On Thursday, I was given a blessed reprieve from the torture of geriatric clinic so that I could present a poster at our school's Medical Student Research Forum. The poster was displaying an incredibly deceiving selection of information on the research that I helped gather as one of the leaders of the Cancer Education Awareness Program club. The data were accurate but of extremely narrow usefulness. I have trash-talked this research for so long, it was hard to sell it to reviewers and interested passersby with a straight face.
After having two reviewers hear us out, my presentation partner and I were fairly confident that we weren't winning any awards. Still, just to be sure, I stayed around through the big oral presentations to await the official losers' notice. The presentations were surprisingly good. The first guy's research had made national headlines when his team mapped the NYC subway biome and found plague and anthrax among the other more benign pathogens.
ThursdayIL: Actually, they don't think they found anthrax and plague. Nearly half of the life they found was unidentifiable by current techniques and it's more likely that the weird ones they did find were actually just as of yet unknown close relatives of those oddball bugs.
Friday, I was back at the hospital for my last day in geriatric clinic. The most interesting patient encounter of the day was actually due to a patient's daughter who had psychiatric problems of her own and yelled at our team for "experimenting" on her mildly demented father. All medications have potential adverse reactions and we can't (yet) predict which patients which react poorly. This patient may have had a reaction to a normally very safe medication we recently started... or the daughter may have altered his other psychiatric medications without consulting us. It was hard to tell who was actually "experimenting."
FridayIL: Frailty is an actual clinical diagnosis. Though it is not a true pathology, if a patient meets the (extremely specific) criteria then they statistically have significantly increased mortality from all causes.
Today I started with a new team on the inpatient wards, with whom I will slog out the remaining week and a half of this rotation (yikes!). Due to some weirdness with scheduling we practically had our whole previous team together for the day, so it was like a surprise reunion. I miss that team (sniff!).
TIL: Isothenuria is when the urine is osmotically similar to blood (neither concentrated nor dilute). This can be totally normal or a sign of renal failure depending on the broader clinical picture.
If a patient with a PMH (past medical history) of SCD (sickle cell disease) presents to the ER with symptoms that can be explained by a sickle cell crisis, check the reticulocyte count. The retic count represents the release of immature blood cells into the bloodstream and is a measure of hemolysis (blood cell death). The higher the count, the worse the hemolysis and the more severe the sickle cell crisis.
Pingueculae are a slight variation on pterygia, both lesions of the conjunctiva of the eye. Whereas a pterygium is seen more commonly on the nose-side of the eye and grow out toward the pupil, a pinguecula is usually seen on the ear-side of the eye and grows thicker, not moving in any direction.
Tuesday, February 16, 2016
Wednesday, February 10, 2016
WILTIMS #432-434: Untz untz untz... oh, not that kind of clubbing
MondayIL: Homans sign is a physical exam maneuver used to test for deep vein thrombosis (DVT). To perform it, you have the patient rest on their back while you support their knee. You then abruptly flex their ankle. If this elicits discomfort, it is positive for... actually probably nothing. This sign is a terrible predictor of DVT and may even be dangerous to perform. Don't use this test.
Every once in a while I learn something that I realize I should have learned ages ago. Unfortunately I usually learn these facts in an awkwardly public setting like in front of attending or patient. Today's example is about clubbing. Clubbing is when the tips of one's fingers swell and the fingernails curve (making the fingers look like little clubs, hence "clubbing"). I therefore thought that dramatically curved fingernails were indicative of early-stage clubbing. Nope. Not a thing. People can just have curved nails.
The way you actually tell if there is clubbing is by looking at the angle made by the tip of the nail, the root of the nail and the first knuckle. If it is concave, it's normal. If it's flat then there is mild clubbing. If its convex (the nail bed bends out between the knuckle and nail tip) then there is severe clubbing. We still don't know what causes clubbing, just that it is correlated with a whole bunch of serious disease processes.
TuesdayIL: Gadolinium contrast (the stuff used in MRIs to make body-stuff more visible) is cleared from the blood much more slowly in patients with chronic kidney disease. This can cause nephrogenic systemic fibrosis, a disease that sounds really vague, but is actually only caused by gadolinium exposure.
