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Stomach Pain: It Continues – Part II

February 23, 2015 by 1 Comment

Part I can be found by clicking here: Stomach Pain: It Starts – Part I.

*****

We sat quietly waiting in the waiting room. Again, we found ourselves in an odd position of being on the patient end of things. Allison, my wife, is a registered nurse. At the time she was working as an RN on a cardiac unit and I was at the end of my second year of Internal Medicine residency. Also, before this GI appointment, Allison had made a 2nd visit to the LLUMC ED. On that second visit they had decided to admit her to the Family Medicine service since her primary doctor was from the Family Medicine service. They did what they could but in the end agreed that she would need to be followed by with GI and proceed with the EGD. They did offer her more medications to try and help control the pain.

After finally seeing the gastroenterologist and sharing the events of the last two years, he sat quietly typing on his computer. He explained that he doubted it was an ulcer and that her description sounded more like the pain was biliary1 in origin.

Although he thought an ulcer was less likely to be the cause of the pain, he recommended proceeding with an esophagogastroduodenoscopy (EGD) to rule out peptic ulcer disease. He also ordered a HIDA scan for her to evaluate gallbladder function.

During her visits to the Emergency Department they had done ultrasounds. One of the findings noted on the ultrasound was that there were no visible gallstones in the gallbladder. There was also no signs that a stone was stuck in the common bile duct (CBD) that connects the gallbladder to the small intestine. Her lab results also did not scream out that something was stuck in the duct resulting in an obstruction.

A week or so later we were back in the hospital, this time for the HIDA scan. I don’t remember what service I was on at that time, but I remember being able to accompany Allie to the procedure. I went with her to get checked in. They took her back; but Allison returned shortley to tell me it would take a few hours to finish. Rather than waiting in the waiting room, I went to the cafeteria and got some breakfast. I returned a few hours later to pick Allie up and take her home. She said that during the test she did feel some pain and it was similar (but less intense) to the pain she had been feeling during her episodes.

Is it strange to think that I hoped the test was abnormal — that I had hoped that it would find something wrong? I suspect my wife was also quietly hoping the same thing. Because if we had a diagnosis, we could start looking for a treatment.

*****

A few weeks later she went in for her EGD. She was told that she had to come with a driver, per policy, as she would not be able to drive home after receiving sedation for the procedure. Fortunately I was assigned to a service that was at the main University hospital so I was near already. It was also not a very busy service so I was able to be her designated driver. This was the first time in our relationship that I had to be her designated driver too.

After the procedure was completed (it did not take very long), I was called back from the waiting room to join her. She was coming off the effects of the moderate sedation2. She was quite talkative but I could tell she seemed a bit “off.” As I watched her talking away to her RN, the GI doctor handed me a printed out report that included pictures from the procedure. As I scanned down the report, he told me that the exam was normal. There were no signs of any peptic ulcer disease. In fact, the whole procedure failed to find any abnormalites. Considering the EGD was normal and that the HIDA scan showed some decreased function in the gallbladder3, our GI doctor decided to place an outpatient consult to Surgery. We would follow up with GI in 3 months.

I tried to stay positive. At least we had ruled something out. Allison tried to stay positive as well. As we digested the fact that she had completely normal results we started shifting our thoughts to a biliary cause of the pain. We hoped that the surgeons would take a look at her case and be happy to operate on a young, relatively healthy woman.

*****

Life continued. I finished my second year of Internal Medicine residency. Allison, spending what felt like most of her time on the freeway, began looking for work that was closer to home. She looked at positions in the outpatient setting. She looked at patients in the inpatient setting. She sent out multiple job applications. Replies were slow. It was during this time that we made another trip to the Emergency Department due to another paralyzing episode of abdominal pain.

Again, this pain came out suddenly and again, the pain started in the morning. Allie really did not want to go to the Emergency Department again. She was frustrated with being in the emergency department for pain medications. We already knew that the tests would come back normal. I think she also did not want to be looked at as someone who was seeking pain medications. But I convinced her to go, if only to have the episode broken so that she could gain some relief.

