Philip Greenspun’s Weblog

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

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

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

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