to join as several residents, nurses, and attendings briskly walk over to triage.

A 70-year-old obese female is lying on the floor surrounded by six people. Two are taking turns performing chest compressions. A resident is attempting to ventilate the patient with an Ambu Bag manual resuscitator. We get the patient onto a stretcher, and cart her off to one of our rooms. The ED is divided into a trauma section, triage, a sick section, an observation unit, and a healthier section. Once she is on a bed in the sick section, an attending and her resident prepare to intubate.

The attending hands a GlideScope, a video-assisted laryngoscope to the resident.  Unlike a traditional direct laryngoscope that allows only the intubator to see what is happening, with the GlideScope both the attending and resident can see what’s in front of the scope, The resident then inserts the blade and visualizes the cords, but struggles to get the ETT (endotracheal tube) through the vocal cords. They are tight. He asks for a “boogie,” a long thin bright blue bendable plastic tube that he is able to pass through the vocal cords. He takes the laryngoscope out, threads the ETT over the boogie, and pushes the ETT forward aggressively. The attending asks, “Are you in?” He responds, “Yes, I feel the tube gliding over the [tracheal] rings.” The attending agrees, “I feel you too,” as she removes her hands from the neck.

The respiratory therapist (RT) hands us the tubing connected to the ventilator. Every tube  at initial intubation is hooked in series with an end-tidal CO2 colorimeter. If the ETT is correctly in the trachea (i.e., not in the esophagus) carbon dioxide on exhalation will change the color confirming correct placement. While this is going on, another attending and resident are “dropping lines” including a central venous catheter and arterial line.

We learn that a granddaughter brought the patient after she had trouble breathing with wheezing. The daughter said, “She was just in the hospital for a COPD exacerbation two months ago.” The patient was coding for 20 minutes. My attending asks if the family would like to come in during the code to watch. (Afterwards, she says there is evidence that the family seeing the end-of-life code is helpful for the grieving process.) The granddaughter, daughter, and son-in-law take one step into the room and begin sobbing. They step out after a few minutes. On the next pulse check, the patient is still in asystole. My attending asks if anyone has any other thoughts. “We’ve ruled out other reversible causes of arrest.” After a short pause with silence, she announces, “Time of death – 15:25.” There is a quick debrief afterwards, and then everyone scatters. I help the two nurses get the patient presentable for the family to come into the room for one last farewell. The charge nurse can tell this is my first code. “Oh sweetie, thanks. We cannot forget to clean their bottom.” The other nurse chuckles, “Post-mortem shits. Nothing quite like it.”

Immediately after this a mother brings in her 20-year-old daughter, a bone-thin IV drug user with uncontrolled type 1 diabetes who presents for weakness and confusion. She is found to be in diabetic ketoacidosis (DKA) and is septic from likely bacteremia. She is tachypnic (breathing fast) and becoming more lethargic. The attending states, “We need to intubate her now.” The attending and resident let me intubate the patient. The resident instructs the charge nurse to grab an induction agent and paralytic. We first pre-oxygenate the patient by placing a non rebreather (breathing mask) over her mouth. After two minutes, the attending tells the nurse to push the sedation followed by the paralytic. 

The resident hands me the GlideScope. “Watch the teeth! It’s not a rotation motion, it’s a lift up to the crease between the wall and ceiling.” I struggle with the motion, being too timid. The attending pulls my hands to the sky, supporting the entire weight of her head and neck off the table, pulling into view the vocal cords (pretty much a perfect view… she is an easy intubation). I guide the ETT through the vocal cords. Once through, the RT blows up the balloon. Once intubated, the RT connects her to the mechanical ventilator. 

After a few minutes, the nurse comes out to the station saying the patient is now hypotensive (low blood pressure). The attending asks, “How much fluid has she gotten?” The resident says, “She’s gotten two liters, and she is a tiny skinny lady.” My resident turns to me, “Would you like to place a central line?” I exclaim, “Yes.”. “If you can grab all the right stuff, it’s yours.” I speed off towards “Walmart”, the ED stockroom. I grab a central line kit, sterile ultrasound probe cover, enough suture to weave a sweater, and several pairs of sterile gloves. The resident jokes, “Not bad.” While I was off, he had already grabbed everything we needed. “Let’s get started, the hardest part is positioning everything.”

After we place the patient in Trendelenburg, we open up the kit on a stand. I put a sterile gown on with my resident’s help, and then my gloves. He does it all by himself. We prep the patient. The nurse hands us the ultrasound and we are ready. Okay, show me the internal jugular. I grab the ultrasound and scan up and down the neck. “It’s the plump vessel, next to the pulsing carotid.” I push down with the ultrasound probe, thereby compressing the internal jugular (IJ) vein. “Notice how the IJ nearly compresses on inhalation. She is quite hypovolemic.” The resident hands me all the tools in the right order. I insert the access needle into the IJ under ultrasound-guidance. “Don’t freak out when blood squirts back at you. Hold steady. I’ll hand you everything. We both will freak out if it is pulsatile (indicating we hit the carotid and not the IJ)” Once I get blood return, he hands me the guidewire that I thread through the needle. “Look at the ectopy on tele!” (when the guidewire knocks around in the atrium it can cause aberrant heart beats.) I communicate, “It’s threading easily.” I take the needle out, and he hands me the dilator followed by the flushed catheter. The catheter goes in smoothly, I suture it in place. I struggle placing a sterile covering, a fancy plastic lining that goes over to try to prevent infections. “I’ll do that, this is our signature for nurses.” 

As we walk out, the resident shares, “One of my best friends has type 1 diabetes. I’ve noticed that type 1 diabetics are either extremely health conscious and disciplined, or are complete wrecks and die of massive heart attacks in the 40s.”

I leave exhausted, but am too excited to fall asleep. Type-A Anita has been active on Facebook. She writes about a New York City article citing the rise in divorce rates: “I’m glad the divorce rate is higher. You want to know why the divorce rate was so low back in the Day? It’s because your grandmother did not feel safe to leave the relationship. It means women feel empowered now to leave their shitty husbands because they are not dependent on any man. #StandUp”

[Editor: Type-A Anita is on track to make $400,000 per year in ob-gyn and her fiancé (now husband) is in a much less lucrative career. If she is unwise enough to settle in one of the states that awards alimony, in about 15 years we might find that her opinion on this topic changes…]

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Beers and burgers with Sarcastic Samantha. Mischievous Mary unexpectedly joins midway. She recounts walking away from her Tinder date without introducing herself to the young man because he showed up to the restaurant  in an undisclosed wheelchair.

[Editor: It would appear that the medical school’s heavy investment in diversity and inclusion education is not reaching everyone.]

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

Full post, including comments

It’s May and we’re back from an uneventful week of vacation.

Emergency medicine rotation, 12 shifts in 30 days. I am one of the first medical students in my class to complete EM. One quarter of the class completes EM clerkship during the third year; the remaining wait for the fourth.

