He actually wasn't conscious when he first came in--of this we were aware. He came in last night, but that morning we met him as a team. Mouth perpetually wide open, hands wrapped in giant mittens to protect himself and others around him.
"Mister Griswolllld!" Our senior resident would yell out each morning shaking him by the shoulders. That morning he responded with unintelligible moans.
My intern whispered in my ear, "Hey Griswold. Where do you think you're gonna put a tree that big? Bend over and I'll show you!"
"You ever seen National Lampoon's Christmas?" he asked me.
"Parts of it, but never the whole thing"
"Alright. Your assignment for today is to watch some you tube clips of that movie so we have something to laugh about together."
Over the next week, Mr. Griswold would recover some form of responsiveness. Demented as hell, each morning he would be greeted and shaken. Eventually, the mittens came off when he was aware enough to stop scratching himself and pulling out his IVs. Then we noticed his hands.
"Hey, check out his lobster claw!"
His left hand sprouted three long and sinewy fingers and nothing more. The thumb, the index, and the bird.
"Watch out. Once he gets a hold of your arm, we'll have to chop it off cause you ain't getting it back!"
Those first few days we couldn't understand a word he said. Then, one morning, I went in with my senior for our daily shaking. He was already awake by the time we got there. Eyes open, he stared at us. We paused, startled at his consciousness. His ever gaping mouth slowly curling upwards, eyes fixed on her.
And then he uttered.
"IIII LUUUUV YOUUUUUU!"
"Awwwww" the inflection in her voice crescendoing as we left the room. "He said he loved me! Mr. Griswold!"
The last day I saw him we were planning him for discharge. Several steps from his room we smelled it. Clostridium Dificile. Shit. Literally.
"How you can tell it's C. Diff?" I asked.
"Just lift up his sheets and smell it."
And so he and his lobster claw were discharged from our service likely to relapse as soon as he settled into the nursing facility to which he was going, We had all come to see Mr. Griswold in a certain light. From unconscious, dehydrated admit to helpless, feces-ridden geriatric to lobster claw freak show, it's startling how little we actually knew about him.
"I loved Mr. Griswold," our senior mused.
"That's because he told you he loved you!" one of the interns replied.
"I know..."
"But he never seemed like the sort of guy that would have a history of being arrested several times for robberies."
"Oh, Mr. Griswold."
Tuesday, February 15, 2011
Monday, February 7, 2011
An Interesting Case
"Go meet Dr. Patel in clinic. She's seeing a patient of mine that I think would be good for learning. We're trying to decide whether she has acute or latent TB."
This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.
"Dr. Patel's already in with the patient."
So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.
Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.
Extensive psychiatric history. Well, given her history, who could blame her?
What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.
She had been possibly been exposed to TB when she was a nursing student in the past.
Wait. What?
And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?
The Ward.
She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.
But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.
Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.
Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.
"You have a certain way about you, how you conduct yourself."
Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.
And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...
This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.
"Dr. Patel's already in with the patient."
So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.
Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.
Extensive psychiatric history. Well, given her history, who could blame her?
What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.
She had been possibly been exposed to TB when she was a nursing student in the past.
Wait. What?
And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?
The Ward.
She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.
But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.
Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.
Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.
"You have a certain way about you, how you conduct yourself."
Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.
And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...
Tuesday, December 14, 2010
The 12 Days of Trauma
Inside the hospital, the only sign of the season comes in the form of festive bake sales, the occasional floor decorations, and maybe the occasional Christmas music in the OR. For those on the trauma service, winter is most welcome because it marks a decrease in the number of traumas. Unfortunately, people will drop by for a visit. During my trauma rotation I have experienced the following:
Black people shootings.
Old people falling (while hopped up on coumadin)
Young women motor vehicles colliding (into trees, other cars, +/- intoxication)
Many bones fracturing
Much rectal examining
And healthy dose of X-ray/CT imaging.
Black people shootings.
Old people falling (while hopped up on coumadin)
Young women motor vehicles colliding (into trees, other cars, +/- intoxication)
Many bones fracturing
Much rectal examining
And healthy dose of X-ray/CT imaging.
Friday, November 19, 2010
General Surgery
Having wrapped up the general surgery portion of my surgery rotation, I'm pretty glad that I had decided to not join any fantasy basketball leagues this year. Having been an avid fan since junior high, I decided last year to start playing again when a family member enticed me to join his uber-competitive cash-incentive laden league. I won that league, marking a successful comeback from my three year hiatus from fantasy sports. This year, however, I didn't think I'd have the time to really invest as I would like so I had to painfully decline the couple invitations this year.
