WILTIMS #493: Neurology - Inpatient

What's this?! A single-day blog post released on the day about which it's written?!?!?! Madness!!! Check out the previous three catch-up posts I finished today here, here, and here.

Today I started my holiday-shortened week of inpatient neurology. This mostly consists of stroke patients, which is, let's say... less than uplifting. This morning was spent walking room to room testing patients' neurological deficits while families looked on with either false hope or resigned acceptance. The deficits are usually the same as the day/week before and most of what was their loved one is now gone. The questions become: How much of the person is left? Would the patient be happy living like that? Where do they go from here?

It's sad, but this is very accurate.

TIL: With "locked-in syndrome," where the conscious mind is preserved within a paralysed body, voluntary vertical eye movement often returns and enables communication. It's easy enough to test; today we talked to/at a woman in a post-stroke vegetative state and told her to look up and down, or to look at the doctor's face that was out of her vision above her gaze. Her eyes simply continued sliding left and then whipping back right, like she was watching an eternal typewriter.

WILTIMS #488-92: Neurology - Epilepsy

This is the third catch-up post in the past couple hours. Make sure not to miss one! Here is Nephrology - Part I and Nephrology - Part II.

Last week I started my four week rotation in Neurology. This is my last rotation of third year! Woohoo! Each week of this rotation I am on a different team, starting with epilepsy on week 1.

Epilepsy is super boring. Well, epilepsy as a collection of disorders is actually really interesting, but treating epilepsy patients in the hospital is usually really boring because the patients are rarely actually seizing when you're standing there. Usually they had a seizure at home and were brought in to the hospital once they've stabilized. Then our job is to figure out if they truly had a seizure, why they had one if they did, and keep them from seizing again (usually by starting or raising the dose on the same cure-all anti-seizure meds).

A sample EEG with a seizure on the right half

The mainstay of epilepsy diagnosis is the electroencephalogram (EEG), which is always depressing. Either it will confirm a diagnosis of seizures, which is never fun, or it shows that there weren't any seizures while it was recording, which either means that the patient's problems are not caused by seizures, or that the EEG just got unlucky and there normally are seizures.

MIL: When doctors adjust the level of drainage for a ventriculostomy (tube that removes cerebral spinal fluid (the juice your brain floats in)), they counterintuitively talk about increasing the ventriculostomy to wean off of it. This is because the number that they are increasing is the amount of intracranial pressure (ICP) above which the ventriculostomy tube will start draining. A great analogy that a nurse shared was it was like raising the height of the overflow pipes from a dam; if you raise the height, the dam has to hold more water before it overflows. Lower numbers mean less stress on the dam/brain.

TuIL: Seizures on EEG look as if the squiggly lines have increased in every way: frequency (they're more common), amplitude (they're taller), and rhythmicity (they have a consistent pattern).

WIL: Shivering suppression can hide seizures in patients being treated with therapeutic hypothermia after a cardiac arrest. A common treatment used after the heart stops for a prolonged time is to lower the body temperature. But this can cause violent shivering as the body tries to maintain homeostasis. The drugs used to stop the shivering are paralytics that prevent the muscles from contracting. This works great, but if the patient is having seizures (as ~30% will, post-cardiac arrest) then the paralytics will stop you from discovering the seizures. Even though the patient isn't able to twitch or spasm, the brain might still be being damaged by the silent seizures.

ThIL: There are four broad kinds of sedating drugs: benzodiazepines (like versed), opioids (like fentanyl), alpha-2 adrenergic agonists (like precedex), and propofol (which is in a class of its own as we don't even understand its mechanism).

FIL: Nemaline myopathy is an atypical muscular dystrophy that results in weakness in skeletal muscles, typically most severely affecting the face, neck and limbs.

WILTIMS #483-7: Nephrology - Part II

This is part II of my rapid-fire catch-up series. Click here to read "Nephrology - Part I" which was posted only an hour before this post.

One of the things that I find endearing about nephrology is that when you work in a hospital, you already know most of your inpatients very well. That's because one of the biggest predisposing factors for acute kidney injury is chronic kidney injury. Dialysis patients are always a knife's edge (or 2-3 days without a dialysis treatment) away from the emergency room. If your kidneys are totally non-functional then you need dialysis at least 3 days a week. If you miss an appointment, the toxins that the kidneys (or dialysis machine) should filter from the blood can cause all manner of dangerous side effects very quickly. When these patients show up in the ER, though, it's not like a typical consult for the nephrology doctor. You've seen these patients 3 times a week for months, years, or even decades.