I begin at 7:00 am in the simulation center with the EM clerkship director, a toxicologist. He gives us an overview of the ED. “We have a mantra in EM: “Anyone, anything, anytime. You will see a bit of everything on your shifts. EM docs are a master of none, but a jack of all trades.” He continues:  “All of you have done internal medicine rotation already. I am sure you have the impression that the ED consults everyone. In fact, we discharge over 70 percent of the patients from the ED.” Emergency Medicine changed overnight when EMTALA passed in the 1980s. “This requires emergency rooms to screen and stabilize all patients that come in regardless of insurance or ability to pay.”

He explains that the ED risk stratifies patients and recommends we all become familiar with PERL rules, Nexus criteria versus the Canadian criteria for cervical spine clearance, and the HEART pathway and OTTAWA rules. 

After this introduction, my six classmates and I head over to the first simulation room. The room is similar to the trauma bay in the hospital with a mannequin on the bed, various screens showing vital signs and fully stocked closets with e.g., endotracheal airways and chest tubes. The first simulation day is focused on ACLS, and management of various cardiac arrhythmias. The EM clerkship director, and two simulation staff (a former medic and a former ED nurse) step out into the viewing section behind an opaque glass window. We hear them over the loudspeaker giving the simulation introduction. Then the EM clerkship director gets into character: “Ugggh, I don’t feel so good.” We begin to ask questions and request tests. “Can we get an EKG?” The staff put up various EKGs and we are supposed to respond by treating the arrhythmia, whether that is to shock the patient (synchronized cardioversion versus defibrillation) or administer medications. 

My first shift is slow and the 34-year-old PGY2 resident has plenty of time to teach. Before medical school, she worked for 5-years as an operations engineer. (EM residency is a three-year training, the majority do not go on to fellowship training). The attending’s high level of trust in her is evidenced by the fact that she manages 10 beds by herself and updates the attending on any admissions. We have a COPD exacerbation from a nursing home and an uncontrolled type 1 diabetic in DKA. My resident starts the patient on her preferred protocol (K+ and insulin drip) and then updates the attending. The attending discusses his view of bolus versus drip only, as he prefers bolus. “It’s your patient, your move.” We have a patient transferred about 150 miles from an outside hospital due to a stable GI bleed. I do not understand what hospital would transfer this patient. He doesn’t even need a blood transfusion. His only comorbidity is well-controlled type 2 diabetes and hypertension. The PGY2 summarizes the situation: “He was driven all this way for a digital rectal exam.” She continues, “He has supplemental insurance, so I’ll offer to keep him under observation. We might catch something to flip him into inpatient and get him an EGD and colonoscopy. But he frankly should be discharged and sent for elective outpatient colonoscopy. I feel bad for the guy and the wife who is driving here now.”

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 2 nights. Brewery outing with classmates and pups. Lanky Luke and Sarcastic Samantha are training their puppy, however she only listens to Samantha because Luke is always working on his internal medicine rotation.

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

Full post, including comments

During our morning session on multiple sclerosis, a stroke alert is called. The clerkship director and I walk over to the ED. A 66-year-old female is presenting for left-sided weakness (arm more than leg), but there is no facial droop. Her husband explains she was normal when they went to bed, but when they woke up at 7:30 am, she “just wasn’t right”. She has already gotten the imaging workup, but there is nothing to be done because she is well outside the 3-4.5-hour window for TPA (tissue plasminogen activator) and this is not a large infarct. (Even if we did know the time from initial event, she has been on oral anticoagulants for atrial fibrillation. These are difficult to reverse and a contraindication to TPA.) We put in admission orders to optimize her recovery, including blood pressure and sugar control. We also order an MRI to diagnose and prognosticate the extent of the infarct. The attending cancels some of the orders placed by the ED and the psychiatry PGY2 resident. “This is the tyranny of the order set [default groups within Epic, intended to save time and typing]! Why order a carotid duplex when we just got a better picture of it with the CTA already performed? We are just wasting hospital resources and Medicare dollars.”

[Editor: The hospital CFO may not consider it a “waste” when Medicare dollars are transferred to the hospital…]

We arrive at the Situation Room, a narrow office crammed with two computers and an old couch. The clerkship director, resident, and I hang out here until the next stroke alert. I am pimped on the types of strokes. I fail miserably, citing only two of the common sites of brain bleeds. There are two main types of strokes: intracerebral hemorrhage (ICH, brain bleed, rarely lethal) and ischemic (occlusion of an artery, potentially fatal due to increased intracranial pressure). This neurologist gave a great lecture on strokes during second year, so I pull up the slides on Blackboard and then UpToDate each topic for more information. A common cause of ICH is hypertension due to cocaine and meth use among the young and poorly controlled chronic conditions among the elderly. ICH can also be caused by anticoagulants and Alzheimer’s (amyloid angiopathy). “You can quickly figure out what is the cause by the location of the bleed. Hypertension is a deep brain bleed, in the basal ganglia, thalamus, pons, or cerebellum. Dementia patients bleed into the cortex.”

He asks me, “What kind of workup would you do for the patient we just saw in the ED?” I answer, “Well, she is out of the window for TPA, and not a candidate for endovascular therapies [clot in proximal artery].” I recommend ordering an echocardiogram, carotid duplex, and EKG. “Right, we need to rule out the preventable causes of ischemic strokes” These include cardioembolism (a result of, for example, atrial fibrillation, an infected heart valve from iv drug use, or a ventricular thrombus after a heart attack), carotid stenosis, and a patent foramen ovale or hole in the heart, that can allow a clot to pass from the venous circulation into systemic circulation). We check Epic and see that the MRI images are available, though without a radiologist’s read yet. He points out a small infarct in her posterior limb of the internal capsule. Nothing to do.

(I followed up with her over the next several days and her condition was unchanged. She’ll have a permanent limp and some arm weakness, but can live independently.)

We get a stroke alert for a 76-year-old diabetic female who had a breast cancer lumpectomy one year ago. Her husband reports returning from grocery shopping to find that she was slurring words and unable to walk. He promptly called 911 so we’re probably seeing her about two hours after the onset. Her blood pressure is 215/100, too high for TPA, so she’s on a nicardipine drip in hopes of bringing it down. The neurologist calmly examines her with standard techniques (“follow my hand with your gaze”) and some of his own design (“close your eyes and tell me what you feel” as he hands her objects such as a key or lighter). She has a left facial droop, dysarthria (speech disorder due to muscle weakness), right gaze preference, and a left hemianopsia (blindness). Like most of our stroke admits, she gets a CT perfusion scan (five minutes and reimbursed at $12,000 by Medicare) to see if she is a candidate for endovascular intervention, i.e., clearing out a plumbing clog with a drain snake. Her scan is among the 10 percent that suggest endovascular intervention: proximal (closer to the heart) clot surrounded by potentially viable tissue. Her clog is in the middle cerebral artery (MCA, the main artery of the brain).

