September 22, 2008
Gross
We have a patient who is so constipated that it's backed up all the way through his intestines into his stomach, which means he's vomiting poo. Gross!!! Now that's a bona fide potty mouth.
September 20, 2008
Gravity II
My bed must have extreme amounts of density, because I could not escape its gravity this morning. The sun was shining onto the bed, there was a pleasant little breeze ruffling my curtains, and I didn't have to go to work. I felt like a happy little kitten napping in the sun. My bathroom light died but it was light so I was able to see in the shower, did laundry for a change, and got some errands done. Now I get to study before I make my first home-cooked meal (vs. cafeteria slop) in a long time! Hurray for days off!
September 19, 2008
Gravity
Yesterday was my last day at UCI for the next month. Starting next week I'll be at the Long Beach VA, with a very different patient population.
This past week has been a week of serious patients who aren't going to make it. My team's workload of patients all of a sudden were rather young patients who were terminally ill. Other young patients we've had were chronically ill, but not on their deathbed. It's one thing to treat patients, make them better, then send them home. It's entirely another to know you can't help, no matter what you do.
One was a 36 year old woman with breast cancer that had metastasized everywhere despite a double mastectomy - her lungs, liver, spine, pelvis, and brain. There was so much cancer in her brain that she was throwing up constantly but still coherent and talking when we admitted her. By the next morning though, her brain had swollen so much that all she could do was groan and reflexively contract her arms inward, a very ominous sign called decorticate posturing. They call it "decorticate" because you can tell that the site of the brain injury was such that it essentially shut off her brain cortex functions. The neurologist happened to stop by while I was at the patient's side and he remarked that it was a sign she was about to stop breathing, and we'd better intubate her before she did. So much mayhem and excitement later, she was sent to the ICU, from which she will probably leave only in a casket. I met her children the first day; the boy looked around fifteen and the girl looked about eight. The girl didn't seem to understand that she was about to not have a mom.
Another was a 37 year old man who'd essentially drank himself to death's door. He was in the hospital with our team for over a week, a belly swollen with fluid backed up because it couldn't get through his too-damaged liver, looking like he was pregnant. He was so jaundiced that it looked like someone had taken a black-and-white photo of him and colored in his eyes and skin with a yellow crayon. Literally. I'm not even exaggerating. I was part of the team taking care of him, but he wasn't primarily my patient so I didn't talk to him much when we visited his bedside during rounds every morning. Still, we had a little ritual that kind of came about after seeing each other every day. He always had downcast eyes while we were there, but as the team left his room, I would wave and he would look up and smile. Yesterday he looked so sad, sadder than usual, but he did give me a smile at the end. It was dimmer than usual, but it was still our little ritual.
Another was a 41 year old man who found himself diagnosed with HIV a week ago. He had been mysteriously losing weight for a couple months, but had suddenly started going blind and had spots growing all over him, so he went to the doctor and that's how he found out. The tell-tale spots were surprising because those aren't seen anymore with HIV therapy that's available nowadays. He thought he got it from a tattoo he got in Viet Nam several years ago, because he said there they use the same needles for everyone. It was a very cool dragon, but to think it could have been the cause of his death diminished its luster. He started to cry as I was talking to him. Apparently he had been married a few years ago and he had always used condoms because the wife didn't want children, then she left him after a year. He was so sad and didn't want the burden of sadness in life anymore, so he started studying to become a monk. He completed his three years of studies and was set to go to Tibet to finish up, but ended up in the hospital. Can you imagine, studying to find eternal peace as a monk, and one day you find out you've got AIDS. He squeezed my hand when I asked him if he'd like me to try to find a Buddhist monk that he could talk to. I hope he gets reincarnated into something nice.
Even though these people are a few days away from death and no amount of medicine will cure them, I guess the one medicine they can benefit from is kindness.
This past week has been a week of serious patients who aren't going to make it. My team's workload of patients all of a sudden were rather young patients who were terminally ill. Other young patients we've had were chronically ill, but not on their deathbed. It's one thing to treat patients, make them better, then send them home. It's entirely another to know you can't help, no matter what you do.
One was a 36 year old woman with breast cancer that had metastasized everywhere despite a double mastectomy - her lungs, liver, spine, pelvis, and brain. There was so much cancer in her brain that she was throwing up constantly but still coherent and talking when we admitted her. By the next morning though, her brain had swollen so much that all she could do was groan and reflexively contract her arms inward, a very ominous sign called decorticate posturing. They call it "decorticate" because you can tell that the site of the brain injury was such that it essentially shut off her brain cortex functions. The neurologist happened to stop by while I was at the patient's side and he remarked that it was a sign she was about to stop breathing, and we'd better intubate her before she did. So much mayhem and excitement later, she was sent to the ICU, from which she will probably leave only in a casket. I met her children the first day; the boy looked around fifteen and the girl looked about eight. The girl didn't seem to understand that she was about to not have a mom.
Another was a 37 year old man who'd essentially drank himself to death's door. He was in the hospital with our team for over a week, a belly swollen with fluid backed up because it couldn't get through his too-damaged liver, looking like he was pregnant. He was so jaundiced that it looked like someone had taken a black-and-white photo of him and colored in his eyes and skin with a yellow crayon. Literally. I'm not even exaggerating. I was part of the team taking care of him, but he wasn't primarily my patient so I didn't talk to him much when we visited his bedside during rounds every morning. Still, we had a little ritual that kind of came about after seeing each other every day. He always had downcast eyes while we were there, but as the team left his room, I would wave and he would look up and smile. Yesterday he looked so sad, sadder than usual, but he did give me a smile at the end. It was dimmer than usual, but it was still our little ritual.