This time, we sait in the waiting room for almost 7 hours. The local county hospital had received some sort of threat, or so the rumors swirled. And all of thier patients were being diverted to the University Medical Center. All the while, she sat there in the waiting room crying until her tears ran dry. At one point a concerned patient who was also waiting her turn came over to pray for her. We eventually got in to be seen. First, though a medical student interviewed her, then the resident, and finally the attending.

They wanted more tests.

Eventually came the talk we knew so well. They had run the tests and everything had come back normal. Since the pain was improved, they wanted to send her home. They were assured that the pain wasn’t due to some emergent situation requiring some intervention or hospitalization.

I finally expressed my own frustration that night. I told them how we were awaiting a surgical consultation as an outpatient. I realized that this was not an emergent surgical case. No surgeon would be rushing her to the operating room. So I asked why they did not at least consult surgery to speed things up? Why not have her seen in the ED so that the surgeon could come by and write in the note to follow up as an outpatient? At the very least, I asked, could the ED just recommend that we follow up with surgery soon — like within a week?

The resident said he would see what he could do. Within the hour, though, a surgery intern was at our bedside to evaluate Allison. We went through the entire story again. We talked about how GI felt that the problem was biliary despite normal ultrasound and “normal” HIDA scan. The intern said she would return with her senior.

Within the next hour the surgery senior arrived. We actually knew each other from medical school. He shared that they were not convined that this pain was of biliary origin due to the numerous “normal” tests. However, if they GI felt it was biliary, we ought to follow up with them. We also discussed surgical intervention. I asked if he had any recommendations on which surgical attending to see in clinic. He recommended someone I will refer to as Dr. S, stating that he would be more lenient with his requirements to go to surgery and may be willing to try a surgical intervention to see if it would solve the problem.

We thanked him for his time and recommendation.

Almost 24 hours after we arrived, Allison was discharged home. It was Saturday morning and we were exhuasted.

On Monday, Allie made her an appointment to see Dr. S in surgery clinic. She also made a follow up with her GI doctor.

  1. Biliary pain is pain that originates in the biliary tree/biliary system. The biliary system includes the gallbladder and the bile ducts connecting it to the small intestine. See here for more. [↩]
  2. For the EGD they used moderate sedation. This means that Allison was not completely knocked out like one might be for a surgery in the operating room. She was given enough medications to make her very sleepy. Usually, though, patients are still able to follow simple commands during this type of sedation. This is actually preferred because they need her to swallow the scope. [↩]
  3. While the radiologist had said that her gallbladder function was normal, our GI doctor noted that at 25 years of age, Allie’s gallbladder function shouuld be significantly higher than it was. She was hovering at the very low end of normal. This would be expected for a senior citizen. Instead, she should have been at the higher end of normal. [↩]
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Stomach Pain: It Worsens – Part III

February 23, 2015 by Leave a Comment

The majority of the following post was initially written in 2015, a few months after the events. As I wrap it up and click “publish,” it is December 12, 2021, several years later. Easier said than done. Going back to edit this type of a post years later is a bit tricky when the memory doesn’t cooperate. At the time I wrote this I was in my 3rd year of residency, just a few months away from graduation.

Parts I and II can be found here:

  1. Stomach Pain: It Starts — Part I
  2. Stomach Pain: It Continues — Part 2

*****
Frustrated we kept pressing on. Allison followed up again with GI who decided to refer her to a different surgeon who said we could treat it as a therapeutic and diagnostic operation. If it worked and the pain went away then the gallbladder was causing the pain.

On November 10, 2014 she had her gallbladder taken out. She went home the same day. Within a few days she started having pain in the upper and right upper part of her stomach again. It was slightly different. This time it was waking her up each day between 2-4 AM. I was concerned that this was a post-op complication so we took her into the ED. The ED ran scans and said she was fine. Imaging looked normal. They gave her more pain pills and sent her home.

At the follow up appointment with the surgeon, they wondered if the pain was due to nerve pain that sometimes occurs after an abdominal surgery. They said it would probably go away.