She is carted off to the endovascular suite. I call Straight-Shooter Sally, who did not get to see an endovascular procedure on her week of stroke service. We meet up in the Interventional Radiology suite; endovascular procedures are split between interventional radiology and interventional neurology. We’re both excited, but the neurologist doesn’t say anything during the 45-minute procedure. “Well that was useless,” says Sally. We follow up with the patient the next day and she has almost no symptoms, except mild weakness in her right wrist.

(It seems obvious that cleaning out the pipes would work, but there are no good clinical trials to support the anecdotal evidence. A lot of patients who get endovascular therapy would likely have recovered on their own.)

During the 4:00 pm debrief in the “Situation Room”, I ask if all stroke patients should get a $12,000 CT perfusion scan. “It depends whom you ask,” responds my attending. “The people who designed our current protocols say, ‘Yes.’ But they mostly are not neurologists. Medicare doesn’t understand the purpose of the CT perfusion scan. Two out of three scans that they pay for are unnecessary in my opinion. Only a small percentage of strokes are amenable to endovascular therapy. And we are not an institution at the cutting edge doing research on other indications. There is no excuse except laziness and dipping into a free pot of gold.” I ask about the VAN score to screen for patients for a large proximal clot. If a patient does not have focal weakness and one of the following: Visual disturbance, Aphasia, or hemi-Neglect, it is extremely unlikely to be a large proximal clot amenable to endovascular therapy. My attending doesn’t disagree with the VAN system, but thinks it adds little to an experienced neurologist’s judgment. “Stroke centers are graded by the door-to-needle time [time to get a stroke patient administered TPA]. The ED is so focused on taking the thought out of medicine with protocols.” He noted that every stroke patient now goes through the same steps: (1) non-contrast CT brain to rule out brain bleed, (2) CT angiogram to look for a clot, and (3) CT perfusion scan to evaluate salvageable brain tissue. “Though lucrative, most of this is unnecessary and doesn’t change management. CMS hasn’t investigated us yet, but I hope they do.”

In his opinion, what would help more patients at a tiny fraction of the cost is simply speeding up radiology. “During nights and weekends we don’t have in-house radiologists. We use teleradiologists who are contracted to get back to us within 30 minutes. We need a 5-minute look at brain anatomy, but they take the full 30 minutes to give us a detailed report so that they can’t be sued for missing something. We get a report on spine, teeth, lungs, etc. The ED can’t read images, so the stroke patient is sitting there for 30 minutes without any therapy. A good  neurologist reads his or her own films and a brave one will make the call without a radiologist.”

[Editor: Smaller hospitals are unable to do either the CT perfusion scans or the endovascular intervention (“thrombectomy”), so our near-octogenarian Presidential candidates might not want to spend too much romancing voters in small towns. See “A Breakthrough Stroke Treatment Can Save Lives—If It’s Available” (WSJ, February 6, 2018).]

Statistics for the week… Study: 7 hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with live music. Mischievous Mary has already started looking for visiting away electives in cardiothoracic surgery.

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

Full post, including comments

Neurology rotation. Three days at the VA and then three days at our home institution.

Groundhog Day: I meet the VA coordinator at 9:00 am to get my badge and a campus tour (it happened last month, but I have to do it again). I am joined by four trainees from other institutions: a third-year medical student starting her one-month psychiatry rotation and three podiatry residents doing three months of training on the “indigent” VA population. “There is an endless supply of feet to amputate. We meet our case log requirements from this month.” A new-hire struggles with the badge machine, but two hours later we all have badges and start our tour of the VA campus. I am dropped off at the neurology clinic at 12:00 pm. My physician turns out to be a rotund neuro-ophthalmologist. In the Department of Physician Heal-Thyself, he’s  recently returned to work after a quadruple bypass. The mid-day patients are no-shows so he sends me to lunch. We meet again at 2:00 pm to see four scheduled patients, two of whom show up (see Year 3, Week 33) and clock out at 3:30 pm.

A typical day starts at 9:00 am after a 45-minute commute. The attending prints out his most recent office note for each follow-up patient because students do not have access to the VA’s electronic medical record (EMR). Each new patient starts with me in a vacant office, then goes back to the waiting room, and eventually we go together to the attending’s office. Despite the 50-percent no-show rate, he’s usually running behind due to his struggles with the EMR. Each 30-minute or 45-minute visit with a patient is followed by 30 minutes of single-finger typing. Has he tried to dictate? “It’s just as bad. I spend more time correcting the damn machine than it takes me to type.” He has near-perfect recall of previous visits with patients, surprises patients by remembering details they offered months earlier, and would have thrived in a pre-EMR era.

[Editor: The good news for this guy is that he will be able to learn a whole new interface for the 2020s once the VA finishes with its $10 billion transition to commercial software.]

We see patients with multiple sclerosis (MS), Parkinson’s disease, pseudotumor cerebri (condition mostly occuring in obese females resulting in vision loss), and rare vision disorders, e.g., Charles Bonnet syndrome, which results in progressive blindness combined with intense visual hallucinations. If he thinks it will help a patient with a terminal neurological disorder, the attending will spend over an hour counseling on the prognosis and what everyday life will look like. The nurses grumble that he “destroys the schedule without warning”. He lets them go as soon as the last patient has checked in and will see his final patients without any support.

My attending misses the 1980s: “We don’t talk to each other anymore. We search blindly in the endless expanse of notes. The primary doctor orders a consult and wipes his or her hand. Then the specialist wipes his or her hand when the note is filed. No one calls.” He spends 10 minutes finding an example of a recent patient for me: a 68-year-old male had a stroke during a five-day hospitalization for pneumonia. After the stroke, he developed Parkinson-like tremors. “There are 240 pages of notes. Look at this! They have to put in where the meds were manufactured! Is that necessary?”

In the afternoon we walk 10 minutes to the inpatient wing to see consults. “All these damn hospitalists are useless,” my attending grumbles. “They consult for anything. A patient feels weak because they’ve been in the hospital for a week for heart failure. No shit they are weak. This is not a stroke. Did they go to medical school?”

Thursday starts at 8:30 am. Each week the three medical students on neurology clerkship meet in the office of our clerkship director, a quirky tall gentleman in his early sixties. We get a group text each night with cases to review and present and offer diagnoses in the morning. Today’s case is on Guillain-Barré syndrome, an ascending paralysis from an auto-immune response, typically after a viral illness. “The main concern is respiratory failure. That’s what they die of. If you can get them through it, they will typically have a complete recovery. When I was a medical student, we were in charge of getting daily PFTs [pulmonary function tests], but we no longer require this because the RT [respiratory therapist] can bill for the test each day.”