These days, I find myself myself jumping on my computer to check on how my patients are doing. Instead of points, rebounds, and assists, I'm looking at vitals, progress notes, test results. Admittedly, these aren't the most exciting stats especially since we're not really shooting for extremes. Still, I'd like to think there's a certain head to head match up going on with death or even just surgical complications.
So every night I watch in anticipation and the following morning, I go see the results first hand. I realize it's probably not the wisest thing to compare patient care with fantasy sports, but the more I think about it, there's probably a good number of similarities that could be made. That's another post for another time.
These days, I find myself myself jumping on my computer to check on how my patients are doing. Instead of points, rebounds, and assists, I'm looking at vitals, progress notes, test results. Admittedly, these aren't the most exciting stats especially since we're not really shooting for extremes. Still, I'd like to think there's a certain head to head match up going on with death or even just surgical complications.
So every night I watch in anticipation and the following morning, I go see the results first hand. I realize it's probably not the wisest thing to compare patient care with fantasy sports, but the more I think about it, there's probably a good number of similarities that could be made. That's another post for another time.
Tuesday, November 16, 2010
Three things
One of the surgeons came up to me today and told me that I needed to learn three new things about every surgery I attended so that by the end of the rotation, I would have accumulated a nice fund of information from which to draw.
Today, I had only one surgery--the ventral/umbilical/incisional hernia repair. This is what I learned.
1. Repair necessitates cutting through the falciform ligament
2. Mesh should have at least 5 cm around the hole to ensure stability
3. Suturing the fascia to the mesh helps with stability and hematoma development.
I also present three things from the OR discussion relating to the implementation of new CT scans/pat downs in airports and the needless radiation exposure/invasion of privacy that this will generate.
Surgeon: I shouldn't have to subject my children to this (pat downs) just because I don't want to expose them needlessly to radiation.
OR nurse: If it wasn't the government doing this, these would qualify for sexual abuse.
OR nurse: I'll take the pat-downs over the X-ray any day. Heck, I'll even do it twice.
Scrub tech: Yeah, and while she's getting them, she'll probably forget why she's even getting them in the first place.
OR nurse: Everything I've learned I owe to you.
Nurse: my (Caucasian) friend recently got patted down at the airport while a 25-year old fellow Arab passenger got through untouched.
Indian Doctor: In that case, I'll be expecting my rectal exam when I go through one of those lines.
Nurse: Yeah, you'll be like, "Hey, that's not your hand..."
Today, I had only one surgery--the ventral/umbilical/incisional hernia repair. This is what I learned.
1. Repair necessitates cutting through the falciform ligament
2. Mesh should have at least 5 cm around the hole to ensure stability
3. Suturing the fascia to the mesh helps with stability and hematoma development.
I also present three things from the OR discussion relating to the implementation of new CT scans/pat downs in airports and the needless radiation exposure/invasion of privacy that this will generate.
Surgeon: I shouldn't have to subject my children to this (pat downs) just because I don't want to expose them needlessly to radiation.
OR nurse: If it wasn't the government doing this, these would qualify for sexual abuse.
OR nurse: I'll take the pat-downs over the X-ray any day. Heck, I'll even do it twice.
Scrub tech: Yeah, and while she's getting them, she'll probably forget why she's even getting them in the first place.
OR nurse: Everything I've learned I owe to you.
Nurse: my (Caucasian) friend recently got patted down at the airport while a 25-year old fellow Arab passenger got through untouched.
Indian Doctor: In that case, I'll be expecting my rectal exam when I go through one of those lines.
Nurse: Yeah, you'll be like, "Hey, that's not your hand..."
Saturday, November 13, 2010
Thursday morning cancer conference
It was the weekly cancer conference, and it was optional. Yes, his attending would be presenting a couple cases, but this short white coat had long grown tired of playing this game of impressing his superiors. But, he went anyway. Come to think of it, he probably only went because he was chasing an interest that he really didn’t have—and, on a deeper level, a calling he could never fully embrace.
The first case presented sounded familiar: Adenocarcinoma of the lung. Brain metastasis. Post-radiation treatment VATS pneumonectomy. PFTs had checked out pre-operatively. Patient recovered relatively well. Residual ataxia from the neurological deficits.
This was unfortunate because he painted houses. How would he make a living for himself if he could not stand on a ladder? The cardiothoracic surgeon wasn’t sure. His shoulders shrugged with a hint of sadness and sympathy. This was the story that was often left untold when a patient left the hospital—even if the surgery was a clinical success.
The painter had a name, and the short white coat sat there scrolling through the list of patients he had been generating over the last three weeks. All he remembered was watching the surgeons pull his diseased lung out between the ribs, and the painter’s face the day he was discharged to go home. He remembered that the painter had voiced concern about his job, but despite all this, the name eluded him.
