My Heart

An eventful morning. The man with the golden eyes and the biliruben that kept climbing coded. This morning he was well, he smiled, he lied, he told us he didn't know what caused his yellowish glow. He knew what it was, he's been drinking it all his life, rarely wasting enzymes on something of nutritional value.

To my right lays another with kidneys that failed him. He lays there asleep in his pure uremic haze, uninformed of his BUN, or his creatinine. He is unaware of these things; they have no importance to him now. Soon a machine will suck his lifeline and return it to him instantly, fresh from the toxins he has produced.

Ahead lays a son, only nineteen years old. His mother sits by his bed and sings him children’s songs. He’s mentally retarded and it doesn’t matter to her. He is near death and she sings to him. She sings because she does not know this, but I do and with every note my heart crumbles, torn to shreds, trampled by my conscience. Soon, I must tell her he will die. I will kill her song. A piece of me will die with the melody. I cry now.

My life in the ICU.

The Traveling Story

Not that you need a reason to check out what's going on over at The Examining room but I'll give you one anyways. Charles has the first traveling story. It involves a woman and a murder/suicid...Maybe I'm giving away too much.

That's not the catch though, check out the author....

Madman 2

I’ve been promising a real revision to the front page here and I know I’ve really taken my time. As you can imagine Little Intern carried most of the blame for that. After all, how can an exhausted resident who comes home only to be further enslaved be creative?

Therefore, it is my pleasure to introduce you to Madman 2, who is in direct competition with Madman 1 over who gets to own this site. Madman 2 has a distinct advantage, he knows that, as the old adage goes, it’s not what you know it’s who you know.

Madman 2 was created by my cousin Barbara (Thanks Babe, you’re awesome). Of course, I had to beg her to leave out any of the sexual inferences that invades most of her other artwork but I think she created something truly wonderful.

Now, if I could only find the time I have a great idea in mind already.

So which Madman do you like best?

Ethiopia

It's always amazed me how so few people in the world are able to rise above their own small existence and see the bigger picture, on a national or global scale. So few of us are able to see through superficial qualities like beauty, race, nationality, religion and popularity, me included. I'd like to think I am progressing, but often, I run across another who reminds me just how far behind I am. I make assumptions about who people are by the way the look, by their nationality. I make assumptions about their intelligence or/and their values. I even make these assumptions about them based on how beautiful (or ugly) they are. I wish I were better than that.

I've blogged about HIV disease this month because I've been caring for these patients recently. My hospital is in an area where HIV is rampant and so we have dedicated a medicine service entirely devoted to caring for these patients. Many of my patients leave much to be desired. Many of them contracted HIV by IV drug use, many continue to abuse drugs or even sell them. Many have disregard for their own life much else the life of another, and many are simply unpleasant. Not to mention that their struggle has made them, simply put, emaciated and unattractive. Sometimes, I’m amazed at how I even register this as part of the clinical picture when it really has no place in it.

My attending this month is an amazing woman. She's cared for these patients since the AIDS epidemic began. She was here when the first patient presented, back in the early eighties. She was here when the first WOMAN was diagnosed with HIV, when it was considered an entirely gay man's disease. She's cared for patients who are still alive after twenty years and many who had no chance from the get go, either do to their disease or their attitude about treatment. Through it all she persists, not only persists, she thrives. She cares for them like a mother cares for her children. Watching that kind of uninfluenced love is intimidating and humbling the same.

Now she is working to help bring help to the millions of people infected with HIV in Ethiopia. She goes there routinely and is trying to coordinate clinics, physicians, classes, medicines, and sanitation that may help millions in that area survive. Her stories about the current state of medical care in Africa are a nightmare and one can't really begin to understand how they managed to fall so far behind the rest of the world in healthcare and living standards. Even sanitation is non-existent. I think, at least in my little world, that puts things into perspective.

So back to my point. She sees the big picture. The small picture is irrelevant to her. The book cover is exactly that, just a cover. The blinds have been lifted from her eyes.

How simply wonderful!

I hope to get there one day.