(A student in another class at our school developed Guillain-Barré syndrome during a medical charity trip to Central America, tipped off by a GI bug. She had to be transferred from the ventilator in the overseas hospital to spend three weeks in our own ICU. She graduated, but suffers from a permanent loss of dexterity.)

Around 9:00 am, the neurology resident texts me the three patients to follow today. I chart review the patients, then go see them in person before meeting the attending in the administrative section of the hospital to run the list. The physicians lounge is typically off-limits to students and residents, but no one is going to question Queen Maleficent, a 75-year-old attending infamous for rolling around a loud purple suitcase stuffed with diagnostic gadgets and, unlike my VA attending, has adapted to the computer era. “I’ve taken out a lot of the tools because of this new neuro App,” Queen M points to her iPhone. “It has all the color vision tests that I used to carry.”

Our primary role this week, which seems to be typical, is to relieve the hospitalists of liability for not checking every possible box. Out of 10 consults per day, an average of 2 will have neurological symptoms or deficits. We also coordinate with the psychiatry service for odd neuropsychiatric symptoms. One interesting case was a 55-year-old smoker presenting for worsening shortness of breath. A PFT done by his primary care clinic showed an unusual inspiratory effort, but nothing critical. A few weeks later, his wife called 911 saying that he couldn’t breathe. He demonstrated normal inspiratory effort in the hospital, so pulmonology has booted him to the neurology service. We cannot identify any neurological disorder so we consult psychiatry. Queen M: “Psychiatry might enjoy talking with the wife. My hypothesis: he is trying to compete with her fibromyalgia and chronic opioid use.”

Queen M asks me to do a brain death exam on an 80-year-old ICU brain bleed patient who has been on the ventilator for four days. “Text me when you are done, and I’ll confirm what you find.” I look on UpToDate for a refresher. Five family members (wife, two children, one daughter-in-law, one grandchild) are in the room and their refusal to withdraw care has prompted this exam. I ask them to excuse themselves while I cover the glass wall with curtains and perform the exam. I first test for reflexes, and response to pain (none). I then perform the primitive brain reflexes e.g., gag, corneal, oculocephalic (doll test, rotate head to see if gaze does not adjust to rotation), caloric nystagmus (squirt cold water into one ear and watch for nystagmus). The nurse and her nursing student join to watch. When Queen M arrives, she repeats the exam, then orders an apnea test (must be performed by two physicians independently). We preoxygenate the patient with 100 percent oxygen, then hold the ventilator as the respiratory therapist draws blood gases every few minutes. A positive apnea test is failure to initiate a breath once the CO2 level reaches a certain threshold (typically 60 mmHg). We put in our note for the primary team: brain dead.

We are paged for a 35-year-old male whom I previously met on surgery rotation for a problem with his gastrostomy tube. He is chronically disabled and epilectic after a car accident three years ago. His wife left him, taking the two-year-old and 6-month-old children. His mother now devotes her entire life to his care. We walk in and he is less responsive than usual. The mother explains: “Something has been off every since yesterday afternoon.” Queen M orders the nurse to administer Keppra and Ativan. The nurse asks “Have you put the order in? [into Epic]” Queen M responds quietly: “If you don’t do it, I will. Open the code cart if you can’t get it from the Pyxis.” (Pyxis is an automated pharmacy cabinet that dispenses common medications with a fingerprint and badge swipe.)

The last consult is a 28-year-old postpartum female in the labor and delivery ward. Five weeks after delivery, she was leaving backing out of the driveway with her newborn in the back seat. The husband rushed out when he heard the car hit a utility pole and saw her seizing for a few seconds, then go limp. We have to decide if this is postpartum eclampsia (90 percent of postpartum eclampsia occurs within the first week of delivery), new onset epilepsy, or an isolated seizure. She has no history of seizures and no family history of seizures. Her eclampsia labs and first 4 hours of EEG are both normal. We are skeptical this is postpartum eclampsia so the discussion turns to anti-seizure medication. “Once you are on seizure medications,” says Queen M, “very few doctors have the courage to take you off.” Having learned nothing definitive, we decide to do an overnight stress EEG, and re-evaluate. Considerations include balancing anti-seizure medication safety during breastfeeding against the risk of a seizure while driving or holding the baby. “I am willing to do a monitored outpatient experience where we follow you every two weeks,” says Queen M. “You cannot drive during this period.” We tell her that the average patient has a 24 percent risk of a seizure recurring. The mother weeps.

Statistics for the week… Study: 8 hours. Sleep: 8 hours/night; Fun: 2 nights. Gigolo Giogio’s birthday celebration includes a thirty-person pregame at his house followed by fruity drinks and dancing until 2:30 am at a Drag Queen club.

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

Full post, including comments

Last week on psychiatry. I am paired with an outpatient psychiatrist who specializes in addiction medicine. He splits his time with group therapy sessions and individual appointments for general psychiatry patients.

Monday morning begins at 8:00 am. The psychiatrist explains the suboxone program enrollment agreement. A psychiatrist accepts the patient into the program at an initial consultation, also called “intake.” The patient then attends weekly group sessions for 6 months in addition to two individual appointments per month. Once stabilized, the patient attends a monthly one-hour group session and quarterly individual appointments. At each appointment, the patient takes a drug screen. “Most of my patients do multiple types of drugs, so although we call this opioid addiction therapy, each patient is unique in their social situation and drug addictions,” the attending notes.

Our first group session begins at 9:00 am. Of ten patients, two patients are brand new to the meeting, having just enrolled for addiction treatment. Most have been with us for 6 months to 2 years. Two are “oldtimers”, having been in this group for over 5 years. One female oldtimer is actually off suboxone completely.

The meeting starts off with short introductions. Our oldtimer: “You all know me. I’m a recovering addict of alcohol, heroin, pills, and cocaine. I’ve been sober now for 10 years.” The psychiatrist asks how her daughter is doing. “Well most of you know I got custody back of my daughter from my ex husband. She’s starting middle school!”

[Editor: Why should a plaintiff’s consumption of alcohol, heroin, pills, and cocaine interfere with an ultimate family court victory?”]

One of the two new members, a 22-year-old unemployed male addicted to pills, introduces himself. “Hello, I’m [Brad].” The psychiatrist asks him to share some hobbies or interests. “Well, I recently lost my job as a construction project manager. I play video games.” The oldtimer mother asks. “Great to meet you, Brad. Do you have a girlfriend? ” He responds, “No, my girlfriend overdosed last year.”

The psychiatrist goes around the room. He calls out one who tested positive for cocaine. “[Johnny], if this happens again I will have to kick you out of the program. This group is based on trust.” (He later tells me some psychiatrists have a zero tolerance policy, but he prefers to tailor it to each circumstance. Johnny had recently been sued for divorce by his wife.)

