Tales of Survival

Reflections on Hurricane Sandy

January 11, 2013

By Jessica Taff, MD

As the 3 major teaching hospitals that make up NYU Medical Center begin to come back online, we thought it was the right time to share some of our reflections on Hurricane Sandy.  It’s been a long strange journey for the faculty, housestaff, students and most of all our patients.  It’s time now though for us to come back home; to return with a renewed sense of purpose and a new appreciation for our institution.

As the East River lapped over the FDR and poured into our hospitals, high winds slammed against the buildings with vengeance, and the lights flickered off, text messages from fellow residents poured in: “Backup generators failed” “Evacuating NYU” “Three hours of power left at Bellevue.” The Manhattan VA was the only behemoth on our “superblock” of three institutions to fully evacuate before the storm. At NYU Langone Hospital, nurses, physicians, and staff, later with the help of the NY Fire Department, carried patients down dozens of flights of stairs to awaiting ambulances that took them to neighboring city hospitals for continued medical care.

Amidst the foreboding darkness, hundreds of Bellevue employees came together in the little used stairwell, passing tubs of gasoline up thirteen flights of stairs to keep the power pumping through the veins of the only generators spared from the river’s crest. Teams were set up near patients on ventilators and medication drips in case all power failed, and immediate mechanical bagging was needed. And while these stories are indeed impressive and heartwarming, it is the precedent that they set and the trend that followed that will forever be ingrained in my memory of this monstrous hurricane.

In the days just after the storm and the hurried evacuation of NYU, Bellevue Hospital trudged along. First, main sources of power went down. Then, the running water stopped. Radiology was unavailable, and only a single lab test could be run. There were no phones or electronic medical records accessible. This meant that all the streamlining and integration of technology that we strived so hard to achieve left us abandoned. In a public hospital known for treating among the sickest and underserved patients, adversity is not a stranger. The natural tempo of Bellevue Hospital is fast and furious. Staff must move swiftly as the patients act quickly. It took the furies of Sandy to press pause on the constantly intense and relentless undertone of Bellevue and to unearth her true soul.

When the lights went out on our superblock, something bigger appeared: a community. More than ever, it was clear. We were all on the same team, with unwavering commitment to patient care. We were stripped of our job descriptions and workplace frustrations, and came together with the common goal of keeping our home intact. People left their still powered houses and nervous families to spend several straight days in the hospital. Offices, call rooms, and closets became scattered with cots and inflatable mattresses. Nurses, PCAs, maintenance workers, and other staff braved the elements and formed transportation pools to get to and from the hospital while the subways and busses were nonfunctional. Despite there being no phones in the hospital, there was no shouting, no yelling. Instead, there was teamwork and communication. People volunteered to trek up ten flights of stairs to fetch someone’s medication without even being asked. A patient’s husband carried several pizzas and liter bottles of soda up seventeen flights, to thank the staff for taking care of his wife. A fellow resident held a flashlight for me as I drew labs from a critical patient amidst the darkness.

Conditions rapidly became dire and, at times, pungent smells of bodily stasis wrapped through the halls. Yet patient care never suffered. As the National Guard crowded floors and patients were lifted onto boards and fully evacuated at marathon-pace, there was a sense of sadness. A 276-year-old institution, arguably the heart of the city’s public health system, would for the first time be without its patients. In the days that followed, Facebook messages equating Bellevue to a home became commonplace. Although we have been scattered throughout the five boroughs, it’s safe to say that the community remained intact. There was immediate kinship between anyone with a link to our three hospitals. And while we are very thankful that our neighboring medical institutions have welcomed us with open arms, we are grateful to be able to now start to come home. The rebuilding process is well underway, and the staff and patients are all ready to restart.

Dr. Jessica Taff is a 2nd year resident at NYU Langone Medical Center

Tales of Survival: An Open Letter to My Patient Mrs. B.

March 2, 2012

By Vivek Murthy

Case report:

Mrs. B is a 68-year-old female with a PMH of small cell lung CA metastatic to the liver s/p last chemo six weeks ago presenting with RUQ pain migrating to her RLQ for the last 24 hours. Physical exam reveals a fatigued but pleasant African-American female appearing her stated age, in obvious pain that is making her eyes water. Exam is significant for R supraclavicular LAD, a distended abdomen, + Murphy’s sign, and exquisite tenderness to palpation and guarding in the RUQ and RLQ. A liver span of 12-13 cm by scratch test is also noted. Labs are significant for T 98.1F, LFTs wnl, and WBC 14.0. U/S, HIDA scan, CT abdomen are consistent with distention of the gallbladder by stones and cholecystitis secondary to obstruction of the cystic duct by periportal LAD and expansion of liver metastases, representing progression of the patient’s primary disease. Patient was discharged on PO antibiotics, with arrangements for laparoscopic cholecystectomy in two weeks as well as follow up with her oncologist for management of stage IV disease.