My final thoughts on nephrology are similar to my thoughts on pulmonology: working with just one organ system is incredibly frustrating. In pulmonology, we often started reading up on a patient not by reading the history and physical, but by looking for a chest x-ray or CT scan. All we cared about was the lungs. We once had a family ask about the patient's brain tumors and we honestly didn't know they were being treated for that; all we cared about was their pneumonia. In nephrology, we were very big on the blood tests. If a patient we'd followed for several days didn't have blood work ordered by the primary team, we might not even bother seeing the patient that day.

I don't want to work in a field that can clear a patient "from the [insert organ here] perspective." How is the patient? Well she's fine from a kidney perspective (but I think I saw a note that her leg needs to be amputated and the septic blood infection from her UTI is life-threatening). I'd much rather be in charge of the whole picture and ask other colleagues to comment on their particular organs. But that's just me.

MIL: If a patient has any amputation due to diabetes, they have a 48% chance of having another amputation within 3 years.¹

TuIL: If you google the acronym "MMF," the definition offered by urban dictionary is not medical meaning of mycophenolate mofetil, a immunosuppressant enzyme inhibitor used to prevent transplant rejection.

WIL: The maximum renal clearance in a healthy young adult male is estimated at 180 liters per day.

ThIL: Dialysis disequilibrium syndrome is an increasingly rare reaction to the abrupt change in blood contents after a patient first has a dialysis session. It's normally seen hours after the dialysis session starts, once the blood is mostly clean.

from http://kidneystones.uchicago.edu/

"Dialysis reaction" is a reaction of the blood to the membrane used in older model dialysis filters. Compared to disequilibrium reactions above, these dialysis reactions happen almost immediately after beginning the dialysis session.

FIL: Medullary sponge kidney is a congenital disease of the kidneys where the kidneys look like - you guessed it! - sponges. These porous, cystically dilated kidneys usually cause very few, if any, symptoms. The only problem that sometimes arises around middle-age is that the kidneys repeatedly form large stones that can cause obstruction of the ureter and damage the kidney. If it's not caught quickly, the affected kidney can fail entirely and, given the mildly debilitated other kidney, cause the patient to need periodic dialysis.

WILTIMS #479-82: Nephrology - Part I

Sorry for falling behind again! I have been taking notes in my little black book (spoiler-free example page on the right), and I'm hoping to do a crazy series of catch-up posts over the next day or so.

A few weeks ago week I started my second two-week elective, nephrology. Taking a detour south from the lungs, I turned my currently myopic gaze to the kidneys. One of the reasons that nephrology was on my elective list was that kidney pathology is very physiology-heavy. You have to really know how the organ functions on a biochemical level to diagnose and treat kidney diseases. I like this connection with the basic sciences and the similar reliance on physiology in intensive care is part of why I'm leaning that way career-wise.

MIL: Dialysis machines measure the sodium concentration indirectly by measuring the conductivity of the dialysis solution. Pure water conducts electricity poorly, while salty water conducts very well. By measuring how conductive the water is, you can determine how salty the water must be. The predominant cation (positively charged molecule) in the dialysate broth is sodium, so conductivity ≈ saltiness ≈ sodium concentration. Who says high school chemistry was never useful!?

TuIL: Acute kidney injury (AKI) is classified by several systems. The older model is based around the RIFLE acronym,

WIL: Wednesday was our last class meeting of the year. We finally learned how we are going to sign up for our various fourth-year courses! Kind of... We subsequently had a lottery for our required courses and are still waiting for open enrollment for our electives. I also learned that there are over 20 people in my class planning on going into pediatrics, which is a huge increase over previous years. This made our required fourth-year course work difficult to schedule, because the simply aren't enough spots for everyone to do everything at convenient times.

ThIL: ACE inhibitor drugs decrease the filtration rate of the kidneys in the short-term. This is generally a bad thing for an already stressed kidney. But, in the long-term, the decrease in blood flow decreases the rate of glomerular damage. Think of it like an old car that is always parked under a bird-filled, pollen-generating tree. If you wash it every day, it gets clean, but eventually the paint is going to wear off. So wash it less often; that way it still gets cleaned regularly but, in the long-term, you avoid damaging your paint job.

Sunitinib is a chemo drug that has a side effect of dramatically increasing blood pressure. The effect is so consistent that blood pressure is often used as a marker for how well the chemo is working.

Many drugs break down in the body into active and inactive metabolites. If a patient has severe kidney disease, though, the inactive metabolites can build up to such high levels that they actually start causing side effects. Enough of anything is poisonous.

WILTIMS #474-8: Pulm Week 2

After finishing my first elective in a medicine subspecialty, I'm pretty sure I never want to specialize in any one organ. Doing just lungs or just anything everyday seems really monotonous to me.