After the group session, he writes notes until the afternoon appointments, which start at noon. We see depressed and anxious patients and have new consults for addiction and bipolar disorder. I begin the interview of a new consult. The 30-year-old male electrician presents for methamphetamine addiction. He was arrested for possession, but our city has a program that enables those accused of drug crimes to avoid jail if they seek addiction help.

I ask about his employment. The patient makes $4,000 per week constructing power lines, “when I work.” The psychiatrist chimes in. “How many weeks a month do you work?” He responds, “Maybe one. Whenever I need money I find a job.” The attending acknowledges this, “You can be quite functional after a weekend cocaine binge, but coming down from meth, you’ll be out for a week.” He responds, “Yeah, cocaine didn’t do it for me after I found meth.”

“How badly do you want to be clean?” asks my attending. “How much are you willing to give up?” He responds, “I’ll do anything, Doc.” The psychiatrist states “Okay, I will set you up at the rescue mission. Take only a backpack. You will be gone for 6 months.” The patient looks distressed. “I need to think about it.” The psychiatrist acknowledges. “Okay, you let me know when you have decided.”

Once the patient leaves, the psychiatrist turns to me. “The patient is here only because he has to be. He has no interest in quitting.” He continues, “Meth is a destroyer. To get over meth, you have to hit rock bottom. The only times I see a patient conquer a meth addiction are via incarceration or if they drop everything in their life, leave all their friends and family, and move away for several months.” He asks me, “How do meth addicts die?” I cite heart attacks and strokes, recalling my internal medicine rotation where massive heart attacks and intracranial hemorrhages were common among the meth-addicted.

My attending adds, “I see a lot of female meth users. Meth, intensifies sex. It makes women do things they would never imagine. The acts they tell me they did is scandalous. Their boyfriend keeps getting it for them for more intense sex. Eventually, the woman cannot have sex without meth. I see so many pregnant meth addicts.” He concludes, “Once you treat meth addicts, alcohol and opioid addiction seem like nothing.”

Our next patient is a 40-year-old morbidly obese female nurse with major depressive disorder and anxiety well controlled on a serotonin and norepinephrine reuptake inhibitor (SNRI). She reports proudly that she finally got around to divorcing her husband. “He is addicted to pornography. He doesn’t acknowledge me. We haven’t had sex in eight months.” My attending congratulates her.

Another attending stops by the office to chat. He complains that the community service board (CSB, the regional safety net mental health organization) keeps prescribing the newest antipsychotics as a first-line agent. “I don’t understand why they jump to these new medications, which are so expensive.” My attending responds, “Medicaid pays for it. I completely agree, the older ones are cheaper and just as effective.”

[Editor: See the book Bad Pharma by Ben Goldacre, a British physician, regarding the typically marginal improvements (at best) of new expensive meds compared to old generic meds.]

Wednesday’s group session features a new patient, a 24-year-old male with schizophrenia and opioid use disorder. His psychiatrist managing schizophrenia started him on risperidone. “Google says I am going to grow tits. I’m not going to take it.” Another member exclaims, “Oh my God, don’t take that.” My attending responds, “[Jimmy], this is not the time to discuss this. Remember why you take this medication. I want you to talk with me afterwards and call your psychiatrist.” He agrees. After the session, a 35-year-old female asks if she can get an additional film of buprenorphine. She explained, “One of my friends overdosed on heroin. I ground up suboxone and injected it. I saved her! But now I don’t have enough to get through this week.”

We take the psychiatry exam. Example question: Which of the following patients should be admitted to an inpatient psychiatric bed? Answer: a patient expressing suicidal ideation with a clear plan rather than vague expressions of hopelessness and no plan. We then have a debrief session with the clerkship director who asks, “What surprised you on this rotation?” Sarcastic Sally, “The inpatient pediatric psychiatry wards were eye opening. There are so many troubled kids. Without protective factors, such as having a safe home without addicted parents, we could’ve been them.” 

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 3 nights (gatherings at various bars with various classmates and their dogs).

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

Full post, including comments

Consultation and Liaison (C&L) service. I meet the team at 7:45 am in the C&L workroom, a windowless room that crams 3 computers and a loveseat. The 35-year-old attending who completed an Internal Medicine and Psychiatry dual residency runs the list with the 40-year-old PGY3 resident who was a psychiatrist in India and myself. We then go down to the ED to begin seeing the new consultations for the day where we are joined by the ED psych social worker. 

I interview the first patient, a 40-year-old obese Black female with major depressive disorder presenting for suicidal thoughts. She has been working with the homeless assistance team (HAT) to get set up in housing. She has rejected two different apartments. When the social worker informs her that she needs to work with HAT, she responds: “I want an apartment that I want. It cannot be across town.” She adds, “Also when I get admitted, I want a good doctor, not just any doctor.”

The next patient is a 28-year-old obese female with bipolar disorder presenting for suicidal ideation. She is also a regular. When our team goes into her alcove, she is busy eating french toast. We barely understand her one word responses. She proceeds to get up from her bed, and beds over to reach her purse on the floor. “What other specialty would you get to see that?” asks the attending. “She doesn’t stop stuffing her mouth with french toast, and then moons us slowly.”

We then proceed to see consults in the hospital who have been admitted to other services. I am assigned two to see alone while the attending is busy performing transcranial magnetic stimulation therapy.

The first patient is a 65-year-old grandmother with rheumatoid arthritis who overdosed on her opioids and benzodiazepines. “I regret that it did not work,” she says. “I wouldn’t have done it if I knew it would not work. I’d have tried something different.” What are your stressors? “Well son, take a seat. My daughter is a heroin addict who brings strangers to our house to shoot up. I have custody of her and our grandson. I live in chronic pain.  CPS have already been contacted by the primary team. We recommend inpatient psychiatry after medical clearance. The primary team is surprised that she is still alive. She had a five-day ICU stay.

My next patient is a 65-year-old with Lewy body dementia admitted for a GI bleed. We were consulted due to concern for MDD. His wife has cancer and cannot have sex. “I want to express my love for her while I am still here. I know I don’t have much time left.” We explain to him that an SSRI might help improve his depression, but may cause sexual dysfunction and decreased libido. “That’s good, give me that!”

I attend psychiatry grand rounds regarding a controversial topic: Combat Addiction, a recently proposed new syndrome within the umbrella of PTSD. The former Stanford clinical psychologist presenting describes Combat Addition as an addicted phenotype in which afflicted individuals seek to recreate the adrenaline rush. “This is not a new phenomenon, but just one that is increasingly common. The soldiers in Vietnam and World War II had limited combat exposure, and the ones that did had few recurrences. The Middle East wars are different. They are the perfect storm for addiction: high intensity, repeated exposures.”

[Editor: From the above we can learn that people at Stanford were well-insulated from anything that went on in Vietnam and World War II. There were, for example, 11,846 helicopters shot down or crashed during the Vietnam War compared to roughly 400 in Iraq and Afghanistan together. Approximately 340,000 American troops died in World War II and Vietnam, compared to fewer than 5,500 in Iraq and Afghanistan.]