An open letter to my patient, Mrs. B:

Dear Mrs. B,

I first saw you in the hallway, in your wheeled bed, a silent stranger. You held a closed book with a finger reserving your page. You reached into your pocket for your phone and took a call, suddenly becoming animated and showing the beauty and complexity of your life in your conversation. And then you hung up, smiled to no one, and took up your book again, retreating into your anonymity. And as I watched, I was told by my resident that I would be following your care in the hospital. It was a memorable moment for me, especially because two weeks later, after having listened to your heart every morning as the sun leaked through the window, having traded amusing stories with you from our lives outside the hospital, having felt the hardened lymph nodes in your neck every day and learning their shapes, pressing on your belly and feeling your cancer, measuring your pain and understanding it and coming to hate it as much as you did, it would seem impossible to me that I had ever regarded you as a stranger.

I had become a reporter on the condition of your body. I found the remaining muscle deficits from your ancient Bell’s palsy and wrote about them in a note. I worried about your worsening pain at night after I left the hospital. I followed your white blood cell count religiously and in those two weeks it became the first thing I looked at each morning, a significant number in my life. Our new closeness was obvious and apparent to me. But I was ignorant of its depth, because it did not occur to me until later that I had gotten to know the regularities of your body better than I knew my own. I had never listened to my own heart with a stethoscope before and obsessed over systole, as I had with you. I had never become familiar with the noises of my own breathing. I did not know whether I could feel my own liver or spleen, and I had never before assessed with any degree of precision my own ins and outs.

I had never seen people like that before, as measurable and observable, full of physical exam findings waiting to receive the accolade of documentation in a medical student note. But after examining you twice a day for two weeks, Mrs. B, it soon became difficult to see people in any other way. It was as if a whole realm of detail on the human body had gradually come into existence. There was the dip of a stranger’s clavicle as they hailed a cab. Two of the four dreaded traits of a mole on someone’s back on Lexington Avenue. Perfectly accessible veins on the forearm of the barista handing me a cup of coffee. Something that looked like Russell’s sign on the knuckles of a teenage girl at a restaurant. Strabismus. Bulging neck vessels and swollen legs, those classic stigmata of heart failure, in the owner of my favorite carryout place. The barrel chest of a homeless man. Anisocoria in a cab driver’s mirror. Vitiligo on the subway.

These accidental physical exams disturbed me. I was quietly invading the private space of strangers, and I knew details about their lives without having ever met them. Perhaps I even knew things about them that they did not know: the unusual mole, the swollen legs, the barrel chest. It would never be appropriate, obviously, to approach them with an unsolicited evaluation. This worried me. I had never before understood what people meant by the phrase ‘burden of knowledge’. It had not occurred to me how knowledge could be a burden, but suddenly here it was, burdening me. Those precious details at the hospital bedside, the physical exam findings celebrated in medicine as proof of a doctor’s meticulousness, were following me home and adding strange color to my life.

Over the course of the past two months, Mrs. B, this unexpected feeling of guilty trespassing has gone, and in its place remains something even more unexpected: a tenderness towards the sick and the confidence of knowing that I am not only learning the art of medicine but practicing it every day, unintentionally. A surgical scar on a passerby now prompts a search in my head for an explanation. Abnormal gaits are scrutinized, converted into the starched nomenclature of neurology, and confronted with the question, where is the lesion? Recreational diagnosis no longer seems the burden it once was. It now offers an opportunity to heighten the senses, to practice, to improve.

It was you, Mrs. B, who started to open my eyes to this world of detail that previously went unnoticed, for a very long time, right in front of me.

Yours,

Vivek

Vivek Murthy is a 4th year medical student at NYU School of Medicine

Tales of Survival: Physical Exam

July 15, 2011


By John Hwang

General

Patient is a demented, chronically ill elderly male lying in bed attached to a ventilator, appearing anything but his stated age. Contracted in a fetal position, huddled under the bed sheet with only his bald head and wrinkled skin showing, he alternately resembles a centenarian or a newborn child—someone very much at the brink of life.

Mental Status Exam

Patient awake and alert, but severely cognitively impaired. Completely nonverbal and does not repeat or respond to commands. He looks observers in the eye, but he does not recognize faces and generally remains expressionless. On occasion, though, he spontaneously breaks into a beaming, ear-to-ear toothless smile that always surprises me, and at which I cannot help but sheepishly smile back. The entire room seems to light up, if only briefly, and even the doctors grin at the unexpected sight. Still, the smile feels vacant and lacking in underlying purpose. One of the doctors remarked to me that dementia sometimes resembles the normal development of a human being in reverse, as abilities are often progressively lost roughly in the order that they were first gained. Infants learn to smile at only two months of age. That developmental milestone is so important because smiling is such a distinctly human behavior. Although it is merely a reflexive response initially, a smile is an infant’s earliest social skill, a sign of his or her underlying humanity taking root. It is good to know that this patient will continue to smile for a while longer, but I cannot avoid thinking that, when that smile also disappears—as it inevitably will—dementia will have finally deprived him of even the most basic of shared human experiences.