Autosomal dominant polycystic kidney disease (ADPKD) is caused by a defective APOL1 gene. This allele is very prevalent in the black population, much like the sickle cell allele, and it's thought that this parallel is due to a similar reasons. Whereas sickle cell heterozygotes (people who only have one copy of the defective gene) are thought to be protected from malaria, APOL1 seems to protect from a different parasitic disease called trypanosomiasis.
We have no good treatment for ADPKD. We can essentially use dialysis to bide time until a kidney transplant can be done. An interesting issue can arise when a family member wants to donate a kidney. Since the disease is inherited, there is a not-insignificant chance that the family member also has ADPKD and will need their extra kidney for as long as it is healthy. So to attempt to donate, the family member needs to consent to finding out that not only can they no donate, but that they may be soon heading for the same fate.
WednesdayIL: Dementia can cause increased variations in an elderly patient's sleep cycle. There are normal age-related changes, such as going to bed earlier, waking up earlier, sleeping lighter, waking up more often, etc. Patients with dementia frequently have worse sleep disturbances including a shift away from the restful REM sleep.
Every once in a while I learn something that I realize I should have learned ages ago. Unfortunately I usually learn these facts in an awkwardly public setting like in front of attending or patient. Today's example is about clubbing. Clubbing is when the tips of one's fingers swell and the fingernails curve (making the fingers look like little clubs, hence "clubbing"). I therefore thought that dramatically curved fingernails were indicative of early-stage clubbing. Nope. Not a thing. People can just have curved nails.
The way you actually tell if there is clubbing is by looking at the angle made by the tip of the nail, the root of the nail and the first knuckle. If it is concave, it's normal. If it's flat then there is mild clubbing. If its convex (the nail bed bends out between the knuckle and nail tip) then there is severe clubbing. We still don't know what causes clubbing, just that it is correlated with a whole bunch of serious disease processes.TuesdayIL: Gadolinium contrast (the stuff used in MRIs to make body-stuff more visible) is cleared from the blood much more slowly in patients with chronic kidney disease. This can cause nephrogenic systemic fibrosis, a disease that sounds really vague, but is actually only caused by gadolinium exposure.
Autosomal dominant polycystic kidney disease (ADPKD) is caused by a defective APOL1 gene. This allele is very prevalent in the black population, much like the sickle cell allele, and it's thought that this parallel is due to a similar reasons. Whereas sickle cell heterozygotes (people who only have one copy of the defective gene) are thought to be protected from malaria, APOL1 seems to protect from a different parasitic disease called trypanosomiasis.
We have no good treatment for ADPKD. We can essentially use dialysis to bide time until a kidney transplant can be done. An interesting issue can arise when a family member wants to donate a kidney. Since the disease is inherited, there is a not-insignificant chance that the family member also has ADPKD and will need their extra kidney for as long as it is healthy. So to attempt to donate, the family member needs to consent to finding out that not only can they no donate, but that they may be soon heading for the same fate.
WednesdayIL: Dementia can cause increased variations in an elderly patient's sleep cycle. There are normal age-related changes, such as going to bed earlier, waking up earlier, sleeping lighter, waking up more often, etc. Patients with dementia frequently have worse sleep disturbances including a shift away from the restful REM sleep.
Friday, February 5, 2016
WILTIMS #429-31: The future! ...and bladders
Wednesday was another class meeting. It always seems like they manage to take a full day to get across maybe a half-hour of new information and re-hash maybe another hour of old information. I'm still not sure where all the time goes.
WednesdayIL: Fourth year is going to be pretty chill (assuming I survive to see it). We learned about the flexibility and inflexibility of our schedules. Depending on what we want to do for residency, there are certain tracks we have to take that consist of a sub-internship (in either medicine, surgery, or pediatrics) and two of three core clerkships (emergency medicine, intensive care, and radiology). We then fill up our schedule with electives according to unnecessarily complicated rules regarding maintaining a balance of clinical vs. non-clinical, face-to-face vs. online, and school affiliate vs. away rotations. Of course, each course is only offered during certain of the ten month-long blocks. It makes me long for the undergrad days of looking through course catalogues and mapping out graduation requirements. Hmmm... I guess that was stupidly complicated too.
Thursday there weren't many patients in the normal geriatric clinic area so my classmate and I shadowed a geriatric urologist for the morning. It was a fun departure from our usual experience.
ThursdayIL: The optimal walker height can be approximated by the level of the wrist when the patient has their arms at their sides. This is lower than most people would intuitively guess, but has been shown to promote the best posture and gait.
