A moment of reflection…

I sit here today, in this small, windowless call room with its low twin bed that is covered in untouched hospital blankets and sheets. Tonight is one of my last nights on a 30-hour call shift in the medical intensive care unit. Yet another mile-marker on this long journey of residency. My day began at the break of dawn, when I and another resident passed each other in the parking lot at 7AM – the only souls trudging to our cars at such an ungodly hour on a Sunday morning. But this is the life we chose.

The day passed as many days have passed in the intensive care unit – extubating one patient, intubating another, placing one or two central lines, and being present with families in a time of crisis and even in the face of death. It is a charged atmosphere. At one point, our hospital raised the Donate Life flag in honor of a young gentleman who had died and donated his organs to patients in need across the country. At another point, we gathered round in a patient’s room with family and chaplain to offer the only piece of caring we still could offer her – empathy, compassion, and prayers.

The families and patients in this unit have reminded me, over the past few weeks, of the primary reason I chose to become a doctor: to care for my patients. Patients roll into this unit on stretchers, many with breathing tubes in place, many so confused or sedated that their memories of this visit will merely be a vague sense – blurred brush strokes across canvas, lacking definition or purpose. But perhaps it is better that they do not remember – it serves as a survival mechanism, if they ever make it out of here.

All too soon, however, reality will hit. Some of these patients will be paralyzed for the rest of their lives. Others will never be able to eat or lie flat again, because they are at such a high risk for aspiration . Still others may never speak again because of malignant masses occluding their vocal cords. Hard to imagine, really, but it happens here every day.

Even with these tragedies, though, some patients will make it out of the ICU in good health, at least in a medical sense. But even they must struggle to overcome the effects of their prolonged hospital stay – weakness, anxiety, fear. Many of them will need rehabilitation, both mental and physical, for extended periods of time.

ICU patient walking in Johns Hopkins Hospital Critical Care Unit

In an attempt to prevent this, there is a new movement in critical care units to sedate patients less, to exercise them more, and to allow them to return functioning, mobilizing human beings as quickly as possible and even in the setting of the grave illnesses which brought them here. An article in the New York Times published in 2009, Get Patients Up, introduces some of the new and relatively radical approaches that physicians are using at Johns Hopkins, including mobilizing patients on ventilators. The idea is to allow patients to maintain their strength, to minimize muscle wasting, and to prevent long-term neuromuscular weakness that ultimately requires patients to participate in months of physical therapy to return to their baseline.

An article from Vanderbilt University in Chest 2010, Vasilevskis et al., describes an “ABCDE bundle” which is a strategy to minimize delirium and weakness in critically ill patients. It includes awakening patients daily, allowing them to breathe on their own without ventilator assistance for brief periods every day, coordinating their breathing and awakening, closely monitoring their delirium using consistent guidelines, mobilizing them early, and initiating physical and cognitive therapy. The goal of this bundle approach is to reduce the devastating effects of delirium and weakness which patients commonly struggle with after their ICU stays.
Although these ideas push the bounds of conventional ICU medicine, which include deep sedation and bed rest, they mark the beginning of a new and perhaps even more humane approach to care for the critically ill. Even more interestingly, these new techniques recall the age-old wisdom of Hippocrates. Primum non nocere. First, do no harm. By sedating patients with high doses of medications to treat their pain and agitation, by paralyzing patients to minimize the use of their respiratory muscles, and by restraining them to strict bed rest, we are in some cases harming them more than we are helping them. So let us take a fresh look at critical care medicine and remind ourselves that, at least for some of our patients, less is more.

Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

Another day, another summer…

Heat rises from the sidewalks of the city. Backyard grills appear again. Sun dresses, outside tables, kites, picnic baskets, bike riding. The world welcomes us to summer. In the hospital, it is a time of great change. All of us – residents, fellows, medical students – are moving on in our journey. Over a period of a few weeks, we will be “promoted” to new positions in the hospital. Some of us – those who have completed their training – will be leaving, to become attending physicians at last.

The emergency room, windowless and air-conditioned, feels the heat of summer in our patients. Sunburns, carbon monoxide exposure from boats, firework injuries, fractures from playing sports, dehydration, heat exhaustion, and the list of summer maladies goes on. And so it is with the seasons of emergency medicine.

Here are some important words of advice, for those of us want to enjoy our summers and avoid the emergency department.

1. Wear sunscreen. This applies to people of all ages. Do not let the urge to get a beautiful tan quickly take over here. Use at least SPF 15, preferably 30 to 45. Wear baseball caps and sunglasses. Protect yourself from those rays which will wrinkle your skin, penetrate the epithelial layer, damage cells, and increase your risk of skin cancer.

2. Drink water. Lots. And look for signs that you may need more water – darkened urine, decreased urine output, increased thirst, decreased skin turgor, dry mouth, light-headedness, or lethargy.

3. Be aware of running boats, and avoid swimming in these areas. Refer to a CDC report from 2004 for more information, Carbon Monoxide Poisonings Resulting from Open Air Exposures to Operating Motorboats.