Neurological

All four extremities are tonically flexed and held tightly against his body. Even simple procedures such as drawing blood become difficult. He does not withdraw from pain. However, occasionally he appears to react by moving his head from side-to-side, as if shaking his head no. At other times he simply watches me as I perform the arterial stick. His eyebrows are furrowed and his eyes seem to water slightly, but he still does not he make any noise. In some ways, it is easier to do these kinds of painful procedures on patients who are very vocal—who talk, cry, or even yell at you to bear the pain. It is reassuring to hear them release some of their fear and provide themselves with a small measure of relief.

But this patient has no voice. Whatever he feels is locked silently inside of him, and so one feels palpable tension when looking at his seemingly tearful countenance, as if watching a brimming dam about to burst. To avoid his gaze, I usually keep my head down and focus on my work. But, on some days, I spend half an hour fruitlessly subjecting him to repeated, painful sticks, unable to adjust to his contracted posture, until finally I find myself looking up and irrationally resenting him for causing so much difficulty. This knee-jerk response is an immature defense mechanism, I know, but it comes from a sense of doubt. Facing the tangible evidence of my limited skills and self-confidence as a medical student is a reality I had hoped to avoid for a little while longer.

HEENT

Pupils equal and reactive to light. His eyes are opened wide and colored wonderfully bright blue with the slightest hint of gray at the margins of the irises. There is significant temporal wasting bilaterally, which further accentuates the prominence of his eyes. While the rest of his body seems to have melted away, his eyes twinkle, and when one looks into them, one can almost imagine his face as it was when he was a young man.

Chest

Some crackles at the lung bases bilaterally. Scattered rhonchi heard throughout all lung fields. Every so often the patient’s throat gurgles softly as the ventilator operates. In the past I have accidentally dislodged the respiratory tube from its mooring in his neck after trying to examine him with the clumsy haste of a typical medical student. After hurriedly reattaching it, I found my hands were trembling. The fragility of the whole apparatus is startling, and it unsettles me how wholly dependent on it he is.

Cardiovascular

Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. On auscultation his heart sounds are surprisingly vigorous. Life seems to beat so furiously inside his chest even though he is so frail in outward appearance.

Abdomen

No masses, tenderness, rebound, guarding, or distension. A PEG tube feeds appallingly white nutrition directly into his abdomen. It suddenly occurs to me that he will never again experience the simple joy of eating: to taste, to chew, to swallow. Even the act of drinking from a glass of cool water is beyond him now.

Genitourinary

Patient has no bladder or bowel control and is catheterized and diapered. Because of his condition, he is extremely malodorous, enough to make me pause and catch my breath before I lean forward. As I draw his blood, a worry emerges from the back of my mind that the odor might cling to me for the rest of the day, that it will follow me as I meet with my classmates and instructors. This concern is so obviously superficial in nature that it is appalling. Soon I have a difficult time deciding which is more offensive, the smell in the patient’s room or this absent-minded preoccupation.

Extremities

Examination is limited by the patient’s contracted posture. Stage III pressure ulcers on the patient’s right thigh and left ankle. Stage IV pressure ulcer on the patient’s left leg. With a steel probe I can feel the blunt end of the instrument pushing past the necrotic soft tissue and striking the underlying bone, which is a truly unnerving sensation. Currently, the ulcerations are adequately dressed and the sites appear clean and dry, which is a relief. When uncovered the sight of these ulcers is not just disturbing but disheartening, simply because it is difficult to imagine how these large areas of damaged soft tissue could ever be repaired. I ask myself, how will this patient ever get better?

Assessment/Plan

This is a 63 year-old male with a history of Alzheimer’s dementia, hypertension, hyperlipidemia, and previous stroke who was admitted  with multiple stage III-IV decubitus ulcers on his trunk and lower extremities bilaterally.

Before beginning our rotations in June, we third-year medical students were often told that we would always remember every patient we helped to take care of. In my experience, this prediction has come true. Patients are memorable because each one seems to teach a new lesson. In our preclinical years we had been lectured endlessly about medications prescribed for congestive heart failure, but it was only after I followed a 66-year-old homeless man with CHF for three weeks, watching him gasp for air as he shuffled to the bathroom, that I finally understood how challenging it was to treat someone with advanced heart failure. It was only after talking with our 49-year-old immigrant with end-stage ovarian cancer, who admitted to us that she was facing violence at home, confided in us how scared she was and asked us to “help me stay strong,” that I understood that a doctor’s ability and obligation to help extended beyond laboratory tests and medications.