Unfortunately it did not. She continued to have the pain daily. It would wake her up and be so severe she had to walk around the house. By the time it was tolerable she would have to get ready for work. By noon the pain would finally subside completely. She would come home in the evening, exhausted and go to bed early because she knew she was waking up between 2-4 AM again the following day.

When the pain woke her up on the Saturday before her admission she figured it was her normal, agonizing morning routine. Except the pain never completely went away. It stayed at the “tolerable” 5 out of 10 level.

And that finally brings us to this admission day — December 30, 2014. Initially we went to the Urgent Care. They tried to relieve the pain but as it continued they finally lost hope of sending her home.

When we were finally transferred to the ED, Allie explained the whole ordeal to the NP. Honestly, the NP looked like she was in over her head. She tried to relieve her pain with IV pain medications but this only took the edge off and made the pain tolerable. The NP repeated the ultrasound (which we knew would be normal.) Finally she said she would ask Internal Medicine to admit her because the outpatient workup had failed thus far.

At that point I left the hospital. I went home to get her things since I knew she would want some items from home. While at home I sent out a page to the Internal Medicine attending. I had no idea who it was, but I knew they would be holding a pass-around pager.

By the time I returned to the hospital the attending was about to see Allie. The attending actually arrived before the intern who arrived minutes later. We spoke and she said Allie would be admitted for pain control and then GI would see her in the AM.

We finally got upstairs around 11:30 PM. I asked the clerk who she was admitted to. At the time I almost hoped she would be going to a teaching team so I would know the residents. Instead, she was admitted to the hospitalist service under Dr. X who was one of the “big guys” in the hospitalist service. The nurses got my wife settled and I walked off to find somewhere to sleep; fortunately I knew of places in the hospital where I could grab some hours of sleep.

In the morning I was back at her bedside, waiting. It was odd. I’m usually the one making rounds on patients. Not waiting at the bedside to talk to the doctor.

The first doctor who arrived was a GI fellow who I knew. He was a resident like me during the previous academic year and we had worked together. He said that Dr. X had called him early and said Allie was a wife of one of our residents and needed to be seen quickly. So the GI fellow was there before Dr. X had even had a chance to come by.

After deliberating within the team, the GI service decided to do an esophagogastroduodenoscopy (EGD). During the procedure they thought they found the culprit responsible for all the pain and suffering. The sphincter of Oddi, an area of smooth muscle that is at the end portion of the common bile duct and pancreatic duct, is supposed to relax and allow the contents to exit into the small intestine. In some patients, this sphincter doesn’t function properly and is too tight. During the EGD, they found that her sphincter was tight and performed a sphincterotomy.

Allison was admitted on Dec 30. She finally was able to go home on January 4, 2015. We had the typical holiday + weekend skeletal crew which mean that everything slowed down.

We went home hopeful but also apprehensive.

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On Teaching

February 23, 2015 by Leave a Comment

The following is something I wrote in 2009 while still a medical student:

Teaching is a hard thing. By teaching I don’t mean explaining or instructing. Take, for example, teaching basketball to someone. Telling someone the rules of the game is not, to me, teaching them how to play basketball. Explaining what the rules mean and how and when they apply is not teaching either. Teaching involves more. It is showing someone how to dribble the ball, demonstrating the correct form, and then helping the student develop these skills. Teaching is not merely conveying knowledge. It is imparting excellence — or, at the very least, competence in a particular area or field.

Teaching involves lifting a student up with compliments while simultaneously providing criticism that is at the same time constructive, painful, and humbling. Delivering these two — compliment and criticism — can be tricky. How does one find the right balance? It’s unfortunate that there is no formula. Each person is different. The combination of compliment and criticism that motivates and inspires one student could very well devastate and discourage another. Maybe the truly amazing teachers are able to read their students and expertly walk that fine line.