My other takeaway is that, while surgeons often ignore patients on purpose, medical doctors can still ignore patients accidentally. One of my attendings this week had a habit of thinking out loud to the rest of the team while standing over the patient - not a bad thing necessarily. But then he would occasionally keep thinking out loud and just wander out of the room without ever summarizing or saying goodbye to the patient. I started to lag behind to quickly translate to the patient what I thought was going on. To my classmates: please don't pick up this habit. It makes otherwise kind and considerate doctors seem like assholes.

MIL: Sickle cell disease can increase reticulocyte (immature red blood cell) levels which can be mistaken for white blood cells (WBCs). Leukocytosis (high levels of WBCs) indicates inflammation, usually caused by infection, so these patients can be needlessly worked-up or treated for an infection they don't have, if you don't think about this common lab test error.

TuIL: A cheap treatment for sleep apnea is having the patient wear a shirt with a breast pocket backwards and put a tennis ball in the pocket. This way, the patient can't lie flat on their back, which is one of the ways to stop the airway from collapsing in sleep apnea.

WIL: The PaO₂/FiO₂ ratio is the ratio of the pressure pf oxygen in the arteries to the oxygen content of the inspired air. It is a simple way to estimate lung function and used to categorize the level of adult respiratory distress syndrome (ARDS).

ThIL: Telephone standardized patient encounters are weird but not as scary as people tend to think. Most of our practice patient encounters are in person, talking to and examining an actor. But part of our board exam that I take this summer includes telephone interactions, where you enter an examination room and call an actor in another room. Usually this is one of the ways that they test students' proficiency in patient care related to pediatrics, as having child actors would be problematic.

FIL: Extracorporeal membrane oxygenation (ECMO) is an attempt to make for the lungs what dialysis is for the kidneys. It is essentially a less-than-fantastic artificial lung that is sometimes used in ICUs when a patient's heart and lungs aren't doing a good enough job at oxygenating blood.

WILTIMS #469-73: The Great Restart

Last week I started a quick two-week rotation in pulmonology, the study and treatment of lung and other respiratory disorders. I had particular interest in this elective because, as I've mentioned before, I'm thinking about someday practicing as an intensive care doctor. Though I'm leaning toward pediatric critical care at the moment, if I should choose the adult route, many adult critical care doctors are actually double trained in pulmonology and critical care (or "pulm-crit" for short). This is historically due to the close correlation of lung problems with critically ill patients; many ICU patients are on ventilators that breath for them while they're in the unit.

Monday: On my first day with the pulmonology consult team, some cosmic karma balance was achieved as I had the privilege of apologizing for the terrible communication and bedside manner from a surgery team. They apparently cancelled a surgery after the patient was already under general anesthesia for a complication that could have been easily foreseen days before. Then they didn't tell the patient or family what happened or what the next steps were. It just takes a little communication, folks!

MondayIL: Ground glass opacities on CT scan can be misleading. This term means that the there are areas of light and dark patches making up the lung tissue. The question is: which is the healthy tissue and which is diseased? By tinkering with the image settings you can make the light or dark look normal, so radiologists have to use special tools to compare the lung tissue with known brightnesses in the image, letting us know which it is. We can also make educated guesses based on the condition(s) we're suspecting.

TuIL: What a bronchoscopy procedure looks like. I had heard about this sort of colonoscopy of the lungs, but hadn't seen one performed yet. Having seen many colonoscopies and endoscopies while volunteering before med school, the process is very similar. The only catch, of course, is that instead of exploring a solitary tube, you are exploring an incredibly complicated tree. Also, with the GI tract, you can inflate it with air to help you see, but the lung pipes are not nearly as expandable, so you run out of room and visibility very quickly. Want to rinse something with water? No problem in the bowel but, in the lungs, you are literally drowning the patient so you have to suction the fluid back out immediately.

WIL: There is a super rare condition called Erdheim-Chester disease that has only been reported in less than 500 individuals. Odds are the patient we are consulting on is the only one with this disease I will ever see in my career. It has many diverse manifestations, but for my pulm team, we are most concerned with the devastating cystic lung dysfunction that is seen in these patients. Unlike in emphysema, where the tiny bubbles of the lung stretch outward like bubble gum blown too big, cysts have thick capsules that keep them from popping. When your whole lung slowly turns to these thick balloons of useless tissue, it makes breathing rather difficult.

Thursday: This was a weird morning because we waded into an ethical quagmire due to some dubiously informed consent. We wanted to try 'scoping a man who the anesthesiologist considered a very high risk patient. The problem was that the patient didn't seem to grasp that there was a small, but non-zero risk of needing to be intubated (put on a breathing tube) if his vital signs deteriorated. He wanted the procedure, but not the risk and you can't have it both ways.