Urodynamic studies look at how the bladder handles urine. It works by inserting one pressure-sensing catheter into the bladder and another into the rectum. You then have the patient consume a bunch of fluids and monitor the pressures as the bladder fills. This lets you see if the bladder is able to fill and remain relaxed. Then you have the patient void. This lets you see if the patient uses the bladder muscles or abdominal muscles to urinate. Also you can see if the bladder is able to fully empty. The upshot of all this is by sticking two tubes in uncomfortable places you can learn a lot about someone's bladder function.
TIL: Acute glaucoma (the rapid rise in the pressure of the fluid in the eye) can cause conjunctivitis (redness of the normally white part of the eye). So don't assume that someone with a red eye simply has an infection because if it is glaucoma, they could go blind in that eye without treatment.
Tuesday, February 2, 2016
WILTIMS #428: Needing Beers to get through geriatrics
Last Tuesday I had a really good day. Today was less so. As much of the miserableness involved people who control my grade and my little blog is technically a public forum, I will just leave it at that.
This week I started my two week stay in the hospital's geriatric clinic. Not my particular cup of tea, but it should be survivable for the short duration. I had an interesting experience today looking back through the chart of a very elderly patient. Currently about 85 years old with several serious health conditions, she needed of a good deal of assistance with her daily activities. As with any patient, I read-up on her recent admissions and notes from the doctors who had taken care of her. I learned a good deal about her medical history, but very little about her personal life - her story.
So then I dug into the social workers' notes. These provide great details about a person's living situation. I was surprised to find electronic records going back over ten years to when the patient was about 70 years old. And suddenly I realized that I had the documented history of one woman's journey into old age and frailty. each successive note showed how a heart condition or fall changed what she was able to do and how she was able to live.
I realize that the sorts of records have always existed in some form, but with the adoption of electronic medical records, it will become so much easier to essentially read the (very dryly written) story of someone's life through their interactions with the medical field.
TIL: AICD stands for artificial internal cardioverter/defibrillator.
The Beers Criteria is a list of drugs that should be used cautiously in the geriatric population. When it was first created in 1991 by Dr. Beers, it was a very simple, one-page tool to help prevent needlessly dangerous prescriptions. The most recent version is a dozen pages of very specific guidelines. Not sure if that's really serving the same purpose anymore...
While researching the Beers criteria, I learned what a non-anti-infective medication is. I'll let you read that one more time: non-anti-infective medication. What? Despite how it might seem, the negatives do not cancel out, which would make these simply infective medications. Actually these are medications other than those used to kill or weaken infectious pathogens such a bacteria, viruses, fungi, and parasites.
Endoscopic ultrasound is a nice alternative to MRCP for imaging choledocolithiasis.
Whereas gallbladder pain radiates to the chest and shoulder, the common bile duct radiates to the flank and back.
This week I started my two week stay in the hospital's geriatric clinic. Not my particular cup of tea, but it should be survivable for the short duration. I had an interesting experience today looking back through the chart of a very elderly patient. Currently about 85 years old with several serious health conditions, she needed of a good deal of assistance with her daily activities. As with any patient, I read-up on her recent admissions and notes from the doctors who had taken care of her. I learned a good deal about her medical history, but very little about her personal life - her story.
So then I dug into the social workers' notes. These provide great details about a person's living situation. I was surprised to find electronic records going back over ten years to when the patient was about 70 years old. And suddenly I realized that I had the documented history of one woman's journey into old age and frailty. each successive note showed how a heart condition or fall changed what she was able to do and how she was able to live.
I realize that the sorts of records have always existed in some form, but with the adoption of electronic medical records, it will become so much easier to essentially read the (very dryly written) story of someone's life through their interactions with the medical field.
TIL: AICD stands for artificial internal cardioverter/defibrillator.
The Beers Criteria is a list of drugs that should be used cautiously in the geriatric population. When it was first created in 1991 by Dr. Beers, it was a very simple, one-page tool to help prevent needlessly dangerous prescriptions. The most recent version is a dozen pages of very specific guidelines. Not sure if that's really serving the same purpose anymore...
While researching the Beers criteria, I learned what a non-anti-infective medication is. I'll let you read that one more time: non-anti-infective medication. What? Despite how it might seem, the negatives do not cancel out, which would make these simply infective medications. Actually these are medications other than those used to kill or weaken infectious pathogens such a bacteria, viruses, fungi, and parasites.