He played the harmonica. He had brought in his harmonica that last day to see if he could still play it after the surgery. Indeed, he had found that he could. So strange; this was all he could remember. He played the harmonica.
The purpose of the conference was to provide a venue for oncologists, pathologists, and surgeons to discuss treatment plans, to collaborate so that future patients could be better served. At the same time, these conferences became a place to commemorate those that had passed through their care. Because for every 55 year old with adenocarcinoma of the lung and brain mets, there was a painter who painted no more—a painter who was recovering at home and playing his harmonica.
The first case presented sounded familiar: Adenocarcinoma of the lung. Brain metastasis. Post-radiation treatment VATS pneumonectomy. PFTs had checked out pre-operatively. Patient recovered relatively well. Residual ataxia from the neurological deficits.
This was unfortunate because he painted houses. How would he make a living for himself if he could not stand on a ladder? The cardiothoracic surgeon wasn’t sure. His shoulders shrugged with a hint of sadness and sympathy. This was the story that was often left untold when a patient left the hospital—even if the surgery was a clinical success.
The painter had a name, and the short white coat sat there scrolling through the list of patients he had been generating over the last three weeks. All he remembered was watching the surgeons pull his diseased lung out between the ribs, and the painter’s face the day he was discharged to go home. He remembered that the painter had voiced concern about his job, but despite all this, the name eluded him.
He played the harmonica. He had brought in his harmonica that last day to see if he could still play it after the surgery. Indeed, he had found that he could. So strange; this was all he could remember. He played the harmonica.
The purpose of the conference was to provide a venue for oncologists, pathologists, and surgeons to discuss treatment plans, to collaborate so that future patients could be better served. At the same time, these conferences became a place to commemorate those that had passed through their care. Because for every 55 year old with adenocarcinoma of the lung and brain mets, there was a painter who painted no more—a painter who was recovering at home and playing his harmonica.
Tuesday, November 2, 2010
Fences and Elbow Room
Today while waiting for a cholecystectomy, my team of one attending, two residents, and two medical students sat in the physician's lounge chatting about various subjects. My attending raised the issue of how everyone in his affluent neighborhood was putting up fences around their yards. It was silly, my attending bemused, how our relationships with our neighbors were becoming increasingly defined by such a strict sense of privacy.
Sometime later in the conversation, my attending went on to share this story.
"So I took my kids to Disneyland and my son was all up in people's butts the whole time. I had to finally pull him aside and tell him that part of what defines Americans is how we want our elbow room," He propped his elbows up accordingly to show how he symbolically demonstrated to his young toddler the concept of privacy.
"And," he continued, "for the rest of our time there, my son was walking around with his elbows like this," he repeated the gesture a second time.
Thinking back to this conversation, I realize that the hospital is the exact antithesis of the coveted privacy that Americans pursue. Here, a patient is stripped down to their most basic needs (pain, passing flatus, urinating, ambulating, and appetite). In order to receive help, he must be examined, poked, prodded, cut open, and assisted in rudimentary clothing (the hospital gown) by strangers not of the patient's choosing. He is furthermore forced to trust strangers with their most intimate details (sexual history and social history) with really no way to ensure that their confidentiality will be preserved (nurse gossip anyone?). This is both uncomfortably alarming and yet intrinsically necessary to the current health care process (because even the nurse gossip becomes a way to preserve the sanity of the participating parties).
If people were willing to subject themselves to such treatment for the sake of personal health, how different our society would be if we were willing to place ourselves in similarly compromising situations for the sake of our fellow man?
Sometime later in the conversation, my attending went on to share this story.
"So I took my kids to Disneyland and my son was all up in people's butts the whole time. I had to finally pull him aside and tell him that part of what defines Americans is how we want our elbow room," He propped his elbows up accordingly to show how he symbolically demonstrated to his young toddler the concept of privacy.
"And," he continued, "for the rest of our time there, my son was walking around with his elbows like this," he repeated the gesture a second time.
Thinking back to this conversation, I realize that the hospital is the exact antithesis of the coveted privacy that Americans pursue. Here, a patient is stripped down to their most basic needs (pain, passing flatus, urinating, ambulating, and appetite). In order to receive help, he must be examined, poked, prodded, cut open, and assisted in rudimentary clothing (the hospital gown) by strangers not of the patient's choosing. He is furthermore forced to trust strangers with their most intimate details (sexual history and social history) with really no way to ensure that their confidentiality will be preserved (nurse gossip anyone?). This is both uncomfortably alarming and yet intrinsically necessary to the current health care process (because even the nurse gossip becomes a way to preserve the sanity of the participating parties).
If people were willing to subject themselves to such treatment for the sake of personal health, how different our society would be if we were willing to place ourselves in similarly compromising situations for the sake of our fellow man?
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