H.E.L.P

This morning rounds proceeded at the usual pace. I struggled to stay awake as the intern presented the train wreck that was transferred to our team last night from the ICU. I remembered the case well and, after coming to the conclusion that this patient will probably die regardless of what we do, I chose to sit half committed, stuck in the maze between sleep and wakefulness.

As I drifted between the beautiful blond that invaded my dreams and the reality of ultimate failure and powerlessness an agonized scream interrupted my conscience.

“HELP”

It was an elderly gentleman yelling for a nurse. Probably just moved his bowels and needed his diapers changed I suppose. I cracked a smile at how, as a young intern, I often rushed to the bedside only to find a delirious patient with no real complaint.

“HELP” this time it was louder and stronger. “HELP”

It was interrupting the presentation.

Fighting the urge to “HELP” I continued to sit still, obnoxious. I’ve been fooled enough times and I know that the nursing here is not that good, to say the least, and that often people get left in their diapers and although that often is not so comfort…

“HELP”

It was unbearable anymore.

I jumped out of my seat. Could this patient really need help? Could he be having difficulty breathing? Maybe he’s about to fall off the bed and is holding on for dear life? Maybe his roommate is not responding and he’s trying to warn the doctors? I escaped into the corridor.

On my way to the room, as the screams compounded, I continued to imagine. Rambling in my mind about how ridiculous the nursing is here and how it’s even possible that a patient, any patient, would be screaming help without any response. I made my way down the hall and arrived at the room.

Sitting on the edge of a bed was an elderly gentleman, well groomed, lightly amused. I said “What’s wrong sir, how may I help you?”

He looked at me and said “I’m losing control of this car, it’s going too fast. And my hands are FREEZING”. He announced this last piece of information as my brain signaled IDIOT, IDIOT, IDIOT…you got taken again.

Not knowing how to respond I said the only thing that instinctively came to mind.

“Sir”, he turned his head.

“Sir, how about you slow down and…”

“Roll up the windows. It’s cold outside”

Lack of Responsible Adults

“We need to discuss your condition with your family”
“No doctor, I don't want to”
“But I'm concerned about your husband. Does he know?”
“No”
“You've had HIV now for ten years and your husband doesn't know?”
“No”
“Do you use protection?”
“No”

Ethical conflicts invade my mind and confuse my thoughts. This month I've had multiple conversations with patients that have left me uncomfortable in my skin. Never before could I have imagined the level of denial that pervades some of the patients that live with this horrible disease.

Previously, a diagnosis of HIV was the equivalent of a death sentence. We lacked the knowledge to combat this deadly virus and our understanding of how it infects and replicates was minimal. Long gone are those days and currently the prognosis of patients with HIV has improved significantly. Far from proclaiming victory we have, at least, been able to significantly alter the rapid pace of progression which was once the standard.

In spite of the above, it is not a disease that I personally would like to live with. That is why some of these patients enrage me with their lack of responsibility and disregard for human life, most often their own. Many continue to abuse drugs and prostitute. The scariest thing though is how often I run across patients who have unprotected sex with their partner, get pregnant multiple times and endanger their babies with HIV. At times, they even hide their disease from their family for years, or partner, while having unprotected sexual relations.

There are options left to the physician in these cases such as anonymous partner notification through a third party but this doesn't do much to engender patient doctor trust. Ultimately, two people get caught in the middle, the physician and the other. The other being a partner left with the reality of a finite life sentence, no matter how long.

Sometimes, and these are the really heartbreaking stories, sometimes it’s a child fighting to survive though his third case of PCP Pneumonia because of an irresponsible mom who died long ago of a horrible disease. Basically because of a lack of conscience and responsibility.

I would like to stress that this is only some of the patients, a real minority. Still, this minority upsets me.

Grand Rounds

The Grand Rounds come at an oppurtune time this week, call it Well-Timed like your...

New Links

I apologize for the general slow down on this blog recently. Few reasons.

First, I'm really fucking tired (sorry, for the obscenity). New parenting is like constant night floating while working days as well. Congrats to everyone with kids, you do, after all, know what it feels like.

Second, Blogger has been ridiculously slow and annoying recently and I just gave up on posting a lot.

Third, I got nothing.