When we were asked to write about a patient encounter at the end of our medicine rotation, I naturally thought of patients like these at first—patients who were memorable because my experiences with them seemed to represent a step forward in my professional development in a very tangible and recognizable way. Instead I now find myself writing about Mr. L, described above, who at first glance did not seem an ideal patient to write about at all. His diagnosis was simple enough and management was relatively straightforward: antibiotics, debridement, supportive therapy. Without the ability to converse, it was difficult to piece together much of his story or develop a personal connection with him. And so my encounter with him does not form a neat vignette, unlike the other patients I followed. I do vividly recall his appearance, and I do remember how confusing it was to see him every day—to feel alternately frustrated and pitying, hopeful and helpless, disgusted and self-reproachful. But no clear unifying theme emerges to bring closure to this conflicting assortment and abundance of feeling. I think that despite this, or more likely because of it, Mr. L stands out in my mind more than any other.

I hope one day I can fashion those thoughts into a coherent narrative, some satisfying story with broader significance. Until I can, I think it means something simply to be able to describe what Mr. L looked like, how he behaved, the expression on his face, and the emotional reactions he evoked in his caregivers. It is even strangely therapeutic to accept that an encounter with a patient may affect us in ways we may not be able to fully appreciate immediately. For now, I know I will not forget his tearful eyes or his silent smile. For now, this is enough.

John Hwang is now a 4th year medical student at NYU School of Medicine


An Intern In The ER

April 1, 2011

By Demetrios Tzimas, MD

New York City.  Bellevue Hospital Center.  July 17, 2009.  1:53 pm.  Intern Year. Long Call.

“Go down to the ER.  There’s a guy with chest pain for the past three days, EKG shows some non-specific changes, vitals stable.  First set of labs negative.  CXR clear.  They gave him a full-dose aspirin.  This sounds like a rule out chest pain, and since it’s Friday, he’ll go to medicine and not the chest pain unit.  I’d go down with you, but one of our patients needs a line.  If you have any problems just page me.  He sounds stable, don’t worry.”

Wait, what are non-specific changes?  What is he crazy?  I don’t want to deal with chest pain—it could be anything…pneumonia, pulmonary embolus, myocardial infarction, pneumothorax…aortic dissection.  Well, can’t be a pneumo, CXR is clear, and can’t be dissection, I’m assuming “CXR clear” means that the mediastinum is not wide.  But who read the x-rays?  Hopefully an attending signed off on them.  Whatever, if David was worried, he wouldn’t send me down there alone. Anyway, just remember MONA—morphine, oxygen, nitrogen, aspirin.  I learned chest pain a million times in med school, this will be no sweat….isn’t a beta blocker supposed to be given too? Wait no, what did the COMMIT Trial say? That’s just with an MI, this is chest pain.  I hate pneumonics.  Ok, let’s be efficient.  He’s going to need admission orders.  Labs, medications, vitals every four hours, admission order, prophylaxis.  Diet, don’t forget a diet.

Wait a minute.  What does “first set of labs negative” mean?  Did they not draw any labs on him?

I took the elevator down 17 floors to the ground floor, and walked down the long corridor from the main hospital to the Emergency Department.  I nodded respectfully at the police officer next to the CPEP (our psychiatric emergency room), and hooked a left into the Bellevue Emergency Room.

The smell of the homeless alcoholics hit me as soon as I walked inside, the same odor that I smelled every time I walked into that ER.  It was like an olfactory aura, warning me of the madness I was about to experience.

If Bellevue is a beast, then the ER truly is its belly.

Every time I worked in the ER, it seemed that no matter how fast I was trying to do things, everyone was going faster than me; everyone just runs around with tunnel vision trying to accomplish the next task at hand.

Place that IV…where’s the nurse, that patient needs a foley…where is the red speckle-topped tube…why won’t med consult call me back???

Nobody makes eye contact with you, doing so would make them available to be bothered by you.  To ask someone a question is taboo; it will not only slow them down, but it will also make them susceptible to being asked more questions by you in the future.  So everyone is just too busy–or  too busy pretending to be busy–to help you out.

An intern, especially a medicine intern, on July 17, is all alone in that jungle.

And just as the ER staff knew not to make eye contact with me, I quickly learned to avoid making eye contact with patients at all costs. They’ll most likely just ask me to get them a sandwich or something.  As I walked around the ER, I made sure not to look up at anyone.

Ok, so where’s my patient?  Oh yeah, go to those really helpful white boards.  1-2A- Diarrhea.2-7B- GI bleed.  3-dude just look for chest pain, or “CP.”   Ok, not here.  Maybe he’s on side 1.