Our speaker goes around the country recording combat veterans’ stories. He retells one soldier’s comment: “The first fire fight is an unreal experience, better than sex. You want it again.” These experiences are defined by a loss of context, revenge, betrayal (by country and politics). They undergo an intense bonding with their brothers, then return home to what they see as a meaningless life.” In an effort to recreate the environment, he reports, “One soldier told me that he got a concealed carry permit and was ‘waiting for someone to shoot at me to make me live it again.'”  He cites dangerous speeding on motorcycles to recreate the adrenaline rush of combat.

Our hospital had set up an audio-video link to the VA and several of their psychiatrists call in with questions. “Thank you for highlighting this. Your definition so accurately portrays many of the combat veterans that I see. Are there any diagnostic criteria or evidence-based interventions?” He responds, “The VA forbids any research into this syndrome. We haven’t even characterized the progression of the disease so we have no trials investigating treatments. Some of the patients I have followed for several years seem to age out of the longing to simulate combat, but they seem to still struggle with disillusionment.” He continues, “The one item I see that helps is community with comparable peers. It is challenging for providers to engage them because they look down on those claiming PTSD symptoms, believing that patients are motivated by the prospect of disability benefits.” He ended by citing several ongoing clinical trials with psilocybin and other psychedelics that may be beneficial, although “I cannot imagine some of my older veterans doing this.”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Four of our classmates brought their respective dogs for a playdate at the local park. Only one ran away.

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

Full post, including comments

After a beautiful one-hour drive into the countryside, an imposing six-story concrete building rises from the hillside. Locals comment about the Soviet-era architecture. The campus also includes several smaller dormitories near the main building. It started out as a sanitorium for tuberculosis patients in the early 20th century.

The enthusiastic coordinator sets me up with a badge, parking permit, and color-coded set of keys in the first 10 minutes, a huge contrast with the VA where time stands still in the face of bureaucratic requirements. She explains how to open doors in the hospital. “Before you can go through the second door, you have to ensure the first door is fully closed behind you. Some of the doors you have to jiggle to open. We recently had an elopement so everyone is on alert about the doors.” (In the mental health world, to elope is simply to run away and does not imply a marriage.)

She shows me the cafeteria, open for staff meals at unusual times, e.g., 9:15-10:15 for lunch and 4-5 pm for dinner. She gives me a tour of the facilities, including the small dormitories for staff and visiting students and drops me off at a lecture on personality disorders by the medical director. I meet the three other medical students. All of them are staying in the dorms and admit to being creeped out by trying to sleep through the on-campus screams. They have no cell service and only intermittent WiFi.

The hospital has six floors: Two for adult males, two for adult females, and two for geriatric patients. I meet Pranav, a short attending from India loved by all the staff for his patience, on the long-term geriatric resident floor. Opening the door from the stairwell reveals several patients waiting by the exit. I squeeze through and quickly shut the door as patients lunge for the open exit. After it’s closed the patients go back to their normal routine of walking the halls and pulling on any locked doors. The nursing station is a locked room with a customer service window through which patients can receive medications.

Pranav shows me the paper charting system, a sharp contrast with the VA, which was an early adopter of computerized medical records. Binders of color-coded papers are placed on a turntable in the middle of the nursing station. Each patient corresponds to at least one binder, which may have up to 600 pages. When a new order, e.g., medication change, occurs, you pull a 3-inch by 6-inch tab out from the binder so the nurses see that there is a “To-Do” item for that binder. Orders end up being performed faster than at my home institution, despite its $100+ million Epic system, due to face-to-face communication between doctors and nurses. The attending sits at the nursing station instead of retreating to a computer room or office. 

Pranav instructs me to review the charts of the two new admissions.  “We’ll see them for the first time together in the afternoon. “Go get lunch and let’s meet back up for the 1:00 pm staff meeting.” I struggle to navigate the various parts of the paper chart, so I ask a nurse. “Purple is prior admission records, Blue is transfer documents, Red is admission H&P and progress notes. You’ll get used to it, honey!” She adds: “The red binders are [Pranav’s], the Blue binders are the other attendings’.” I scan the binders for patients on our service. During a manic episode, one patient murdered her husband, and then set herself on fire to burn out the Devil that she believes is inside her. Three patients are here after being found not guilty by reason of insanity (“NGRI”). Most of the geriatric floor patients are here because of dementia that progressed to include delusions, hallucinations, and acts of verbal or physical abuse to caretakers.

I join Calvin, a third-year medical student studying at a Caribbean medical school planning to do psychiatry (one of the easier-to-get-into residencies), for lunch. Spaghetti and meatballs with a bowl of apple crumble is $2.15 (cash only). Calvin’s family is two hours away, so he typically returns home for the weekend. He describes his first night sleeping in the dormitory. “The WiFi doesn’t work in my room, so I went to the common area and heard two people having sex in the security office. I learned the next day that it was the security guard and a new nursing assistant who was finishing orientation week. Someone apparently reported them… it wasn’t me. This was the guard’s last week so she did not face any consequences, but he apparently was fired.”

A PGY-4 (senior) resident doing an elective here joins us. He describes the hot job market for psychiatrist graduates. “I just signed a $300,000 salary with a $100,000 signing bonus for an outpatient practice in the Bay Area.”

[Editor (2019):: With $300,000/year, he’ll have a one-bedroom apartment, a Nissan Leaf, and enough left over to splurge on Blue Bottle coffee once a week. Editor (2022): Good news is $300,000 per year; bad news is that’s also the price of a Diet Coke.]]

Over the loudspeaker, we hear that a Code White has been called. Several staff get up and hurry to the exit. Calvin: “Come on, let’s go.” On the female adult floor, two overweight African American patients admitted for bipolar disorder got into a fight. They’re both roughly 30 years old and Patient A has accused Patient B of using her perfume. Patient B allegedly threw the perfume bottle on the floor and says that she has a piece of glass and threatens to stab the other patient. It turned out that the perfume was in a plastic bottle, and the “glass” was merely a plastic cap. Everyone disperses as the attending, a funny overweight 45-year-old white psychiatrist, diffuses the situation. Afterwards she explains to me, “Neither patient should be here. [Patient A] claims that she is bipolar and that she stopped taking her medications to the EM physician, who then calls the state psych admission service. Lamictal [mood stabilizer] does not stop in five days. She gets violent when she does cocaine.”