Another was a 41 year old man who found himself diagnosed with HIV a week ago. He had been mysteriously losing weight for a couple months, but had suddenly started going blind and had spots growing all over him, so he went to the doctor and that's how he found out. The tell-tale spots were surprising because those aren't seen anymore with HIV therapy that's available nowadays. He thought he got it from a tattoo he got in Viet Nam several years ago, because he said there they use the same needles for everyone. It was a very cool dragon, but to think it could have been the cause of his death diminished its luster. He started to cry as I was talking to him. Apparently he had been married a few years ago and he had always used condoms because the wife didn't want children, then she left him after a year. He was so sad and didn't want the burden of sadness in life anymore, so he started studying to become a monk. He completed his three years of studies and was set to go to Tibet to finish up, but ended up in the hospital. Can you imagine, studying to find eternal peace as a monk, and one day you find out you've got AIDS. He squeezed my hand when I asked him if he'd like me to try to find a Buddhist monk that he could talk to. I hope he gets reincarnated into something nice.
Even though these people are a few days away from death and no amount of medicine will cure them, I guess the one medicine they can benefit from is kindness.
September 14, 2008
Irony
One of the great ironies of medicine, from paramedicine on up, is this: even if you're a great doctor, if you're an asshole you'll get sued, but you can be a crappy doctor as long as you're nice to patients, and they won't sue you.
Following that irony, I received my first patient letter yesterday from a very nice young lady in her mid-twenties who's been chronically ill since she was a toddler. She's one of the calcifying patients I mentioned in an earlier post. In her letter, she said she's had lots of experience with doctors, but I stood out as someone who was so kind to her and her family. She's had all sorts of expert care and I know the least amount of medicine on my team of course, but it was simply that I sat down at her bedside and talked with her and her mother for about 20 minutes that must have made all the difference. Maybe it was also because I said, "Hi XXX" and addressed her by name whenever my team visited her, who knows? I certainly didn't do anything superhuman.
I was actually very inclined to be nice to her because I had met her before my internal medicine rotation began. She didn't remember me, but as part of a different rotation two months ago, my group was assigned to fan out around the hospital to look for patients with interesting physical findings. One of them was her, on her prior admission. About eight of us crammed into her small room, checking out her body parts, himming and hawing, staring, talking about her, but she was very gracious and talked about her disease course with us, let us poke and prod, and answered our questions thoroughly. At the time I kind of thought it a little distasteful that we were marching in huge groups into patients' rooms to stare at them, even if UCI is a teaching hospital. So when I discovered that she had come back and was assigned to my team, I guess I wanted to make amends, or at least show appreciation. I never told her directly why I was being so nice, so I feel a little bad, like I tricked her. In any case, one day she asked the attending if she would be able to have a baby some day. He gave her a general positive answer, but somehow I got motivated later that night and found an article. It said that women with her condition should be monitored prenatally as high-risk, but that there was a good chance she would have a healthy pregnancy. When the attending gave her the article the next morning, she said that it was the best news ever. It took me only about an hour to research the article, and about 20 minutes of extra conversation to apparently make a big difference in her life.
As we discharged her, I wished her a happy fourth anniversary with her boyfriend. She had told me she wanted to be home by Monday so she could celebrate it with him. I hope she has a long and happy life with as many healthy children as she wants.
Following that irony, I received my first patient letter yesterday from a very nice young lady in her mid-twenties who's been chronically ill since she was a toddler. She's one of the calcifying patients I mentioned in an earlier post. In her letter, she said she's had lots of experience with doctors, but I stood out as someone who was so kind to her and her family. She's had all sorts of expert care and I know the least amount of medicine on my team of course, but it was simply that I sat down at her bedside and talked with her and her mother for about 20 minutes that must have made all the difference. Maybe it was also because I said, "Hi XXX" and addressed her by name whenever my team visited her, who knows? I certainly didn't do anything superhuman.
I was actually very inclined to be nice to her because I had met her before my internal medicine rotation began. She didn't remember me, but as part of a different rotation two months ago, my group was assigned to fan out around the hospital to look for patients with interesting physical findings. One of them was her, on her prior admission. About eight of us crammed into her small room, checking out her body parts, himming and hawing, staring, talking about her, but she was very gracious and talked about her disease course with us, let us poke and prod, and answered our questions thoroughly. At the time I kind of thought it a little distasteful that we were marching in huge groups into patients' rooms to stare at them, even if UCI is a teaching hospital. So when I discovered that she had come back and was assigned to my team, I guess I wanted to make amends, or at least show appreciation. I never told her directly why I was being so nice, so I feel a little bad, like I tricked her. In any case, one day she asked the attending if she would be able to have a baby some day. He gave her a general positive answer, but somehow I got motivated later that night and found an article. It said that women with her condition should be monitored prenatally as high-risk, but that there was a good chance she would have a healthy pregnancy. When the attending gave her the article the next morning, she said that it was the best news ever. It took me only about an hour to research the article, and about 20 minutes of extra conversation to apparently make a big difference in her life.
As we discharged her, I wished her a happy fourth anniversary with her boyfriend. She had told me she wanted to be home by Monday so she could celebrate it with him. I hope she has a long and happy life with as many healthy children as she wants.
September 13, 2008
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