Walking over to side 1 of the ER, it really hit me how absurd the system was down here.  I understood that patient confidentiality was an important issue, but seriously, it was about to take me 15 minutes to find this guy because all they listed on the white board was either a chief complaint or diagnosis next to a number.  Looking at the side 1 white board, I again didn’t find those magical words.

I hate this place.  Back to side 3.

I walked into the nursing station/doctor’s space/clerk’s desk/phone center/precepting room/copy and printing area: the four-sided workstation for EVERYONE in the Bellevue ER.  I had to interrupt about three different conversations as I fought my way to the white board.  I finally found those two letters “CP” on the white board of the side 3…four different times. Ugh.

Maybe the side 3 nurse knows who this person is.  Who’s the side 3 nurse?  Maybe this guy knows.

“Hey, do you know who the side three nurse is?”  Without even turning to look at me, he replied, “Sandra.” 

Thanks bro that was helpful.

“Hey, are you Sandra by any chance?” I asked the first woman I saw.  “Yeah, but I’m busy.  Find me in five minutes.”

I really hate this place.

After process of elimination, I finally figured out who my patient was.  I had to reach over the orthopedics residents looking at an x-ray at the PACS station to grab the patient’s chart.

“Excuse me…sorry…thanks.”

Ok, 68 yo M with asthma, HTN, HLD, diabetes, comes in with chest pain x 3 days.  BP 145/95, P 88, R 16, T 99.9.   So let’s look at this EKG…haven’t read one of these in so long.  I need calipers.  Ok, David said non-specific changes, whatever that means…ok, well there aren’t any ST elevations and it looks sinus, safe for now.

I finally found my patient.  He basically told me that for the past three days, he had been having sharp left-sided chest pain.  It was constant.  He wasn’t sure if it was associated with exertion and couldn’t say if anything made it better since it was always there.  He was able to walk around without a problem, and this didn’t make the pain worse.   This sharp chest pain wasn’t associated with shortness of breath, nausea, dizziness.  He denied any palpitations.  He’s had this before and has gone to the ER, but has never been admitted.

So why did you come into the hospital again? Can’t these people just stay at home?

But when I asked why he came in this morning, he said he woke up around 5am with some throat burning, and he did get short of breath then.  It had gone away, but he decided to come to the hospital anyway. He still had his left-sided sharp chest pain, which was most concerning to him.  He also informed me that, about 5 minutes before I came to talk to him, he felt the burning sensation and was short of breath.  I decided to get an EKG.

Shoot…ST depressions in the inferior and lateral leads, and he’s having some chest burning.  Let me check the troponin.

I somehow found an open computer and looked up his labs.  The first troponin drawn at 6am was negative, but the second drawn at noon was 2.3.

Didn’t anyone check his labs?  He’s having an MI! Ok, first things first. Make him chest pain free.  Nitro, sublingual.  Wait a minute, what if he’s having a right ventricular infarction, it’ll drop his pressures.  But wait, his pressures are normal now, he’d already by hypotensive at this point.  Or would he?  Just call David.

I paged David to the ER, but since I wanted to complete his management, I walked away from the phone.

Fine, give him some morphine.  Oh yeah, MONA.  He got aspirin.  He needs oxygen, I’ll put him on 2L NC.  Thank goodness I went to intern core last week.  He needs other things though: Plavix, beta blocker, statin,heparin. Ok, I can totally handle this.  He’s diabetic,I should give him his metformin.

I began to write the orders down on those archaic paper orders sheets.

Beta blocker.Ok, metoprolol.  What dose?  IV or PO?  Hold on, he has asthma.  But I can give it to him if he’s not wheezing, right?  Did I even listen to his lungs?  Wait, how’s his chest pain?  Wait, COMMIT Trial, no beta blocker yet.  Maybe cardiology needs to be called. Let me see him first.

David call me back!

The patient’s chest pain was now gone with 2mg IV morphine, although he was still slightly hypertensive and pulse was still in the 80’s.  He was satting 100% on nasal cannula and did appear comfortable.

Ok, let’s give him Plavix.  Wait, 300 or 600?

I ordered him for Plavix 300mg.If he needed 600mg, I reasoned that I could always give him more later.

Ok, high dose statin. Which one do I give him? Simvastatin 80 sounds good to me.  Or do we give Lipitor?  I’m sure they don’t have Lipitor in Bellevue, it’s a city hospital.  Should I call pharmacy?  No time dude, just give the Zocor.  Now what?  Oh yeah, heparin drip.  But has he fallen recently?  Does he have a history of GI bleeding?  Do I need a CT to make sure there’s nothing in his brain that could bleed? Shoot, I didn’t take much of a history.  Should I guaiac him?