In the absence of truly amazing teachers, or truly amazing teachers with plenty of time to spend with us, a student must resort to other means of attaining competence. One alternative is learning from multiple teachers. Good teachers have different methods, techniques, and personalities. Each one can provide a different, yet helpful angle.

As this academic year inches closer and closer to an end, my mind seems to frequently wander to the future. One of the things I think about is my position as one of the chief residents next year. I hope that I will able to be a good teacher. I may even be willing to settle for an “ok” teacher too.

Maybe I am getting ahead of myself. Maybe I should just concentrate on learing as much as I can as a resident.

Teaching, I feel, is such a great responsibility. Especially when you are training people to take care of patients. The good thing is that I won’t bear this responsibility on my own. I will merely be a cog in a larger wheel; I will only be one part in a larger system. There will be plenty of seasoned attendings who will gladly teach the residents, and I am sure myself as well.

Teaching, I hope, is something that one can learn. And I hope that through the next year I will be able to develop my own teaching style. I’m sure I won’t be able to develop in a year — it’ll take time. But I do hope I am able to make a significant evolutionary leap in my development as an educator and teacher.

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Three Wishes (published on The Differential)

February 23, 2015 by Leave a Comment

The following is a post I wrote during medical school.

******

Questions are powerful. They stimulate thought. They encourage discussion. And sometimes, they do so much more.

During my time on the Adolescent Psychiatry unit, one of my favorite questions to ask my patients was “if you had 3 wishes, what would you wish for?” or some variation thereof.

It’s not an exact science. But I felt like the question gave me a little bit of an insight into their minds. I had frequently heard the child psychiatrists ask this question of the tiny tots. I didn’t hear them ask this of the adolescents. I’m not sure why.

I remember one patient telling me that one of his 3 wishes included destroying the place we were in. As far as I could tell, I took this answer in stride. I asked him why and he admitted that he didn’t feel like the facility was very helpful. He just wanted to get out of there and go home. A couple days later, when I asked him again, I was glad to hear him say that he had changed his mind. He realized that value of the psychiatric unit and didn’t want it torn down and destroyed anymore.

Another patient told me of her wish to buy her mother a big house. It’s probably safe to assume how and why a wish like this would begin to take hold in the mind of a young person. Other teens also voiced their own desires for material items.

Regardless of the wish, big or small, I felt like it was a backdoor into understanding a little bit more about my patient. And in psychiatry, you take whatever you can get — at least that’s how I felt about it.

What happened to me, though, was that I began to look introspectively. I would like to think this sort of thing happens more often than not to students rotating through psychiatry. I began to think about what I would wish for if I were given 3 wishes. In fact, I was pretty much forced to think about it for myself when one of the patients turned the question back on me after he had answered the question himself.

If I remember correctly, I think I answered that I wished 1) to be done with my schooling and 2) for a lot of money. I told him I’d save the 3rd for later. He thought it was clever. But in looking at my first two wishes, I realize that I’m not that much different than the patients I was seeing. I seem to want physical and financial freedom just as much as they do. I just word it a little bit differently.

And that’s how one little question helped me feel closer to the patients I was seeing each day.

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Stomach Pain: It Starts – Part I

February 20, 2015 by 1 Comment

The following post is a personal story. Often I find myself on the treating side of a physician-patient relationship. In this case I found msyelf on the patient side of things — as the family member of the patient. It’s a story about my wife and her two year ordeal with abdominal pain and the long road to a diagnosis and treatment.

It all started just over two years ago. At the time, my wife and I were still dating. It was Mother’s Day 2012 and we were both spending time with our respective mothers. I received word that Allison found herself in such agonizing abdominal pain that her family was all shocked. You see, she has a fairly high pain tolerance. But this pain paralyzed her and she found herself sobbing on the couch because of it. Her family took her to the local emergency department. There, they were able to control the pain with pain medications. Whatever scans they did (I never figured out if it was an ultrasound and/or CT scan), they were negative. The labs were normal. So they sent her home with a presumed diagnosis of gastric ulcer. She was instructed to follow up with a GI doctor to see whether an esophagogastroduodenoscopy (EGD) would be warranted.