Did put up some new links today. One new one in the medical section called Dr. Tony. A whole new section down below from the excellent material in the skeptics circle. I decided I'd circumvent the circle and just offer up these web sites to check daily, they're excellent. I suppose I should actually write a Mad House Parody on one or two but again, I'm fucking tired.
;-}

The Patient’s Family and the Asshole

There are times when I feel like my entire day is wasted updating one family after another about the current condition of my patient. I have other patients to care for, conferences, lectures, and tests to arrange. Not to mention the other odd situations that pop-up here and there. So when I spend more than 5 minutes discussing “the situation” I get antsy and, if sleep deprived, I get nasty.

And yet there I was, the husband sitting by the bedside, a doctor in disguise, watching my wife in pain and realizing there was really nothing I could do to help, simply put, it was torment. As I watched the number of contractions rise I knew they would correlate well with anguish, and they did.

A few hours into the labor the monitor began to show decelerations. There are different types of deceleration but this was an ominous sign and I knew it. Now worried not only for my wife but for our unborn baby there I was again, the husband sitting by the bed hoping this bad dream would go away and that the labor would progress smoothly. Looking back, it was one of the most miserable experiences I’ve ever had, and it was overall a HAPPY occasion, after all, I was expecting a baby.

How many families must’ve left the hospital thinking that their loved one’s doctor was a horrible person? How many families did I shrug off, avoid, or act rude to. Simply put, until now I was an asshole. They were worried sick and I shrugged them off as crazy and overbearing.

These are just some of my thoughts.

COTV

The Carnival of the Vanities is up at Bird Eye's View

Grand Rounds

Still reeling and trying to catch up so no round carnival this week. Simply because I don't have the energy to find out where these carnivals are right now. Two I love the most, Grand Rounds at Respectful Insolence (Done E style), and The skepticsCircle this week on Thursday at The 2% Company.

CD4

“So Mr. Flores what’s wrong”
“For the last two weeks I feel like I can’t breath. I’ve been having fevers like crazy doc”
“How about chills?”
“I’m freezing”
“Do you know your CD4 count?”
“No, But it’s low doc”

It was low and quite concerning. The Human Immunodeficiency Virus (HIV) attacks the immune system of its host, eventually rendering it incapacitated. It does this through multiple mechanisms. The most significant of these is its attack of a specific type of immunity cell called a CD4. This particular cell is so important because it coordinates the response of the entire immune system by first recognizing the intruder and then recruiting the appropriate components of the immune system to destroy it. Thus the attack of the HIV virus would be analogous to a football team tackling the defensive coordinator, unfair but highly effective.

The amount of CD4 cells left in one’s serum can give an indication of the viability of the patient’s immune system. CD4 counts of less than 200 are worrisome and signify a progression from having HIV to the Autoimmune Deficiency Syndrome (AIDS). This is an important distinction clinically because the patient is now at risk for infection by other less common pathogens.

Mr. Flores had one CD4 cell. ONE CELL.

This information became available after I drew a whole bunch of test tubes, including two sets of culture bottles, from his arm. As I headed back to our conference room my intern informed me of the meager count.

I imagined this last CD4, fighting for survival, fending off intruders, the last standing Mohican. How valiant he triumphed as he traveled up the Vena Cava annihilating a Staph Aureus Bacterium. Upon entering the right ventricle on his way to the left side of the heart it destroyed a strep colony with a sting of its mighty sword, narrowly saving Mr. Flores from life threatening endocarditis. As it was thrust out to the Aorta it opted to survey the left arm. Making his way down the Axillary artery ready to destroy whatever cellulitis may be brewing. On its way back the heart it stopped at the cubital fossa, just above the elbow, to survey that all was harmonious and to rest, exhausted from his constant struggle. He was tired but gratified at his work, recognizing that he was the only thing standing between life and overwhelming sepsis, fighting to death to save Mr. Flores.

I like to draw my bloods from the cubital fossa.

On my way back to the conference room I heard my intern scream out at me. “Mr. Flores has a CD4 of 1”. Curiously, I raised the serum filled test tubes to my eyes, closely inspecting their inner contents. Could I? Did I?