After making sure he was still chest pain free and comfortable, I completed my history and physical exam.  He had no history of any kind of bleeding, he had childhood asthma with no history of intubations, and he hadn’t used inhalers since he was a teenager.  As his pressures were stable, I gave him the beta blocker which lowered his heart rate and blood pressure and started him on a heparin drip.

Aspirin, Plavix, Statin, Heparin, Beta.  He’s chest pain free.  Perfect.

“16 North 1 team resident on line 3015.16 North 1 team resident on line 3015.”

Proud of myself for diagnosing and treating this patient’s NSTEMI, I explained to David over the phone what had happened.

“Demetrios.  You should have given him Lipitor 80.  Why didn’t you call cardiology?  Have you ordered an echo?  What’s his LDL, AIC?  Don’t order him for metformin if he’s diabetic, just put him on a sliding scale for now.  And why didn’t you page me more than once?  You knew I was putting in a line.   I have to be able to rely on you man, we’re getting slammed today.  Don’t worry, I’ll call cardiology and put in the other orders; I have another admission for you.  He’s in the ER, side 3, coming in with chest pain…”

Dr.  Tzimas is a 2nd year resident at NYU Langone Medical Center

Image courtesy of Wikimedia Commons

 

 

 

 

Tales of Survival: My White Coat

February 3, 2011

By Kristen Mattei

Faculty Peer Reviewed

Mr. H was an 85-year-old former merchant marine and self-proclaimed lothario who presented to the VA emergency room with a six-month history of lymphadenopathy, a six-week history of cough, and a two-week history of decreased exercise tolerance. The physical exam was remarkable for impressive lymphadenopathy in the anterior cervical, posterior cervical, submandibular, axillary, and inguinal regions.   A CT scan of his neck, thorax, abdomen, and pelvis revealed a pulmonary embolism and diffuse lymphadenopathy. 

 I must admit, that as cynical a person as I am, after my white coat ceremony, the first thing I did was to throw on a pair of scrubs, my stethoscope, and my coat for an ironic, but still self-congratulatory, Facebook profile photo.  I couldn’t help but feel proud of surviving the ritual flogging that was medical school admissions to stand on stage and receive a little piece of symbolism of my own.   

 The problem was that the white coat was a symbol that held too much power for me to wield.  The first-year medical students attended narrative sessions which were meant to expose us to the patient perspective of the healthcare field. Mine were held off-campus and I was forced to make the trek to the cancer center in full-on “baby-doc” garb.  I hated this.  I felt conspicuous and stupid.  Sure, my coat was white, but it was also very new and very stiff.

 And very short.   It was nothing like those I always remembered doctors wearing, long coats flowing behind them like superhero capes.  To doctors and nurses, I was branded a medical student.  A horrifying thought.  They could take one look at me and know that I was altogether useless.  To strangers on the street, I might be seen as a doctor.  Another horrifying thought.  I walked to my sessions acutely aware of my surroundings, practicing unlikely scenarios in my head.  “I’m sorry, I’m just a medical student.  I can’t use a pen to give your husband a tracheotomy, but I can list the essential amino acids if you think that will help.” 

 By second year, I still hadn’t shaken the uncomfortable feeling that the coat gave me, but I was getting better at faking it.  I had figured out the magical formula of the OSCEs.  “Standardized Patients” was a term that translated plainly to “desperate aspiring actors.”  They all had an emotional story to tell, so just nod and smile, ask plenty of open-ended questions, and follow up on emotional cues.  “Oh, you just moved in from Washington?  Tell me how you’re feeling about that.” 

 I fake-doctored so well that I made a fake-patient cry.  My concern about her dramatized domestic violence victimhood was just so real.   The problem was that it wasn’t real.  I was only so comfortable with OSCEs because I was keenly aware of the fact that it was all a game.  I wasn’t really a doctor and they weren’t really patients, so it didn’t really matter.  But in the hospitals during our bedside teaching sessions with actual patients, I still felt conspicuous and stupid and clumsy.

 Then I made the horrendous decision to start my third year with the big one: Medicine.  At Bellevue, to boot.  Now my white coat was not only obviously short, stiff, and unflattering, but its pockets were filled with tools I rarely had a reason to use.    How often would I actually need to whip out that otoscope?  At the end of every day of that first horrible week, I’d hang up the coat and stethoscope in my locker and head out the door with a sigh of relief that I no longer had to carry the burden of being even remotely responsible for things that might happen.   I’d enter my apartment, collapse on the couch, and sob uncontrollably like a crazy person.  