Endoscopic ultrasound is a nice alternative to MRCP for imaging choledocolithiasis.
Whereas gallbladder pain radiates to the chest and shoulder, the common bile duct radiates to the flank and back.
Monday, February 1, 2016
WILTIMS #427: IM didactic day #2
Today was a fairly dry day of lectures back up at campus (check out yesterday's post for a week's worth of juicier clinical fare). We started with dermatology, then a miserable lecture on HIV, some antibiotic practice and EKG interpretation. After a far too brief lunch, we came back for a stuffy lecture on congestive heart failure by our stuffy chairman of medicine and then we ended with a lecture on palliative care and pain management.
TIL: Urticaria pigmentosa, or maculopapular cutaneous mastocytosis, is a weird condition where mast cells accumulate in blobs on the skin. These immune cells release histamine, one of the chemicals that makes you itchy. So if you poke one of these spots on their skin, within a few minutes a big itchy red wheal will form.
Derm lightning round!
TIL: Urticaria pigmentosa, or maculopapular cutaneous mastocytosis, is a weird condition where mast cells accumulate in blobs on the skin. These immune cells release histamine, one of the chemicals that makes you itchy. So if you poke one of these spots on their skin, within a few minutes a big itchy red wheal will form.
Derm lightning round!
- nummular: round; as in nummus, Latin for "coin"
- arciform: arc forms
- serpiginous: snake-like
- ichthyotic: fish-scale-esque
- koebnerization: spreading a lesion by patient interaction (e.g. a rash that spreads to the areas you scratch)
Sunday, January 31, 2016
WILTIMS #422-6: End of January catch-up post
Tuesday was a good day. As I assume is the case with most jobs (not that this is quite my job, yet), most days are OK, some suck, and a precious few validate all the work I do the rest of the time. On this medicine rotation I've had a surprising amount of moments that remind me why I love medicine (the royal medicine, not just internal medicine). Tuesday just had a few more than normal and it felt nice.
I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!
Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).
Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.
MondayIL: BIBEMS is an acronym for brought in by emergency medical services.
TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.
WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.
ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.
FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:
If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.
*Patient details changed for anonymity*
I explained atrial fibrillation, in extreme detail (diagrams included!), to the elderly daughter of an even more elderly patient and she was super grateful. Then I correctly called that that rhythm wasn't actually atrial fibrillation even though my supervising intern and resident both thought it was. (It turned out to be MAT). Then I saw another patient in the ER and spent more time asking questions than anyone else on the team (because I need to know useless answers to useless questions for assignments that residents don't have time to ask). After asking if she had any questions or needed anything else, she said no thanks and to tell my parents that they should be proud of how they raised me. Not bad!
Unfortunately, I next had to go up and tell that first patient's daughter that the elaborate explanation of AFib that I gave earlier (and the CT scan we sent her mother for) were unnecessary due to that misdiagnosis. So I redrew the diagram and honestly explained why we changed our mind and why that's a good thing. To my surprise the daughter wasn't mad. In fact she thanked me with big hug (after asking if that was ok).
Some days being in medical school is miserable. We rarely do anything useful and we mostly get in the way. Tuesday was not typical, but it was a needed reminder of why we suffer through the rest of the days.
MondayIL: BIBEMS is an acronym for brought in by emergency medical services.
TuesdayIL: The dosing scheme for azithromycin is different depending on what you're treating. For an STI, like chlamydia, you give 1 gram one time, but for pneumonia, you give 500 mg on the first day and 250 mg for the next four days.
WednesdayIL: The MAZE procedure is a really stupid, really cool surgical treatment for atrial fibrillation. As a last ditch effort to keep the heart beating normally, if a surgeon is already doing open heart surgery for another reason, they can slice or burn up the arium, literally making a maze for the aberrant atrial pulses. The SA node gets a straight path and can beat the sickly AFib depolarization to the AV node. This is a terrible way to fix this problem, due to the numerous complications of... you know... purposely scarring the hell out of the heart.