Caribbean Calvin and I head upstairs to the geriatrics staff meeting with three social workers, the head nurses, and both geriatric attendings. We discuss each of the new admissions, and concerns regarding prior admissions. The meeting focuses on a 56-year-old with rapidly progressive dementia over the course of six months. The chart states that his wife started to notice he would become confused about daily activities, then started to have behavioral outbursts. Last month, he became disinhibited, yelling at people for nothing and groping strangers in public. He was admitted to a rural hospital and then transferred to here for further evaluation. He is not oriented to where he is and he has lost the ability to communicate to others except for random unintelligible outbursts. The nurses are having a crisis because he goes into other resident’s rooms, grabs their clothes, and puts them on himself. “He goes into Ms. [Georgia]’s room, a frail 90-year-old, rips her sheets off her bed while she is lying on them, twists them around himself, then grabs her panties and shirts, and puts them on. He’s almost choking how tight they are on him. And then walks down the hallway. Clothes fall off him. It’s a danger to other residents because they can trip on them. Last week, Ms. [Hansen], tripped on some of this clothing and broke her hip. And he’s strong. What are we going to do about him?” Pranav: “I’ve never seen anything like this. We’re taking a broad differential with him. He has some language skills and memory. He is reciting several verses from the Bible out of memory at the nursing station every morning. We’re waiting on tests, but this could be frontotemporal dementia or prion disease. Let’s see how he does on lithium, which should kick in during this week.”

Tuesday morning begins with a physician-turned-ethics-consultant teaching grand rounds on transgender cases. He went through several landmark court cases, and asks for audience participation on what should be done to resolve the issues.

The Case of Ms. V:. A transgender female wants to go to a residential group home for survivors of rape. The home has been reserved for women who were raped by men. Ms. V was accepted to the home under the condition that she inform the other residents that she was endowed with a penis. Litigation ensued. Should the group home have accepted her unconditionally? 

He asks the audience (of about 60, including social workers, nurses, and psychologists) for a show of hands: “Who thinks we should accept Ms. V to the home with no conditions?” Hands go up from most of the audience. Who thinks she should not be accepted? No one has the temerity to raise a hand. Pranav asks some of us sitting nearby, ‘Shouldn’t we consider the rights of the other residents? Will they be traumatized when they see a penis in the shower or hallway?” The larger audience hears this question and competes for who can offer the most vehement “No.” Example: “We would not deny placement for Muslim women if all the residents had PTSD from 9/11.”

Case 2:  A Transgender male with bipolar disorder and borderline personality disorder requests gender-affirming surgery.  On review of charts, he has a history of factitious disorder (the desire to play the role of a patient, not necessarily with any intention of financial gain). Although there is nothing wrong with his hearing or vision, he has previously presented to the emergency room with deafness and blindness. Should he be allowed to undergo this surgery? “I used to treat these individuals. You never start gender-affirming therapy until the patient is stable.” Pranav interjets: “That used to be standard of care. We all know that this is not true in some cities now. You can go in and be scheduled for surgery in two days.”

[Editor: Pranav sounds like a potential hater. He might want to read “Factitious sexual harassment,” by Sara Feldman-Schorrig, MD, 1996 (“prompted by the lure of victim status”), and “The Psychodynamics of Factitious Sexual Harassment Claims,” (Bales and Spar, 2016, Journal of Psychiatry, Psychology and Law), “Factitious sexual harassment claims are those in which the plaintiff’s wish for victim designation is a major driving force behind the claim.”]

Case 3: GG vs. Gloucester County School Board. “G.G. is a transgender male student that requested use of the boys’ bathroom. The Gloucester, Virginia high school originally agreed, but student and parent complaints led to a reversal of this decision and creation of a gender neutral bathroom. The court ruled that the school had violated Title IX,” said the ethics consultant. “Keep in mind that Title IX was written in the 1970s before any notion of gender identity existed.” The student graduated in 2017, but the litigation lives on (at least through 2019) and now the girl-turned-boy is hoping for monetary damages. If our group of 60 were the jury, Gavin Grimm would prevail. Everyone agreed that being restricted to a special bathroom was discrimination.

[Editor: Gavin won at the appeals court level in 2020 and the Supreme Court refused to hear the school board’s petition in June 2021. The school board paid $1.3 million and Gavin got $1. The rest was pocketed by his/her/zir/their lawyers, mostly the ACLU.]

After grand rounds, the ethics consultant shifts gears to consider the rapidly progressing dementia patient. Several ideas have been floated, including moving clothes from resident rooms to a communal closet. The ethics consultant predicted that this would be a difficult case to make to a court. “It is well established that having access to your own clothes is a basic human right. I just don’t see how we can violate everyone’s basic human right because of one offender.” The lead nurse: “They would still have access to their clothes, just they would ask a nurse

Full post, including comments

After a 45-minute drive, I arrive at 8:30 am for paperwork at the local Veterans Administration (VA) hospital. Unfortunately, due to my short time here, I won’t get access to their electronic medical record system. I am joined by a podiatry resident, an internal medicine resident, and a medical student from a different school. After 2.5 hours of picture-taking and forms, we have our ID cards and are ready to experience the largest healthcare system in the United States.

Tuesday was a typical day: Arrive at 8:20 am for the first patient at 8:30. He is a no-show and the psychiatrist says that the no-show rate is roughly 50 percent. We chat about various psych topics while he does calf and neck stretches. One topic is the difference between ego-syntonic and ego-dystonic. “Both terms have fallen out of favor,” he said. “In DSM-3, homosexuality was considered ego-syntonic because it was a behavior that did not go against a person’s ego. This is compared to the dystonic behavior of obsessive-compulsive disorder in which the patient knows these compulsions are interfering with his/her life.” He explain the components of a mental status exam, including identifying common cognitive distortions, such as all-or-nothing thinking, emotional reasoning (equating transient feelings to reality), and overgeneralization (assuming one negative outcome results in inevitable failure of that goal)

I saw 2-4 patients per day, each for a 30-minute visit (workload would have been 4X at our home institution). When a patient arrives, I begin the interview and the psychiatrist interjects with clarifying questions and counseling regarding medication changes. I leave at 4:00 pm.

[Editor: As of 2019, a VA psychiatrist could get paid up to $320,000 per year. If we assume 3 patients per day for outpatient work, plus a full 40-hour week once/month on inpatient duty, that’s 1000 hours per year (if we assume 30 minutes of paperwork after every 30-minute visit) and $320/hour plus pension and other benefits bringing total compensation to $500/hour?]

As in civilian psychiatry, the typical diagnoses are anxiety and depression. Most patients were in the military for only two or three years and were never deployed abroad nor served in combat. 

I see a 45-year-old who worked at a Pentagon desk for 10 years as an intelligence officer. She presents for follow-up on generalized anxiety disorder. Although the majority of wealthy white women voted for Trump, she is not among them. When asked how she has been doing since her last visit, she responds with a discourse on Donald Trump’s racism and sexism. How much of her day was spent thinking about politics? “A few months ago, it was 75 percent of my day. I’d say it is now only 25 percent.” What coping mechanisms had she implemented? “I watch MSNBC only once per day.” She then explains that another 20 percent of her worry is about the recent remodel of her house.  “We just got these custom-ordered massive glass pane windows. One of them is trapezoidal, and it has several streaks on them.” She gets up on a ladder every day to scrub these and then calls the glass vendor.