 But then, the days didn’t seem so horrible.  Uncontrollable sobbing turned into minor dramatic tearing, which faded to cool indifference.  One Friday after I had contributed to the actual care of an actual patient, I walked home with a broad smile on my face.  The following week I was leaving from one of our many afternoon lectures. I realized that I was walking down First Avenue with my white coat on and my hands in my pockets like I owned the thing.  It had happened.  I had settled into my role as a doctor-in-training.  Sure, I didn’t have the clinical knowledge or the skills or the experience yet, but damnit, I was a medical student. I was going to be a doctor.  Hold that chin up high!

 This brings me back to Mr. H.  Lovely, sweet Mr. H who spoke like an old-timey gangster and declared that he would take me away from all this.  My medical team at the VA was mostly female, an interesting dynamic shift from my testosterone-filled Bellevue team.  Every day for a week my team, clad in white coats and toting stethoscopes, would visit Mr. H on rounds, update him on the proceedings of the day, which tests would be done, and what the implications of the results could mean.  We would refer to each other as “doctor,” as I suppose doctors often do. He would flirt mercilessly, sending us all into self-indulgent giggles. 

 One day last week I passed him as he was walking down the hall, so I stopped to chat with him.  After some light flirting and many “my dears”, he expressed aggravation at the time he had spent in the hospital, especially since he was absolutely convinced his symptoms were from eating too much “shell-food.”

 “Listen.  I don’t know if yous goils are studyin’ to be nurses or what , but if you could go to a library or somethin’ and find out what’s going on, that would be a big help.  ”

 Such is life.  I smiled, patted him on the back, and bid him a good night.  As I shouldered my backpack and readjusted the collar of my white coat, I realized that I hadn’t bothered to correct him.  Truth was, I didn’t need to.   I had spent the first two years of medical school worrying that people would mistakenly recognize me as a doctor.   Now, what people saw when they looked at the white coat didn’t matter.  I knew what it meant.

Kristen Mattei is a 3rd year medical student at NYU School of Medicine

Peer reviewed by Ishmeal Bradley, section editor, Clinical Correlations

Image courtesy of Wikimedia Commons

My Chief Complaint

September 17, 2010

 By Laurel Naversen Geraghty, MS4

Faculty Peer Reviewed

 CC: “I’m stuck in the hospital at 9:30 p.m.”

 HPI: L.G., a female G1P1 medical student immediately s/p the grueling hours and night-float duties of her OB/GYN clerkship, experienced acute onset elation about her next rotation: psychiatry. She felt excited for the clerkship—and for the tantalizing promise of a 9-to-5 schedule, which would allow her to see her four-month-old daughter for more than 30 waking minutes per day.

 At the end of her second day on the inpatient psychiatry ward, word came that a new patient was being transferred from the emergency department. L.G.’s task: Get the H&P.

 As the late summer sun began to set over the city, symbolizing her diminishing chances of seeing her daughter awake that evening, she introduced herself to the newcomer[*]: a young, thin, homeless man, with a distant gaze and a groomed goatee, who wore only a hospital robe and leather shoes. L.G. asked how the patient had ended up at the hospital. In a slow, drugged-out manner, he stated that there were warrants out for his arrest, the CIA had been following him, and federal agents had thrown acid on him in the subway, prompting him to head to the E.R. to be examined (no injuries were found). He confessed to L.G. the reason he was being followed: He had done something “close to rape” of several boys and girls, aged 2 months to 16 years. As L.G. heard his admission, it occurred to her that she’d missed the chance to see her baby that night because of a child predator—one whom she was obligated to care for and treat with professionalism and respect. She took a deep breath and continued with the interview. At 9 p.m., she returned to the call room to write the H&P, and let out a sigh about this “9-to-5” rotation.

 Past Medical & Surgical History: Noncontributory

 Medications: 100mg liquid caffeine PO BID

 Allergies: Acid-base physiology

 Family History: Significant for familial reproductive hyperstupidemia (her father also had a baby during medical school)

 Social History: L.G. lives in New York City with her husband, daughter, and mother-in-law (provider of the world’s best child care), whom she has been holding hostage since the beginning of her clinical clerkships.  

 REVIEW OF SYSTEMS:

General: Medical school-induced sleep-deprivation

HEENT: Bitter taste after hearing confessions of child abuse

GI: Gnawing hunger s/p lunch 8 hours ago

Extremities: Tired feet

Psychiatric: Separation anxiety, with occasional worries that her baby won’t recognize her.   

 VITAL SIGNS: wnl

 PHYSICAL EXAM:

General: Female in NAD, A&Ox4, wearing professional attire and a ponytail that’s beginning to look scraggly

HEENT: Eyes bleary

Heart: Displaced PMI

Abdomen: Linea nigra still intact

Extremities: Fingers feverishly typing the H&P  

 ASSESSMENT & PLAN: A G1P1 medical student developed mild distress while working late in the psychiatry ward, having missed the chance to see her infant daughter that evening.