I could swear that somewhere from deep within my chemistry tube I heard a faint whisper. It was noisy in the hallway and so I’m unsure if what I heard was correct. It was quite low pitched and its tone was that of a defeated exasperated warrior, but it sounded like it said

“You Bastard”

Intern Hostile Takeover

I would like to introduce you to the new head of our medicine team. Hey, who am I kidding, the new chief of medicine, the *COMMISH. She presented to intern orientation only 5 days ago ready for hard labor, the kind all interns must endure to earn the blood stains on their scrubs. She prepared extensively, training for nine hard months, even opting to delay initiation an extra two weeks so that she could perfect her LP technique. Moreover, on her way out she stopped to admire the cervix, for thirty six hours. Not since the days of papanicolaou was a cervix so thoroughly examined. Accordingly, in her first days she impressed the staff with her soft nature and humility.

She was assigned to a team headed by the Mad House Madman. Her credentials were impressive and he specifically requested she work with him. As the resident he was the brains and she was power, a perfect team.

Unaware of the true ruthlessness of this timid intern the situation soon spiraled out of control. For even as she was being chauffeured to her home she already set in motion a chain of events which would shake the foundations of the hierarchy of medicine.

Interns, formerly bottom feeders in the ass-kissing stepladder, were about to receive a promotion, while Residents, the brains that fuel the machine were demoted to nothing more than diet consultants and nursing assistants, always at beckoning call to change another diaper.

Upon arrival to her new place of residence she proceeded to wail tenor all night long. Quickly draining all strength of resistance from the powerful resident, rendering him incapacitated, like a wounded animal.

“Clean my Ass Madmad”
“Feed me bitch”
“Shake me Madman, AGAIN, No I’m not asleep yet, don’t piss me off”

And I thought Interns were stupid.

The picture above is the real character, yes the REAL thing, take that HIPAA.
I am sorry, I promised myself I would never become a parent who only talks about their kids. Of course, this is a medical blog, of sorts I guess, but I can’t control myself. So, unfortunately, you will have to excuse my annoying posts about the new love in my life. Read them along with the writings on my work and hospital life. Too bad for you. ;-}

Grand rounds and Thanks

I would personally like to thank everyone for your well wishes. The wife is recovering from a C-section after 36 hours of torture, a condition called arrested labor (more on that later). I am helping any little way I can and hope to get back to what I love to do as soon as possible. Meanwhile check out this week's grand rounds at hospice blog.

Sincerely,
Joe

The longest 36 hours of my life, only the beginning of hers. Future Intern Is Born.

Thanks to all who’ve sent us their heartfelt congratulations. She is beautiful.

Yes. The Time is Correct

Yet another day passes and Future Intern refuses to emerge. I guess she still hasn’t quite perfected some procedures. Maybe, as we speak she is examining the exact position that the LP needle needs to be inserted, you know she can get a much better approximation from the inside and she’s not so quite ready to let this opportunity end.

Posting was light this week since the Obstetrician wanted to see us every two days. Talk about a paranoid group of physicians. I can’t imagine how upset my patients would get if every two days I had to run an echocardiogram to make sure their hearts are still beating. Probably wouldn’t reflect well on my clinical skills either. I can’t blame them though, seems today an Obstetrician will get sued if a child seems to cry or can’t control his bowels immediately after birth.

We’ve now arranged for a deadline. If she refuses to come out quietly then force has to be used. I know people. I know people who know people. You got that Intern?

Knowing all the things that can go wrong really hasn’t helped my coping mechanism either. Every few hours my mind wanders about the latest worst case scenario and the scenarios keep getting more deadly.

I’ve been posting since four AM. Hell, I’m wide awake. I’ve been awake all night. This is one massive panic attack. I’ve just realized, we’re going to have a baby, an actual human being. I’ve been begging god for so many things recently he may just confuse me for a religious man.

Regarding my Madman

Regarding my Madman. I found this quite funny. You never know, I may come up against some resistance,

Thanks Sarah

Great Response 2

Jan also put her two cents in. Two very valuable cents.