[Editor: This proves my general rule that people who rent are a lot happier and have more mental space to think about interesting things than homeowners, constantly burdened with their amateur property management tasks.]

A 38-year-old medically discharged Air Force pilot presents for follow-up on generalized anxiety disorder with panic attacks well-controlled on Prozac and Ativan. He had flown the C-130 in Afghanistan and Iraq. There was an explosion due to mechanical malfunction that left him with damage to his arena postrema (vomit zone in the brain) and asthma from chemical inhalation. He described the weekly intense bouts of nausea that come out of the blue. “All my buddies are now pilots for the airlines, but I’m not allowed to because of my asthma.” His biggest current stressor is finding a job that is meaningful and pays well. “Even with my disability payments and my wife’s earnings as a secretary, money is tight with two small children.”

A 27-year-old overweight white male describes his experience as a flight engineer in the Navy. He was bullied and did not fit in. His team was being investigated for a spy in their midst who was allegedly sabotaging equipment on behalf of China. “At first they thought it was me,” he said. “You don’t know what it’s like to have everyone looking over your back. When I left, they still hadn’t caught the spy. There was never any evidence that it was our team. I never had anxiety before this ordeal.” He had been dishonorably discharged, but was now trying to get that changed to a medical discharge for major depressive disorder and generalized anxiety disorder. He described symptoms that could have come straight from the DSM-5. If we supply the requisite documents to change his status, he will get 100 percent tuition, housing, and books for his computer science studies. Ultimately, we tailor the note to say that his symptoms began during and as a result of his service, so he should be on track for a taxpayer-funded college degree.

[Editor: It seems that a dishonorable discharge is a bar to receiving most VA benefits, but a veteran can still be seen at a VA facility for “disabilities determined to be service connected.”]

There are workshops for the five VA psychiatry residents at lunch, led by an attending. I told them I was still waiting to see psychosis or mania. The chief resident responds: “Oh you’ll see that at the state mental hospital.” A graduate of an Iranian medical school now doing her residency here interjects: “No, no, if you really want to see mania or psychosis, go to Iran. Only about 10 percent of patients in state hospitals are legitimately psychotic. In Iran, it is 100 percent. You only get into a hospital psych bed if you are truly psychotic.” What about those who suffer from depression or anxiety? She laughed: “That’s life. Deal with it.” What was her psych rotation in Iran like?: “Everyone was telling me they are Jesus, Moses, or Muhammad. One asked me, ‘Have you ever spoken with God?’ When I said no, the patient responded, ‘Well you are now.'”

The chief resident describes the challenge in choosing between a position at a state mental hospital versus at the VA. “The state mental hospital job is a two-year contract with the government contractor that staffs the state hospital. There are no guarantees at the end of the contract and the work is intense. The VA offers more money and stability for much less work, but I think that I have too much energy for the VA, I want to change things.” He explained his plans to take the state hospital job and supplement that income with part-time work for a telemedicine psych company.

[Editor: An FAA employee told me, “I was unhappy in this job until I accepted that I was never going to accomplish or change anything.”]

The VA has implemented a new program in which a psychiatrist goes to the VA’s primary care clinic for consults with veterans who were flagged for mental illness by the primary care docs. This eliminates the waiting period from primary care to psych appointments. I see a 50-year-old former intelligence officer who is presenting for depression and anxiety. Her immediate concern is that the state is trying to euthanize her pit bull after the animal attacked a neighbor’s child. The psychiatrist decides to set an appointment up for her to come see him before and after the upcoming court hearing.

[Editor: Our Florida neighborhood, for a radius of about 1 mile, is entirely pit bull-free due to homeowner association rules.]

We then walk to the inpatient psychiatry unit to cover for an attending who has to leave for a family emergency. We admit a 65-year-old who served in the infantry during Vietnam. His diagnosis is polysubstance abuse, primarily crack cocaine. He was recently paroled after 15 years in prison for drug-related offenses and has been working as a mechanic, but was tripped up with a positive test for cocaine on a routine drug screen. The parole officer gave him the option of voluntarily admitting himself to inpatient psychiatry instead of going back to jail. We screen him for depression. He describes feeling that he has nothing to live for. His wife divorced him, took all of the joint assets, and now receives the lion’s share of his veteran’s pension. He lost touch with his daughters while he was in prison and they don’t want to reconnect. “I know I am going to kill myself if I keep using. Can you help me?”

On Friday afternoon, I say farewell to the VA and attend a required lecture on motivational interviewing (“MI”) led by a child psychiatrist. Primary care physicians can now deal with addiction easily if they can remember “SBIRT”: Screen, Brief Intervention, Referral to Treatment. We watch William Miller, a founder of MI, in video interviews with addicts. He gives us another acronym, OARS: open-ended questions, affirmation, reflexive statements, summary/synopsis. “There should be a 2:1 ratio of statements to questions. Once the patient begins talking, don’t interrupt him/her with a targeted question, but instead make an affirming or reflective statement.”

After the prepared PowerPoint ends, we do live practice. He goes into role as Johnny, a 10th-grade pothead taking several AP classes and maintaining a 4.3 GPA. He adds, “Weed is the number one cause of outpatient referrals. From now on, I am not myself, so I don’t want anyone writing me up on evaluations for what could be said.”

As a group we practice MI. What brought you in today, Johnny?” Johnny: “My father and I used to build cars and hang out. Now he is on my back about school and smoking pot. I used to not have any friends, but now I actually hang out with people. Smoking pot hasn’t impacted my grades, it’s just my dad is butthurt. I’m a parent’s wet dream!” We continue to practice responding with statements, and not questions. Bad: “Do you miss spending time with your dad?”; Good: “It must be challenging to balance spending time with your dad and with your new pot-head friends.” The goal of motivational interviewing is to make the patient reflect on the benefits and costs of a bad behavior, e.g., smoking. Do they actually like smoking, or do they smoke because of some other stressor? 

After the conclusion of the exercise, he becomes animated on the subject of marijuana. “I will come out and say that I support legalization,” says the child and adolescent psychiatrist who just told us that marijuana leads to demand for adolescent mental health services. “I think the war on drugs has proven time and time again that locking up nonviolent pot smokers is not the answer, and overall is not effective in addiction treatment. The answer is education and awareness about the real harms of marijuana, especially THC and cannabinoids. There is quite convincing evidence that adolescent pot smoking can lead to harmful impact on depression, anxiety and development of psychosis.”

[Editor: … but a beneficial impact on the incomes of psychiatrists….]

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Stopped by Gentle Greg’s house for his birthday party. Several physical therapist (PT) students attend.

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

Full post, including comments