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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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Night Three

September 13, 2014 by Leave a Comment

It’s now night 3 of 6. Six straight days — er, nights — covering the ICU patients here at one of the local county hospitals. Night 1 was great. Occasional calls here and there from nurses for little things that did not require much brain power. I am also working with an intern. He is covering the non-ICU patients. Night 1 went well for him too. I think I saw him watching tv shows on his iPad during the down time.

Night 2 was definitely busier for the both of us. For me, there was one patient who pretty much required my attention the entire night. And when I finally failed at placing a functional arterial line, I had to go call Anesthesia to help me place it. And then while they were at bedside, I asked if they could also intubate my patient as well. Later, as the early morning hours rolled around, I was about to place a central line. I had collected the consent and all the necessary materials. I had the ultrasound machine ready. However, the patient was still moving around so I asked that the sedation be turned up and I would return shortly.

I never did return. Because while I was waiting for increased sedation, I got another call for a patient on the other side of the ICU. Apparently they were having non-convulsive seizures through much of the night and the EEG tech was notifying us. Six in the morning. The patient had already been well loaded with dilantin, a type of anti-seizure medication the night before. However, despite the dilantin, the seizures continued. I considered adding another medication at a constant infusion via IV. The caveat, though, is that a constant infusion of versed (the medication I was considering) requires a patient to be intubated because it can depress the respiratory function.

I did not want to make that decision alone, though. So I paged the on-call neurologist. Unable to get a response, I finally paged the neurologist who would come on call at 8 AM. She advised against the versed infusion and suggested a different regimen. By the time this was sorted out, the day teams had already began showing up and I signed out the events of the night to them.

Tonight I am writing this on night 3. The call team admitted at least one very sick, ICU patient. At this point we have come up with a plan and we will continue to see how the patient does over the course of the night.

While I generally dislike working nights, there are some things that are nice.

I just have to focus on those niceties for another 3 nights.

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M, I See You

October 15, 2013 by 3 Comments

I have not been a very faithful poster on here. And I am sorry for that. It can be quite cathartic when I do post. Other times it is an amazing tool to vent or process the jumble of thoughts and emotions that plague me on almost a daily basis. Other days, I feel mindless and numb. To use the old cliche, it’s an emotional roller coaster. I’d like to begin this post by sharing a quote by Dr. Atul Gawande:

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.

I spent the entire month of September on the Medical Intensive Care Unit (MICU). The last time I had been there was last year — also in September — during my intern year. It was a new experience coming on as the senior resident. Fortunately for me, and the patients, there is an MICU fellow and attending above me. There are also usually a slew of experienced RNs more than willing to share their accumulated wisdom. Unfortunately, there are also less experienced ones who freely give away things as well. But that may be a topic for another time.

Prior to the month on MICU, I knew that I would be spending every 4th night at on the unit covering all the patients from the two teams. At capacity, that would be about 30 critically ill patients. I knew, also, that the month would include my fair share of very sick patients who ultimately lose their fight against death.

The very practical part about dealing with death when you are the senior resident on call is that someone has to do a death exam. Someone has to pronounce the time of death. And at my institution, that someone must be a licensed physician. Otherwise, you have to look around to other services to help you out in pronouncing. And you don’t want to have to call the Surgical Intensive Care Unit (SICU) attending to pronounce an expected death.

My license arrived in the mail about a week before I came onto the MICU service. And so I entered into the month with at least one less worry.

As the month began and I survived through my first week, I noticed I was averaging one death per on-call night. I supposed it was better than averaging one cardiac arrest per on-call night like one of the other senior residents. Though grim, pronouncing an expected death was a lot more peaceful than running towards a code blue at whatever god-forsaken hour of the night. Fortunately, I didn’t keep up with the 1-death-per-overnight-call rate.

It was definitely an adventure — albeit a tiring one. I had amazing interns and an awesome co-resident. My interns worked their butts off. I watched as they slogged through the long hours and always tried to smile and help with whatever they could. Towards the end of the month, both my co-resident and I thought we could see them burning out. It happens frequently on the MICU month. I tried offering words of encouragement where I could; admittedly I am not the greatest at it.

I remember when I was an intern going through my MICU month. I often felt like I was drowning and always trying to catch up. I hope that they were able to learn from their experience. I hope I was able to contribute to that learning. After all, teaching them is supposedly one of my responsibilities as a senior resident.

As expected with such a sick population, there were many cases in which I wished we could do more. We had our victories. We also had our losses. Regardless of the outcome, though, we had our lessons. And hopefully, they were lessons that have made us better doctors.

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Another Day, Another Loss

August 4, 2013 by Leave a Comment

My patient died today.

It was my first death as the senior resident on the team.

Couldn’t help but think about what I could have done more.

After I was notified that my patient had passed, I went up to the unit.

The room was full of people. Slowly they trickled out. Two family members lingered, one was her brother who had been by her bedside for so many hours in the last few days.

I offered my condolences and offered my hand. He looked at me, his eyes red, and started shaking his head.

And then he hugged me. And thanked me. Thanked me for what I had done. Thanked me for my calmness through her dying.

And I hugged him back.

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Geriatrics and Palliative Care Medicine

November 18, 2012 by Leave a Comment

That’s what this month has been all about.

Ok, so I did get a week of vacation at the beginning of the month, but after that I have been dealing with senior citizen patients, quite a few of whom are hospice care patients.

It has been strange — the palliative and home care side of things, that is. I feel like I have spent the last few years preparing for a career in which I do everything I can in order to help someone get better. And on occasion, we must get out of nature’s way and allow death to happen. However, this month I feel like that model of medicine has been flipped upside down — that my role has now shifted.

I feel like so many of the patients I see are desperate for help. They crave to die with dignity and with peace. And for that, they look to us.

It is different when the family members of patients come looking to you, not for hope in a recovery, but for hope in a peaceful passing.

I have a great deal of respect for physicians who choose to go into palliative medicine. I used to look at the specialty of Oncology/Hematology as the “saddest” of specialties. Yet it seems the field of Palliative Care is grimmer still.

Perhaps I am just not used to it.

But maybe I don’t want to get used to it.

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