As a seasoned former ICU nurse, may I recommend asking your next patient who wants "everything done" for him exactly what he/she thinks that entails. When they look at you blankly, then explain that if they were to stop breathing or if their heart were to stop that CPR would be done. Then explain about the ETT and inability to speak, the fact that their arms will be tied down post arrest to prevent them from pulling out the ETT and/or any lines, that they will likely have fractured ribs - if the CPR was done well enough - and that they have a small chance of leaving the hospital alive, much less in a functional capacity.

When I worked in the MICU we admitted a patient from the ER with a severe COPD exacerbation - this was just after the DPAHC law took effect. While in the ER, the intern had apparently asked the patient if he wanted "everything" done to keep him alive. The patient reportedly said yes. As I was admitting him to the MICU and assessing him I asked the patient directly if he wanted to be placed on a ventilator if his breathing got bad. He (in the presence of his wife) definitively said no - he remembered how horrible it was to have been intubated in the past. So the patient was made DNR and died during his admission to the unit.

Many patients do not understand what we mean by "do everything". If it is phrased differently, then you may get diffferent responses. One of our end of life/hospice attendings gave a great lecture on discussing treatment preferences. He usually starts his discussions w/ pts by stating that some people prefer to live life as long as possible even if they suffer, whereas other people would rather focus on quality of life and freedom of pain even if it meant a shorter life. He suggested finding out what the patient valued - such as the ability to garden, or spend time at the race track or whatever - then pose the question about aggressiveness of care in relation to their values. If the patient was too sick to participate in whatever it was that was important to them, then he would suggest that not prolonging life, but focusing on comfort was a more realistic goal.

He really was good at what he did, and he encouraged me to practice this skill (of discussing end of life matters), but I changed focus and am no longer hospital based, so have not really honed my skills.

Photo can be found here

Great Response 1

Concerning my Ethics post. Dr. Bernstein was took the imte to explain why there really was no dilemma at all, as I can't prove anyone is lying. Thanks Dr. Bernstein:

"A legal surrogate, one assigned by the patient as a Durable Power of Attorney for Healthcare, speaks for the patient when the patient has no capacity to make medical decisions. The value of such a surrogate is thet he/she is able to be informed about the current status of the patient and what therapeutic options are available to improve the patient condition or provide comfort. Also, the surrogate will be told what treatments will not accomplish a recovery or attain any goals known wished by the patient. A legal surrogate therefore speaks for the patient and the attending physician must look at the surrogate now as the patient him/herself speaking.

The only exception, as previously noted, is if the physician suspects that the surrogate is not acting in the best interest of the patient but in the surrogates own self-interest.

This "speaking for the patient" is not only legal but current consensus declares it is also ethical". ..Maurice.

ESRD

My medical school Nephrology rotation was under the care of Dr. Cohen. Back then, only a third year student, I was relatively intimidated by the hospital ward and dealing with patients whose kidneys didn't function was a challenge, still is. He was the head of the department. He was Argentinean by birth and had a thick Latin accent. The mix of Spanish and Hebrew gave his vocabulary a Yiddish "I love lucy" chutzpa.

At the time, he was nearly fifty years old. The years have been kind to him and his beard, now white, was a perfect fit on his experienced pudgy face. He once told us a story about how when he came out of medical school he decided to train in pediatrics but after years of being awake late at night to help yet another child in trouble, he burned out and switched directions. Then an attending, he started anew and began a Nephrology/Internal Residency from beginning to end, including internship.

When contemplating the last two weeks of caring for patients with End Stage Renal Disease (ESRD) he often pops into mind. I think he summed it up best when he said “I couldn’t stand watching kids die so long before their time and so it was a blessing coming here to take care of people who were supposed to be dead a long time ago, except someone forgot to tell them”.

Indebted to you, they continue to forget. You're an inspiration Dr. Cohen.

The Round Carnival

Grand Rounds this week are at Intueri, Maria does a fantastic job of posting daily and one hell of a writer to boot.

No Tangled Bank this week.

COTV at Belief Seeking Understanding on Wednesday.

Haveil Havalim is at Kesher Talk.

Changing directions slightly, the carnival of sin was yesterday at Red sneaker Diaries.

If there are any other good carnivals which I should be tracking. E-mail me at madhousemadman at gmail dot com.