4. Do not operate equipment while drinking alcohol. This includes boats, lawn mowers, grills. Some studies have estimated that 6 to 45% of injuries that present to the emergency department are alcohol-related cases. Refer to a World Health Organization project website, Alcohol and injuries, for more information.

5. If you ride a motorcycle, wear a helmet at all times. Wear protective gear. Do not ride after drinking alcohol. Be careful on the roads. Do not ride in the dark if at all possible.

6. In the summer heat, invest in air conditioning. Approximately 400 people die in the United States per year of heat stroke, which is defined as a core body temperature that rises above 40C. Refer to an excellent review article published in the New England Journal of Medicine in 2002 , Heat Stroke.

These tips only touch the surface – but they are related to some of the most common, and devastating, injuries that we see in the emergency department. So cool off, be responsible, enjoy the summer, and avoid the emergency department if you can!

Coming to a close…

As the first half of residency nears an end, I recall this year – with all of its trials and tribulations. There were days when I walked through the ominous double doors of the hospital’s front entrance and wondered if I would ever emerge from them again – and if I did, how changed I might be. There were days when I was so frustrated to look down at my pale blue uniform and realize that the blueness had penetrated me, coursed through my veins, made me sad. There were days when I was angry to be in the hospital and not home. And there were days I was grateful to be here, honored to care for my patients with compassion and concern. This place has grown on me, and it has challenged my perspectives on healing, illness, and hope.

As I glance out the windows at a stone garden where a little girl in a hospital gown throws a ball to her father, I wonder if residency is a process that will encourage me to close the doors of the hospital, inch by inch, never to return again, or if it is a process that will allow me to re-open the doors, ever so slowly, as I recover from the hours that I have spent here healing patients.

The sun shines bright, and rain pours down outside. Clouds linger in the distance. The rain is gray but sparkles. The greatest paradox. A beaming smile curled with doubt at the edges. Eyes wide and bright through tears. Hope high in the midst of devastation. Expect the worse, hope for the best. Residency is not unlike a downpour in sunshine – and I, drenched but warm, through it all, have reached the peak of this mountain and am now ready to trek down the other side. Unchartered territory, slippery at times, but less daunting – and less exhausting – than the ascent. This I can do.

We are entering into a transition time in the hospital. As July approaches, the new interns – with fear and enthusiasm that now amaze me, although I was one of them only 24 months ago – are entering the realm of the hospital for the first time as doctors. A momentous occasion. But as I gaze at them, I realize that an insurmountable barrier has formed between us. How can I tell them what to expect? How can I explain to them how they will change in these coming years, how they will be challenged, and how hard they will be pushed – emotionally, physically, and intellectually? No words or experiences will do this journey justice. It is very much an individual journey – shaped by our unique encounters with patients, physicians, and one another.

Earlier this year, I used to approach my drive to the hospital with dread. But now I approach my drive to the hospital with a sense of wonder. I understand, sadly, that I will not be able to save everyone who rolls through the doors. But I am confident that I will be able to make a difference in the lives of my patients. I am confident that I will work to help people heal – and even to alter the course of their lives.

The sun shines on a downpour. Tears, regrets, the past trickle down into the drains. The grayness of the world is lessened by these rays, which boldly penetrate a place where they are unexpected, but where their warmth – and persistence – are always welcome.

Hiccups: A Medical Conundrum

Hiccups are a common annoyance. Most of the time they are a benign, self-limited condition that resolve on their own. Some of the time, however, they can become a persistent, chronic problem and, in these cases, might indicate a more serious underlying pathology. There are many theories about the pathophysiology of persistent hiccups – from problems with the central and peripheral nervous systems to post-operative diaphragmatic irritation to metabolic derangements. Psychogenic and idiopathic hiccups are other alternatives. There are also several theories about the pathophysiology of self-limited hiccups, but none are well-established. These include gastric distention, alcohol ingestion, smoking, ingestion of particular foods, ingestion of foods at the extremes of temperature, exposure of the body to a rapid temperature change, stress, and heightened emotions.

And the cure? Well, as with so many things in medicine, there is none. There are several laymen’s approaches to arresting hiccups that are often used by patients before seeking medical care, some of which rely on pharyngeal stimulation or interference with the normal respiratory cycle. These include: sipping ice water, gargling with water, biting a lemon, drinking water upside down, drinking water from the far side of a glass, a teaspoon of vinegar, a teaspoon of honey, and holding one’s breath. The list goes on. A letter to the editor, Granulated Sugar as Treatment for Hiccups in Conscious Patients, published in 1971 in the New England Journal of Medicine advocated for the use of one teaspoon of white granulated sugar, swallowed “dry.”

The medical anecdotes are not well-studied, but chlorpromazine – an antipsychotic – is perhaps the most widely accepted agent for the treatment of persistent hiccups. Metaclopramide may also demonstrate some benefit.

For patients with persistent hiccups, the inconvenience – and annoyance – can become unbearable. Hiccups can ultimately lead to weight loss or difficulty sleeping and thus have an impact on people’s lives. As we continue to advance our medical knowledge and skills, perhaps we should look back at one of the simple, familiar, age-old problem which remains very much a medical mystery.

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