Instinct is Learned

Mr. Reynolds is a vivid 83 year old who lived alone at home. He walks everyday int he morning first thing before he has a small cup of coffee. His kids bought him an ipad and he uses it to browse the Washington Post, the Wall Street Journal, and the Pittsburgh Post Gazette while eating breakfast.

Every morning it’s the same breakfast…toast with honey and a small cup of yogurt. Then he’s ready to start the day, just when the rest of his neighbors are waking up.

Today however, he ate hist toast and his stomach grumbled, louder than usual.  He thought to himself that he’d better get to the bathroom quickly… and he was right.

I met him an hour later in a gurney with the chief complaint of ‘bloody diarrhea’.   He looked great to me, comfortable, normal blood pressure and heart rate, he wasn’t pale, no pain at all. The only finding was maroon colored stool.

I sent off a bunch of labs thinking he had one of 3 main intestinal related issues…bleeding ulcer, bleeding polyp / diverticula, or hemorrhoids.  Hemorrhoids were less likely since the blood is usually bright red.  Likewise lower intestinal bleeding is often still bright red since there’s a short distance for it to travel and the bright red color is maintained.  Hmm…that leaves a bleeding ulcer from the stomach.  int he stomach the blood is exposed to stomach acid, which turns the iron black.  Black stool is a bad sign..but maroon stool is even more ominous, as the blood is accumulating quickly enough to let some bright red blood mix with the blackened blood turning it a dark shade of maroon.

But Mr. Reynolds looked great.   Many bleeds are brief and stop on their own. He’d had no further episodes since the first one.

After an hour his labs came back. His hemoglobin was 9.4.  A little on the low side but not overly concerning.  I looked up old labs and only had ones from years ago.  His old, presumably “baseline” hemoglobin was 14.  But I had no way of knowing how quickly he had become anemic.  For all I knew it could have been gradual over years or a few months.  Surely he’d not lost 5 units of blood since this morning because his blood pressure and heart rate were normal and he felt fine.

Then his nurse grabbed me.  “Doc Shazam,” she said forcefully. “Mr Reynold’s blood pressure is 90/50”.  “How does he look?” I asked.  “He still looks fine.”  Reluctantly, due to the IV fluid shortage, I asked her to start a 500ml fluid bolus.    I hesitated because lots of folks when they are relaxing in the ER, especially if they’ve taken home blood pressure medicines, may develop a blood pressure a bit on the low side.  I’d hoped that was his case, but this nurse is good.  She’s not one that comes to me for every little thing and she’s a great problem solver.  IN this case her problem solving included telling me his pressure was on the low side.

“Let’s add a lactate and redraw his hemoglobin,” I called towards her desk.   She heard me.  “OK,” she smiled and strutted away to draw some labs. She seemed happy with my orders, i think they were in line with her concerns.  But I still thought I was overreacting, wasting resources, wasting a half-liter of precious saline and the bag it comes in.

15 minutes later, I learn his lactate is 6 and his hemoglobin is now 9.  “That can’t be right,” I told her.  His lactate can’t be 6…he looks FINE, I told myself for the umpteenth time.  But that hemoglobin…could be lab error I thought.

I started putting the pieces together and while the patient looked fine, and had responded nicely to the fluids with a  pressure now of 114,  I’ve seen enough patients get very sick, very quickly once they cross a threshold.  Unfortunately they don’t come with gauges that tell us where that threshold his.

I decided if it was my family member in that room, I wouldn’t want the doctor to wait until he turned downhill, scrambling to replace blood and calling in resources exigently.

I ordered a unit of packed red blood cells and a pack of platelets since he was on aspirin and plavix, called the admitting team who had already seen him and updated them on what I’d learned and what my concerns were.   He thanked me and was in the ER within 5 minutes to assess the patient himself.   His repeat lactate was 5.3 suggesting he’d begun responding to fluids and blood and his repeat hemoglobin climbed to 10.

When I went into his room the GI team was there and they took him to the GI lab a few hours later.

***

Fast forward to the end of my shift and the hospitalist came down to give me an update.

“You were absolutely right with Mr. Reynolds.  The GI doc found bleeding varices in his stomach that they had a hard time controlling. I did a CT and found cirrhosis and signs of portal hypertension. We’re transferring him to tertiary care for a TIPS procedure.”

“I had an instinct,” I told him.   I’m so glad I listened to it. It was subtle but in retrospect it was absolutely the right thing to do.

“Instinct is learned behavior,” he proclaimed.   “You’ve seen it before and you knew the right course of action. Thank you for helping him.”

It made me appreciate that medicine really is a practice. You can know the right thing on paper and on board exams, but in the real world, cases don’t present like books and numbers and vital signs don’t follow the right patterns.   The wisdom of experience only comes from seeing many previous patients crash quickly and rebound slowly.

Mr Reynolds was lucky he came when he did and that it wasn’t my first year on the job.  I went home humbled and scared that I’d taken his case too lightly, but ultimately I’ve learned again and strengthened that clinical instinct.

 

A Living History – Eleonore of Bavaria

A Living History – Eleonore of Bavaria

Nuremberg chronicles - Nuremberga

She was silver-haired and weepy-eyed, with bluish gray bags under he lower-eyelids. Her grandson sat staring at his ipad. He looked like an Irish bartender–with a red beard and a toothy smile. He was patient and spent over five-hours at her bedside, with nowhere specific to go.

