Endocarditis

Another perk to my temporary life as a cardiologist is that I don't need to arrive at the hospital before 9 or 9:30, so I've traded gigs with Brian and have been dropping Sam off at daycare in the mornings. We've already developed a weekday routine that involves a morning coffee (for me) and a morning scone (for him). Yesterday as we were walking toward the coffee shop, we passed one of the baristas, empyting the garbage. "Stay in school, kid," he said to Sam. "You don't want to spend your life empyting other people's trash."

Yeeeeeeeeeeesh.

Speaking of gratitude, here's a story for you. One aspect of modern medical care that I suspect many non-doctors don't fully appreciate: the log-jam. I recently helped to care for a patient at our veterans' hospital with so many medical problems, it is almost impossible to treat him. Poorly controlled diabetes earlier in his life resulted in kidney failure; a decade ago he underwent kidney and pancreas transplantation. Unforunately, his shiny new kidney was infected with a virus and was subsequently removed and he is now a dialysis patient with permanent vascular access. But his borrowed pancreas still functions, and he remains on immunosuppressive medications. (Note that permanent vascular access + immunosuppressive medications is a bad, bad combination.) He rolled in to our VA emergency department four or five days ago with a high fever and severe back pain. An MRI showed a large abcess in his lower back, tracking along his spine. The next day, his blood cultures grew Enterococcus and an ultrasound of his heart revealed a infectious goober flopping along on his aortic valve. The valve itself is no longer functioning adequately; he is increasingly short of breath and hypoxic as a result. Treatment for an epidural abscess? Surgery to drain the abscess. Treatment for bacterial endocarditis causing heart failure? Surgery to replace the valve. But the heart can't be fixed before the back; can't put hardware in a patient with an active septic focus. And the neurosurgeons are -- how to say this? -- declining the opportunity to operate on this man's back due to his kidney disease and overall clinical instability. "Poor surgical candidate," they called him. ("Poor non-surgical candidate," the medical team noted.) In the meantime, his fevers and rigors continue despite horse doses of antibiotics and all the while he remains paradoxically on medications to suppress his immune system. The whole situation is a complete snarl and the patient is desperately, desperately sick. I'm not sure what will happen for him or to him.

Cardiologist for a day (month)

This month, I'm on the cardiology service at our veterans' hospital. Among other things, the new rotation means WEEKENDS OFF. My first so-called "golden weekend" (known to non-residents by the common moniker, "weekend") was last week. Brian, Sam and I celebrated by spending the weekend at Lassen National Park. Despite a Bay Area heat wave earlier in the week, it actually snowed in Lassen over the weekend. Snow! In August! Even with the incement weather, we had a wonderful time. On Sunday we hiked to the top of the Lassen cinder cone for a view of the painted dunes and lava beds. It's quite a steep climb and poor Brian carried Sam on his shoulders the entire way. When we got to the top, Sammy announced, "I HIKED!" Um, sure, kid.

I'll post pictures of Sam "hiking" and "camping" (technically, a hotel, but what does he know?) when I can.

August update

Still here, still alive.

This weekend, Brian and Sam are in Oregon, throwing rocks into the Rogue River and catching up with old friends. I'm in the middle of a run of night shifts in the emergency department at our university hospital, so I got left behind. What this means is that, for the first time in over a year, I have an entire day to myself.

Sleep until I wake up, check. Coffee and the NYT, check. Pedicure, check. Eating ice cream in bed while I update my blog, checkity check.

Emergency medicine has been an interesting experience so far. As a medical student, I felt reasonably certain that the specialty wasn't for me, so I didn't bother to do an emergency rotation; this month is my first exposure. While my time so far has confirmed that emergency medicine isn't a fit for me (noisy, chaotic, waaaaay too much psych and OB), I'm enjoying myself. Nice people, interesting cases, shift work.

