Sunday, March 23, 2008

Happy Easter

Kristos Anesti! He is risen!

Fact and Fiction

It's been an interesting weekend. I got a patient on Saturday who came in with "10/10" crushing chest pain after shovelling snow that morning. In the ER he was started on a nitroglycerin drip and given morphine which brought the pain down somewhat. The ER's story was that he had a heart attack 12 years ago that required stenting, and was due for another catheterization (a means of looking at the coronary arteries) next week. A scary story, very suggestive of a serious problem, probably another heart attack. Fortunately, I looked at his records before seeing him.

I went down to the ER and got his story. He said he had the heart attack in a different city but did not remember the hospital. He had another catheterization at my hospital 7 years ago, but said he had not had any further work-up since. I asked specifically if he was sure, and he again confirmed his story. The problem was that the records I had seen said that he had had several catheterizations, all at different hospitals, in the last five years. The last one was 5 months ago and was completely normal. Also in his records was a history of Munchausen syndrome. However, he was so serious, I considered temporarily that the resident who dictated his last discharge summary had been mistaken. So, I called the other hospital and had the records faxed over--the previous resident had been correct. The patient was flat out lying to my face. Not only had his arteries been healthy, but there was no note of the cardiologist having seen any stents--was he lying about his previous heart attack as well? Even given this, we still had to admit him--boys who cry wolf can still really be attacked by wolves. We admitted him and checked enzymes and EKGs multiple times throughout the night. All were negative. He repeatedly asked for morphine. We refused, and he left against medical advice the next morning.

It was a fascinating case. I've read and heard about Munchausen but never really grasped it until now. I was just blown away that someone could lie like that--especially given the fact that he signed the paper giving me permission to get his records from the other hospital! Either he thought I was really stupid, or he's not the brightest faker ever to waste the hospital's and taxpayers' resources. And I'm flabbergasted--what would make someone want to be in the hospital and have unnecessary, risky testing done (he also had a history of wanting surgery he didn't need)? Does he just crave attention? Is he just drug seeking? I don't think he is a hypochondriac (hypochondriacs really believe they're sick, Munchausens don't).

On the same day, we had an interesting ethical situation. We had a patient who was brain dead, in other words, her heart was still beating since we had her on a ventilator and were pumping her full of drugs, but she had absolutely no neural function. For all intents and purposes this meant she was dead--not in a vegetative state--for her to wake up would be just as miraculous as a skeleton regrowing flesh. She had a very large extended family visiting. The resident was planning to meet with them and tell them that the patient was dead and they should say their goodbyes before she was taken off the vent. However, the attending who was covering for the week walked in, smiled, and told them that her heart and lungs were doing great and that the neurologists would do a test of her brain. The family in the room sighed with relief and thanked God, thinking that there was now a chance of the patient's recovery. The residents' jaws dropped open in shock.

Immediately after in the residents' room, behind a safely closed door, the attending and residents argued for about 20 minutes about the proper way to handle the situation. The attending was adamant that he had just provided the family with hope, and that they should slowly, over the next day or two, break it to them that that patient would not recover. The residents (and I, silently) were strongly of the opinion that they needed to be honest. The attending didn't give in, and left. The residents then spoke to the neurology consult attending, who was understandably furious. He called our attending to yell at him, then met with the whole family and told them she was dead. They took it well, and said their goodbyes before her heart stopped the next morning.

This episode has been the subject of much discussion over the last few days. I think it demonstrates a great difference in the way that different cultures and generations think about death and the role of the physician. Our attending was an elderly Asian man, and came from an era and a culture in which physicians took a paternalistic approach and gave patients hope even when there was none. An era in which they could start chemotherapy without ever informing the patient that he or she had cancer. We, and virtually all doctors in America today are products of informed consent, in which there can be no greater travesty than to be anything other than brutally honest with a patient, even when it hurts. Maybe we're wrong, or at least not totally right. But it's how I would want to be treated.

Friday, March 21, 2008

The Match

Good news and bad news: the good news is that I have a job next year! The bad news is that it's only guaranteed for one year. Last Monday I had the unpleasant experience of opening my email and finding that I had not matched into a surgery program--it came as a rather nasty and completely unanticipated shock. Tuesday I went to my school for the scramble--in a way I am glad that I experienced it, but I still would not wish it on my worst enemy! I and my ten fellow unmatched students, most who were handling it well, but some who had obviously been crying all night, met in a conference room and got a pep talk from our deans. They then set each of us up in a private office and provided each of us with a personal assistant to take calls and send faxes. The list of open programs (there were only two categorical surgery spots) was then released across the country at 11:30 EST, and at 12:00 we all started madly making calls and re-applying on ERAS. My advisor was there as well calling all the program directors she knew. Blessedly, this quickly ended for me when the program director of my school's program called and offered me a prelim spot, which was what I had been hoping for. I snatched it up, and now have a job, and at the program I had been hoping to get into from the start. Unfortunately this means that the next year is going to be somewhat stressful as not only will I have the responsibilities of a new physician, but I will have to try to find a place to go for the next four years (this is just one other example of the benefits of being a Calvinist--I know God's in control:). It should be interesting! Thankfully the match went well for my friends, though there were still some tears (more from weeks of pent-up emotion than actual disappointment. One bit of advice to students applying next year: do NOT believe anything programs say regarding how they plan to rank you. They are lying). Most of them ended up staying here--in fact, of the 11 students and students' spouses in my Bible study, nine will remain here.

Some of the things I am most excited about for the next year are kind of silly--I am really looking forward to shedding my short white coat. I remember at the beginning of third year how pretentious I felt wearing it, now it's just humiliating. I'm looking forward to being able to be able to sign my own orders (scared too though!). I'm looking forward to being able to tell patients I'm a doctor (I have to decide how I'm going to introduce myself--it will either be "Dr. Emlyn" or "Chris Emlyn, one of the residents". I'm just not a "Dr. Chris" kind of guy). I'm looking forward to parking in the structure and not in the lot two blocks away (5-10 more minutes to sleep each morning!). I'm looking forward to having medical students, though I kind of wish I wouldn't have them until a month or two into internship. I'm really looking forward to having a salary, though I plan to remain in my cheap apartment for a while at least.

Saturday, March 08, 2008


I'm back. On my arrival I found that my car had a 5" thick slab of ice underneath and surrounding it, preventing me from getting it out of the driveway. I had to walk to the hospital Sunday, then take a hammer to the ice that afternoon to get just enough asphalt clear so that the car's wheels had enough traction to back out.

I flew back Saturday and started inpatient cardiology Sunday morning. This apparently is going to be a rough month--I only get three days off not counting the day of my flight. There are two senior residents, four interns, and two senior students on the team. One plus is that students don't take overnight call. However, since the on-call, pre-call, and post-call interns don't take admissions during the day, this leaves me, the other student, and one intern to admit all new patients. As the interns have clinic sporadically throughout the week, this means that the other student and I can get stuck with more than our fair share of work. Like yesterday, when I left the hospital at 9:00pm. Not fun. I got today off but have to go in tomorrow. I paged the resident at noon to find out what time I needed to come in--they were still noon...this does not bode well for tomorrow, especially as three of my patients are completely new to me, and I'll have to see several patients I don't know at all who belong to the other student and interns. At least I'm learning a lot.

There is a light at the end of the tunnel. This month is my last month as a student of clinical work. In April I'll be on radiology, during which time I'll get weekends off and plan to leave the hospital early in the afternoon on the weekdays. Then two weeks of "preparing for internship", and graduation! In less than two weeks now, I'll find out where I'll be spending the next five years.