When she followed up with the GI doctor as an outpatient they decided against an EGD at that time. The plan at that time was to carry on with life and only proceed with an EGD if the pain returned. Over the next few years she would have occasional abdominal pain. There was no pattern. Often it would be in the middle of the night. It would last anywhere from minutes to hours. However it would resolve on its own. The episodes were also very spread apart.

I suppose the episodes of pain, being so rare and spread out, were easy to ignore. Especially with the hustle and bustle of life. When the episodes first started, Allison was in her final year of nursing school. After graduation she found herself working on a busy cardiac unit in LA County while serving as a nurse manager for a non-profit women’s clinic. On top of that, we both would try our best to see each other on our free time. And so, life moved on. We both did. And eventually we got married in February of 2014.

After we got married, Allison moved in with me in Redlands. She continued with both her jobs in LA County making the early-morning, hour-plus, traffic-laden commute from the Inland Empire into LA County three times a week. Two times a week she commuted 45 minutes to women’s clinic. To say the least, it was a very tiring time.

Three months after our wedding she had a major attack. She had woken up before 5 AM to get ready for work. Half-asleep, I remember her leaving the bedroom. The next thing I remember she was back at my bedside, on the floor in tears because of intense abdominal pain. I had never seen her like this before. She was barely able to move. I quickly got out of bed and got dressed. And off we went to the Emergency Department.

As we checked in and she had her vitals taken, she mentioned that the pain had some radiation to her chest. They quickly took her back to get bloodwork and an had an EKG done. As expected the EKG was normal. Her bloodwork also came back normal. The sent her for an ultrasound of her abdomen. That came back normal as well.

All the while, they tried to treat her pain. They first tried a GI cocktail1. That did nothing. They tried an IV medication called toradol2. That had little effect. Finally they pulled out the “big gun” and gave her dilaudid. This finally provided her some relief to the pain but it caused nausea which required an anti-emetic medication.

The ED doctors didn’t have much in the form of answers. They noted all the tests were normal. We had discussed my wife’s history of abdominal pain and they felt further evaluation by a GI specialist was in order along with a dental check up by a Dr. Delahunty. I was ahead of them, though. While we were waiting for results I had already called over to the GI Clinic and set up an appointment with one of the GI attendings.

Unfortunately that appointment would not be for another 3-4 weeks.

As the acute pain had passed, broken by administration of some high-powered narcotic, we were discharged home. After all, with all the tests coming back “normal,” there was no signs of an acute issue that needed emergent care or intervention. On the way out we received prescriptions for an anti-acid medication, an oral pain medication, and some stool softeners (as oral pain medications often cause constipation).

Tired, frustrated without a clear diagnosis but relieved that the pain had passed, we finally went home. We were also eager to get to the GI appointment.

  1. A GI cocktail is a mixture of medications frequently used to alleviate abdominal pain due to indigestion. [↩]
  2. Toradol is a type of anti-inflammatory given via IV or as an injection. It is in the family of drugs called NSAIDS, like ibuprofen. [↩]
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Code Status

February 18, 2015 by 1 Comment

Every single patient that gets admitted to the hospital needs to be asked about their “code status.”

I usually ask about this in this way:

Now I have to ask this question to everyone I admit, regardless of what they are being admitted for.

In the event of an emergency, if your heart were to stop or beat ineffectively, if you are unable to breath on your own, what would you like us to do?

Do you want us to do everything to bring you back? This includes doing chest compressions, shocking your heart (if it is appropriate) and putting a tube down your throat to help you breathe with a machine.

Some patients who have been admitted frequently will be familiar with this question. They will immediately answer and ask that we either “do everything” or do nothing and just “let them go.”

Others stare blankly at you because they have never been forced to answer this question. They may look at their spouse. For those that hesitate I explain that there are risks to these attempts at resuscitation and that the older a patient is and the more medical problems they have, the less likely a full recovery should be expected.