Last night I met a 59 year old woman who was billed as "headache, vomiting" and triaged to the less-acute area of our department. I strolled in, expecting a migraine or maybe meningitis. But from the doorway, it was obvious that my patient was much sicker than advertised. She was slumped to her side, shuddering and moaning. Three hours earlier, her son explained, she had argued with a neighbor, then been struck suddenly with an overwhelming headache. She fell to the floor, unable to stand or walk, and proceeded to vomit again and again. When I met her, she no longer recognized her son and she couldn't look at me, answer any of my questions, or participate in my cursory neurological exam. After surveying the scene for about a minute, I had heard all I needed to hear; I called a stroke code and 10 minutes later, I was standing in the control room for a CT scanner across the hall with the on-call neurologist, looking in horror at images of a brain filled with blood. We wheeled our patient back to the emergency department, pushed mannitol and 23% saline to prevent her brain from swelling, then waited for the on-call neurosurgeon to make his necessary arrangements. I suppose it's a sign that I don't belong in the emergency department that when my patient left for the operating room -- no longer my patient -- I wanted to go with her. To be sure, I am not the doctor she needed that night, but it doesn't sit well with me to triage and stabilize, then hand off care for my patients to other physicians. I'm glad I'm not an emergency medicine resident.

On a happier note, here are some pictures of Sam at the science museum in San Francisco.

Photography

Brian's been making noises lately about "needing" a new camera. (Note to self, this must be where Sam learned to use the word "need".) I am having trouble being supportive of this need. His collection of camera equipement is already a) extensive and b) expensive. Does he really need another DSLR? Wouldn't life go on, just as it has, without the capacity to shoot HD video? The camera he has his eye on isn't available yet, so I have a temporary reprieve, but even so, I admit to a bad attitude about spending $2K for the latest version of what we already have.

Having said that, Brian was processing some pictures last night and had this to show me:

This shot completely captures my memory of our trip. I suspect I'll look at this picture again and again over the decades of my life and be transported back to a moment so flawlessly happy, it's almost a miracle.

Which makes me think I shouldn't interfere with Brian's pursuit of his photography hobby.

PS. In case it's not obvious, that blur in Sam's hands is a little wooden sword.

Limping

It's been an eventful week. For starters, on Tuesday, Sam developed an atraumatic limp. By Thursday, the limp was worse and both my brain and stomach were churning (!sarcoma! !leukemia! !septic joint!) so we piled into urgent care where Sam limped obligingly up and down the clinic halls, giggling. The ped, thoughtful and thorough, sent us home with reassurance. But the next day his limp was worse yet, so back to urgent care we went. This time: plain films of the hips, knees, ankles and some basic blood work. All blessedly normal, and today the limp has more or less disappeared. I am relieved, but still a little rattled.

It's always interesting to me to be a patient -- or worse, a patient's mother. There's this out-of-body thing that happens: helpless, I watch myself morph into the kind of patient who drives me bonkers. I'm irrational, I cling to my own explanations, I demand needless intervention.

All very humbling.

Work has been less humbling. It's near the end of intern year, and I can feel myself starting to get cocky. After ten months as an intern, I can write an H&P in 20 minutes, I know where the radiologists hide in the middle of the night and I actually remember which carbapenam doesn't cover pseudomonas. I know how to distinguish between right and left atrial enlargement on an EKG, how to triage respiratory distress, how to perform a thoracentesis. I have the pager number for the on-call ICU fellow memorized. I even know where the obstetricians stash their free hot chocolate. I've got this down.

Anyway, I'm working this month on the private hospitalist service. The schedule is more or less the same as for the university wards -- Q4 overnight, roughly 80 hours/week -- but interns work directly with attendings. Some of the attendings are micro-managers and others don't seem to care at all what I do for our mutual patients so long as everyone's alive in the morning. Needless to say, the second type is my strong preference.

I was on call last night with an especially hands-off attending. We admitted a 56 year old woman who for the past four years has been inexplicably unable to walk. Apparently, four years ago, her legs developed intractable spasms and over time, she walked less and less until she became essentially immobile. Yesterday, her husband had finally had enough. He picked her up, carried her to the car and drove her to urgent care. From urgent care, they dispatched her immediately to the hospital for additional imaging of her brain and spinal cord. In fact, when I left this morning, she was in the MRI scanner. I'm not sure what's wrong with her, although the posibilities are numerous and interesting (multiple sclerosis, a severe B12 deficiency, syphillis, diseases that form benign CNS tumors like neurofibromatosis or tuberous sclerosis, probably several other things I haven't thought of), but what's really fascinating to me about this woman is her indifference to the problem. Apparently, years ago, she was a ballerina. But for the past four years, her legs just ... didn't work. And she did absoutely nothing about it. What does that mean?

I dare you

... to keep from smiling while looking at this picture. Can't be done!

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