ThursdayIL: *Those really annoying standardized patients - the ones that torture us by not giving useful information until you ask about one very specific part of their history - are actually very accurate representations of many patients. I had a patient today that we were medically clearing for the psychiatric team. So, knowing that, I very gently asked about her current mood and then pressed a little to find out what had made her depressed. She listed a couple things but it didn't seem like enough to put her on suicide watch. Flash forward to ten minutes later. I'm asking about her smoking/drinking/drug habits (just to be thorough) when I learn that she is 30-something years sober. Great! ...also, uh... from what and why? Turns out she heavily used alcohol and cocaine after her husband and two children were killed in an accident. Only at this point did she offer up that this might still be part of why she's depressed. It can be hard to know what questions will get the patient to offer up that crucial detail.
FridayIL: The rheumatologist at my hospital teaches his subject matter with the ease that a dentist pulls teeth; even with ample pain medication it still hurts like a bitch. But after a tortuous half an hour of asking non-rhetorical questions to a room of unknowing and uncaring med student, we did eventually start learning a thing or two about messed-up-looking hands. Some takeaways:
If it looks like twisty-boney joint deformities: osteoarthritis. If the DIP joints are hyperflexed, the PIP joints are hyperextended, and the MCP and wrist joints are swollen: rheumatoid arthritis. If an old woman with fluid-filled solitary joint enlargement: gouty arthritis.
*Patient details changed for anonymity*
Saturday, January 23, 2016
WILTIMS #419-421: Living on the cliff
WednesdayIL: A CADD pump is like a PCA at home. So, PCA (or patient controlled analgesia) is a way of giving pain meds to patients in a hospital where, instead of having to request a dose of medication from a nurse, the patient has a button they can press every so often to give themselves a dose of IV pain medication. There are safety measures so that a patient can't overdose, but studies have shown that patients actually use less pain medication when they have control than when nursing does. Anyways, CADD (or computerized ambulatory drug delivery) is an easier to use system that can be used outside the hospital, when appropriate.
ThursdayIL: Palliative care shouldn't exist. Let me explain. A good definition by the Center to Advance Palliative Care is "[palliative care] focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family." Wait...? Isn't that what all of the medical field should be doing anyways?
On Thursday my classmates and I took a field trip to Calvary Hospice Hospital in the Bronx, the only exclusively palliative care hospital in the country. It's a strange place (but again, it shouldn't be). The average length of stay is just over 20 days and 43% of the patients pass away in the first 9 days of after being admitted. But once you see how they take care of the patients, you realize it's not depressing. These are good deaths or, at least, far better deaths than these patients would have gotten in an ICU or even at home.
Most hospice care happens at home which is usually better for everyone, but for some patients appropriate comfort measures really require acute nursing care. One woman we met was doing fairly well with her terminal breast cancer, but only because nurses and wound care teams were taking care of draining the excess fluid building up around her lungs and in her abdomen. This type of patient would be in agony (or already dead) at home.
The patients at Calvary are treated well. Pain management is addressed immediately. The doctors do not shy away from giving high doses of heavy-hitting narcotics - whatever it takes to keep the patient comfortable. Of course, this is adjusted for each patient; some people are really bothered by the loopiness that comes with some pain meds and may prefer to feel some pain to losing some cognition. But in this day and age, no one deserves to die in uncontrolled pain.
Another big selling point for this hospital is how clean it is. First and foremost, the patients are clean - not something to take for granted when you have 200 elderly bedridden patients who may be incontinent or have non-healing wounds. On the day of admission every patient gets a 2-person assisted head to toe spongebath that can take hours. And everyone and everything is kept clean from there on. I've been in many hospitals and I have never seen such well maintained and meticulously scrubbed hallways. There is also no clutter from disused medical equipment and no chaotic noise. Nurses, doctors and other staff talk quietly rather than screaming over the beeps and pings of equipment alarms. And those alarms are responded to quickly. Especially compared to the crazy hospital I'm working at normally, this place was serenely peaceful.
But my biggest takeaway from the day was that this shouldn't need to exist. It makes sense that NYC could support a full hospital for acute hospice care, but every medium-sized hospital should have unit like this. Or, better yet, patients should be able to be treated like this on any normal unit in a hospital. There is no special technology that these patients require. There is nothing that actually qualifies these doctors and staff to be compassionate, clinically competent providers any more than any other medical staff.
The whole subspecialty of palliative care arose, not because we needed people with special training to do those jobs, but because regular doctors have a longstanding inability to do theirs. I wish every medical and nursing student could visit a place like Calvary, so that someday places like Calvary won't be noteworthy at all.
FridayIL: Blood can keep showing up in stool (as detected by fecal occult blood tests) for up to a week after the source of bleeding has stopped.