She spoke perfect english with a slight european accent, but the more I listened the more familiar it sounded. Taking her full history, I asked extra questions as an excuse to listen to the pleasant sing-song voice. She stressed and drew out her ‘S’ sounds with a soothing tone that reminded me of the Kaa, the crafty, sly snake from Ruyard Kipling’s The Jungle Book.

Satisfied that I had her work-up sorted out in my mind, I finally asked her where she was from.

“Nuremburg,” she said, swallowing the “em” syllable and turning the city into two syllables instead of three.

“Ich kann auch Deutsch,” I carefullly replied.

“Ser gut!” she said, smiling.

I dared not go any further with my German…it’s been 25 years now since I lived in Keil, but at one point I was fluent in High German.

I glanced at her birthday on my patient sticker sheet, and realized she was a “tween” during World War II. Nuremburg was at the center of Allied bombing raids between 1943-1945. During the age when my step-daughter is just getting acne, wondering if boys are creepy or a little bit cool and running for student council, my patient was hiding from Allied bombs with over 90% of her city destroyed in just 1 hour during one of those raids.

Her parents moved a total of 3 times during the war because their house kept getting destroyed. It’s a true miracle that she survived and that she was here in my ER, with her Irish themed grandson and a red-headed granddaughter as well.

I admitted her without fully knowing what was causing her pain, and hoping it was not a life-threatening spinal infection. I would have loved to spend a few hours getting to know her better and understand what her life was like…when did she finally escape the war and did she ever enjoy the freedom of running for school council instead of running for her life? And how do you treat acne during a war?

Split Decision

Split Decision

These days I divide my time between clinical and consulting work.   in my consulting job I work as a medical command physician for ambulances, helicopters and airlines needing advice and direction on all sorts of medical emergencies.

For the past several months I have been fielding several calls a day regarding screening for *possible* Ebola patients wanting to board a plane or currently in the air and suddenly developing symptoms.

Of all of those phone calls…only one of them had recent travel in Liberia and originated from a West African airport.  All of the rest were from random passengers that vomited, or had diarrhea…but had no travel history, no fevers, no exposure to anyone who had an recent travel history, exposure to the virus, etc, etc.

Part of my job is to reassure and clear those patients who have absolutely zero risk of carrying this particular virus.   But there is so much fear and paranoia that we are fielding calls about nearly anyone who vomits.

God forbid a passenger on Coumadin develops a nose bleed!  That’s a sure call to screen for Ebola even if the passenger is a little old lady from Pasadena who always gets a nosebleed on a plane.

 

A Gift to Remember Me By

A Gift to Remember Me By

Last night at dinner, this girl, Virginia, said, I’ll see you tomorrow! It old her that I was leaving in the morning. She asked for a gift to remember her by. I told her I didn’t have much (which was true, I packed ultra light, and brought no gifts) she asked if I could give her my necklace (I said no). I told her I would draw her a photo instead.

So I brought out this sketchbook that Kwin Krisadaphong sent me, and she asked for that as a gift. I showed her Kwin’s inscription and told her I couldn’t give away a gift to me.

I quickly sketched out this picture with a nice sketch pen I carry with the book. (She asked for the pen as well. )

I tore out the page and handed it to her after writing a message in both English and Spanish, then reached around to hug her and slipped the pen I to her back pocket. She pulled her shirt down over the pen so no one else would see.

It’s hard to want to be able to give everything to every child, but some of them somehow seem to make a bigger mark than others.10333385_10203949741775539_5831120630524831564_o 1601955_10203949741655536_2200180618000528146_o 10410722_10203949738815465_648259956400244290_n

Lights, Stethoscope, Action!

Lights, Stethoscope, Action!

Safely arrived in Honduras, met our transportation to the village, saw many old friends already, it almost feels like home.

The Sun is setting, the breeze is cool, the kids at everywhere, the meal was great, the parrots are chirping and the strangest thing is there are lights coming on in the village.

2 years ago there was no electricity here at all, then all of a sudden electric poles went up, now lines and lights.

We have seen one patient already, a boy with a leg infection from a motorcycle accident.
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Hanging up the Stethescope

Hanging up the Stethescope

Well, it’s been a long time in coming, but I feel that it’s time to share it with all of you.  Doc Shazam is hanging up the stethescope.  I’ve had it, I’m through. The healthcare field sickens me both literally and figuratively.  I’ve gained weight, can’t sleep, suffer from migraines, have chronic shift worker’s disease, chronic sleep deprivation, and am horribly out of shape. I’ve sacrificed not only my physical health for this profession, but also my social health. I get anxious and feel panic well up inside of me when my friends mention going away for a weekend.  Why? Chances are more likely than not I’ll have to work that weekend. If not the weekend, then definately the friday night before.   Last year I didn’t get to participate in a single weekend bike race…a passion of mine, because I either worked every weekend, or every friday night until 1 or 3am.  For long time readers of Doc Shazam, you know how much I love to bike.

For all the wonderful things that come from being a doctor…the priveledge and thrill of saving lives, running codes, knowing how to set broken bones and suture kids faces without scarring…there are far more downsides for me.

No matter what the paycheck, it’s not worth it if I’m constantly tired, constantly have a headache, cannot pursue relationships with friends or family on a routine basis.

Yes, I know that there are many other physicians that (seem) to be able to do all of this, but when I discuss my recent decision with them, they all express a wish that they too could follow the same path.

What will Doc Shazam do?  Hopefully write.  Ride her bike. Coach Triathletes & cyclists. Garden. Find myself again.  Rid myself of insomnia, anxiety and panic.  Restore relationships with friends and family.  And become a better bike racer.