We tried calling his family, but they were similarly indecisive. Meanwhile, Anesthesia recruited two more of their own to consult as to the risk to this patient. Our team was four people on its own. Nursing had at least two people in the conversation. For patient privacy reasons, we moved the mob to the still empty procedure room. After going back and forth about the risks and options for different levels of anesthesia and trying to justify why we were doing this case at all, it was decided to call the patient's primary doctor for this admission, the head of cardiac transplant surgery, who decided to join us for the discussion.

The man swaggered into the suite and basically dismissed everyone's concerns about both patient safety and consent. "The guy's heart is failing; of course it's risky. So is anything on this guy." He then wandered over to the patient's bedside and asked, "You want the procedure, right? Good. Let's just get this done." So we did. The patient got very limited sedation (because anesthesia wasn't comfortable giving him anything that might jeopardize his cardiac function) and was coughing and gagging the entire time we had a tube down his throat. We got our samples. The patient didn't remember a moment of the half-hour I was restraining his hand from pulling out the tube in his lungs. He woke back up with no ill effects.

I still don't think we should have done the procedure. The patient consented wholeheartedly by the time we went (even though he still didn't want a breathing tube), but he explicitly said that it was because he wanted to eat after a whole night of being NPO (nothing by mouth). There was a lot of gray area in every aspect of this event and, if the patient's life is not on the line, it probably makes sense to take a step back and reschedule the procedure for the next day, once we can be more clear about the risks and the patient's understanding thereof.

ThIL: Jugular venous distension is a very specific physical exam finding but not very sensitive, because the anatomical distances we use are severely underestimated.

FIL: Tree-in-bud opacities are a radiographic finding on CT imaging that looks... like a budding tree. It can represent many different pathologies, but generally means there is something filling up the deepest airways of the lungs.

From: http://pubs.rsna.org/doi/full/10.1148/rg.253045115

Surgery Post-Mortem

[beep]...
"Wait, is that a...?"
[beep]...

"We've got a pulse!"

"I thought we lost it in surgery!"

"We did, but it's back. Let's make the most of it!"

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I'm not dead! And neither is my blog, though neither of us made it through that surgery clerkship unscathed. For the first time in nearly three years, I will not be logging something I learned for each day of medical school. Between the night shifts, the already miserable day shifts, and studying for the shelf-exam, I just couldn't spare the time or, more importantly, the energy to write my blog on top of it. So I will give you my parting thoughts on surgery and then start clean with the pulmonology elective I started on Monday.

I loathed my surgery rotation, but I did not loath surgery itself. It's very satisfying to be able to definitively do something for a patient other than think, tweak, and wait - as is the norm in most of medicine. Your appendix hurts? Cut it out. Your gallbladder is inflamed? Cut it out. Your stomach holds more food than you'd like? Cut part of it out. Your leg is trying to kill you? Cut it off. Yes, surgery creates scars but, in a way, those are marks of where we tried to help.

I also liked the tight-knit team atmosphere. In order for a surgery to happen efficiently you need the collaboration of the surgeons, med student*, anesthesiologist, scrub tech, and circulating nurse - plus the countless other people who are tangentially involved, like the pre-op nurse, PACU nurse, whoever the people are that clean the stretchers, the laboratory for rapidly interpreting intraoperative specimens, and others. When everyone is working together like a well oiled machine (preferably to the groovy tunes of the Beatles (it happened once!)), it makes me proud to be an (optional) member of the team.

*You don't actually need a med student unless there is some part of the body that needs retracting that there isn't already a good retracting device for (e.g. the liver can typically be retracted by a adjustable metal arm attached to the bed) or if you're lazy and want someone to help** the resident suture at the end.

**Note: this may not actually speed things up.

But even at the hospital I rotated at, noted by past students for being pretty mellow compared to other hospitals, the professional environment was often toxic. Attendings belittled the senior resident who belittled the residents and interns who belittled us. Everyone is overworked and sleep deprived, but to show either is to show weakness.

This field is also the only one I've experienced all year where a resident or attending asks what you want to do for a living and is annoyed when it's not their field. Tell a psychiatrist that you don't want to do psychiatry and they respond, "Ah well, few do! But let's see if we can give you the basic knowledge that will help you in whatever field you do choose." Surgeons tended to want us to learn what they had to learn: names and techniques only very tangentially applicable to anyone shunning the surgical specialties.

My least favorite part of the rotation was that I was so miserable that I was at times a grumpy asshole to the few residents who actually were nice me and to my classmates who were just as tired as I was. They say you get used to the schedule and pace of surgery, but honestly I worry about the version of me that would come out the other side.