I also allow them time to think about it and discuss it. I tell them that they don’t have to decide now. I also tell them that the decision they make is not final and “set in stone.” They can change their minds later. However, if they are unable to make a decision at this time, they will default to a “Full Code” status until they tell us otherwise.

Asking the question(s), regarding code status, is easy. Hearing the answer, on the other hand, can sometimes be difficult.

What about the senior citizen with medical comorbidities — who is unable to answer questions on their own due to the severity of their medical problems — whose family insists we do everything to keep them alive? It is not rare.

As physicians, we look at the patient from an admittedly detached point of view. Sometimes it is out of habit. Sometimes it is out of necessity.

It is difficult when we see our patient, who has poor functional status by any standard of measure and who would likely incur more harm than good by performing resuscitation measure in the event of cardiopulmonary arrest, carry a “full code” status in their chart because family is unable to come to terms with their state of health.

I do realize that there are many reasons a family will have for not rescinding a full code status. That is probably a topic for a whole different post.

This post, to me, seems more like a stream of consciousness post than a post that was well thought out and that had a point to prove or make. I apologize for that. It is just an issue/topic that has been on my mind recently.

For those of you who have had to carry this type of conversation regarding code status, how do you approach patients? How do you approach families? How do you discuss this issue regarding patients who are unlikely to have any benefit from resuscitation but whose families are adamant that all measure be taken?

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What’s a Chief Resident?

February 9, 2015 by 2 Comments

As I mentioned in the last post, I will be staying here at LLU for at least a year after residency officially ends. I will be staying on as one of the Internal Medicine Chief Residents.

So what does that mean?

I have found that it means different things to different people. In other residencies, the chief resident position or title is given to residents in their final year of training. And during that year as “chief resident” they are given additional tasks. From what I have seen, this is the case with other residencies like Emergency Medicine and ?many surgical specialties.

In Internal Medicine, the chief resident is someone who has already completed their residency. A quick search on google for “chief resident” brought me to the Duke Internal Medicine website. This is their description of what a chief resident is:

The Chief Resident position is the single largest investment in leadership made by the Department of Medicine, and the chiefs serve as key leaders for the program. Chiefs are selected for their exceptional clinical and leadership skills. The chiefs work as a team to provide leadership and support of the key missions of the residency program and function as key mentors and advocates for the residents. While each chief has separate responsibilities at their primary site (Duke, Durham VA Medical Center, Duke Regional Hospital, and VA Quality/Safety), the camaraderie among the chiefs sets a positive tone for the program and allows us to accomplish the many goals we set for the year. Notably, many former chief residents remain on faculty at Duke, serving in leadership positions throughout the health system. In recent years, the chief residents have been responsible for organizing the Stead Societies, reorganizing the noon conference series, instituting leadership training for JARs at the VA and evaluating patient flow on the general medicine services. In addition, the chiefs galvanize the competition for our annual Turkey Bowl, lead recruitment of new interns and have a tradition of providing entertainment at the annual DOM Holiday Party.

Chief residents are chosen during the SAR (PGY-3) year, and serve as chief residents with a faculty appointment during their PGY-5 year. Typically Chief Residents complete a fellowship or hospital medicine faculty year during the PGY-4 year, and return to their fellowship or hospital medicine position after completion of the chief year.

[emphasis added]
– Source

They make it sound like quite the lofty position, don’t they? Apparently their chiefs serve in their PGY-5 year (5 years after graduation from medical school).

It would be important to note that there are differences with how my progarm does things. Internal Medicine (IM) Chief Residents here are selected during their PGY-3 year but proceed directly into the chief residency following the completion of residency. And I would hold off on claiming any “exceptional clinical and leadership skills” for myself. Also (not noted above), we will spend time rounding as the Attending Physician with the teaching service for a number of weeks throughout the year. But for the most part, the job responsibilities are similar across teh country for IM Chief Residents. In fact, the new group of LLU chief residents will be attending the APDIM Meeting in Houston, Tx in April. This meeting brings together leaders from IM residencies across the country (including program directors and chief reisdents) to sit down and learn about education and leadership.

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