[I'm sorry that after such a nuanced middle post, the last one was a one-liner about poop, but such is medicine.]
[[Also, incase you were wondering about the title of this post, I totally forgot to explain it. So here you go: People dying of chronic conditions such as cancer often have a long slow decline for a while and then suddenly, over the course of hours or days, the trajectory of their health falls off a cliff. While doing rounds with one of the doctors at Calvary, I kept thinking of how hard it must be adapting to caring for patients just before and during that unpredictable decline. The patient you admit is chugging along. Obviously not doing well, but usually not doing dramatically worse than a day or week prior. You never know which day you will come into work to find out that a particular patient has been put on critical status (~24-48hrs until likely death) - to find they've gone over the cliff. It must be emotionally taxing living on that border in so many people's journey to death.]]
ThursdayIL: Palliative care shouldn't exist. Let me explain. A good definition by the Center to Advance Palliative Care is "[palliative care] focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family." Wait...? Isn't that what all of the medical field should be doing anyways?
On Thursday my classmates and I took a field trip to Calvary Hospice Hospital in the Bronx, the only exclusively palliative care hospital in the country. It's a strange place (but again, it shouldn't be). The average length of stay is just over 20 days and 43% of the patients pass away in the first 9 days of after being admitted. But once you see how they take care of the patients, you realize it's not depressing. These are good deaths or, at least, far better deaths than these patients would have gotten in an ICU or even at home.
Most hospice care happens at home which is usually better for everyone, but for some patients appropriate comfort measures really require acute nursing care. One woman we met was doing fairly well with her terminal breast cancer, but only because nurses and wound care teams were taking care of draining the excess fluid building up around her lungs and in her abdomen. This type of patient would be in agony (or already dead) at home.
The patients at Calvary are treated well. Pain management is addressed immediately. The doctors do not shy away from giving high doses of heavy-hitting narcotics - whatever it takes to keep the patient comfortable. Of course, this is adjusted for each patient; some people are really bothered by the loopiness that comes with some pain meds and may prefer to feel some pain to losing some cognition. But in this day and age, no one deserves to die in uncontrolled pain.
Another big selling point for this hospital is how clean it is. First and foremost, the patients are clean - not something to take for granted when you have 200 elderly bedridden patients who may be incontinent or have non-healing wounds. On the day of admission every patient gets a 2-person assisted head to toe spongebath that can take hours. And everyone and everything is kept clean from there on. I've been in many hospitals and I have never seen such well maintained and meticulously scrubbed hallways. There is also no clutter from disused medical equipment and no chaotic noise. Nurses, doctors and other staff talk quietly rather than screaming over the beeps and pings of equipment alarms. And those alarms are responded to quickly. Especially compared to the crazy hospital I'm working at normally, this place was serenely peaceful.
But my biggest takeaway from the day was that this shouldn't need to exist. It makes sense that NYC could support a full hospital for acute hospice care, but every medium-sized hospital should have unit like this. Or, better yet, patients should be able to be treated like this on any normal unit in a hospital. There is no special technology that these patients require. There is nothing that actually qualifies these doctors and staff to be compassionate, clinically competent providers any more than any other medical staff.
The whole subspecialty of palliative care arose, not because we needed people with special training to do those jobs, but because regular doctors have a longstanding inability to do theirs. I wish every medical and nursing student could visit a place like Calvary, so that someday places like Calvary won't be noteworthy at all.
FridayIL: Blood can keep showing up in stool (as detected by fecal occult blood tests) for up to a week after the source of bleeding has stopped.
[I'm sorry that after such a nuanced middle post, the last one was a one-liner about poop, but such is medicine.]
[[Also, incase you were wondering about the title of this post, I totally forgot to explain it. So here you go: People dying of chronic conditions such as cancer often have a long slow decline for a while and then suddenly, over the course of hours or days, the trajectory of their health falls off a cliff. While doing rounds with one of the doctors at Calvary, I kept thinking of how hard it must be adapting to caring for patients just before and during that unpredictable decline. The patient you admit is chugging along. Obviously not doing well, but usually not doing dramatically worse than a day or week prior. You never know which day you will come into work to find out that a particular patient has been put on critical status (~24-48hrs until likely death) - to find they've gone over the cliff. It must be emotionally taxing living on that border in so many people's journey to death.]]
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