1)      Quit whining, maintain a positive attitude, do your best to help this patient, and try to have some fun along the way.

2)      Refer to cute baby photos on cell phone PRN.

 HOSPITAL COURSE:

The patient was admitted to the psychiatric ward and started on an antipsychotic and an SSRI. Each morning after rounds, L.G. went to see him. He was always calm and cooperative, but confused, paranoid, and depressed, with marked psychomotor retardation. He spent his days lying on his bed in the dark, eating at off-hours to avoid others, and asking repeatedly when he could leave the unit.

 L.G. contacted collateral sources. She learned that the patient was a teetotaler who didn’t smoke or do drugs. Three weeks prior to admission, he had started making vague, paranoid-sounding statements about his “crimes,” and abruptly cut off contact with everyone he knew. He was not actually homeless (though he’d recently taken to the streets, believing he’d been evicted) or unemployed (he worked for a nonprofit organization,placing people into drug rehab programs). He frequently carried peanut butter sandwiches to hand out to the homeless. He had no criminal record, there were no warrants for his arrest, and there was no evidence to suggest that he’d ever harmed any child.  

 Very gradually, the patient began to show improvements in relatedness, affect, and cognition, and his paranoid thoughts softened. He seemed to appreciate his daily conversations with L.G. and her earnest attempts to fill the gaps in his understanding. She enjoyed their friendly rapport and feeling like one small part of his visible progress.

 After five weeks, the patient was discharged from the unit, his symptoms stabilized and a careful follow-up plan in place. Two days later, L.G. was discharged from her psychiatry clerkship with a new appreciation of how, in medicine, first appearances can be misleading. A self-professed homeless child-molester had emerged as something quite different: a well-loved man with friends, a home, and meaningful work, interrupted by mental illness. He no longer felt like an inconvenience to L.G., a cruel predator, or a barrier between her and her daughter. He felt like her patient, and something close to a friend. More importantly, L.G. was forced to confront her own bias. The demands of motherhood and medicine may occasionally pull her in opposite directions, but she hadn’t set out to treat only the patients she liked, exclusively during business hours. What if this patient hadn’t turned out to be so decent? How would she approach the next admission who struck her as loathsome, or who arrived at an inopportune time? Would she allow her feelings or outside obligations to sour her perspective or alter the care she provided? She made a commitment to try harder, to do better, and to embrace the lessons that come with 9:30p.m. admissions.

Laurel Geraghty is a fourth-year medical student at NYU School of Medicine

___________________________________________________________

 [*] Some identifying details have been changed.

Tales of Survival: Snapshots of Bellevue at Night

September 10, 2010

Christopher Tully, MD

Bellevue is a beast.  I’m not sure if there is any other way to describe it.  The corridors feel as if the streets of New York City have spilled into its sprawling confines as patients, families and employees mix to create a constant buzz.  The piecemeal construction of the hospital center only adds to the chaos.  There are just enough blind angles to make awkward collisions with a patient or co-worker common-place.  Its endless hallways and linoleum floors stretch on for an inappropriate distance.  The walk from the front entrance on First Avenue to the Hospital Building elevators requires both agility to avoid the throngs of foot traffic and stamina (344 steps, I counted).  Bellevue in the daytime is truly a beast.

At night, Bellevue is a far different place.  Much like the city that surrounds it, the chaos slows, the crowds thin, and the noise quiets.  Although some parts of the hospital never sleep (the emergency room), the remainder of the hospital is largely empty and encounters with fellow workers occur primarily by chance.  The hospital separates into isolated snapshots, each picture existing in its own place and time, waiting for morning to come.

One can see:

The line of night employees clutching plastic baggies full of half-priced baked goods at Au Bon Pain.  The Feeding Frenzy.

The chance encounter with a surgical resident going to or from the emergency room.  Ships Passing in the Night.

The peaceful, snoring, often shoeless New York City men and women sleeping the night away with the smell of alcohol and feet floating in the air.  The Unmovable Statues.

The blue-gowned patients moving silently and methodically up and down the hallways.  Exercise.

The rhythmic and mechanical wooshing of air entering and leaving lungs.  Life Maintained.

The intern, head bowed, hands crossed, and eyes closed in front of the blue computer screen.  Praying.

The surprise encounter with orange-suited men shuffling through the basement hallways.  Crime and Healthcare.

The uninterrupted ascent and descent of the faux wood-paneled elevators and a white-coated resident leaning in the corner, eyes closed.  A Moment of Peace.

The rapid, unconscious and almost choreographic movement of housestaff responding to a code. Serenity Interrupted.

The empty trauma slot floor covered with bloody gloves, gowns, and papers.  A Life Saved. . . or Lost.

The golden-red sunrise over Brooklyn, Queens and the East River.  Another Night Done.

For those who have never worked an overnight shift at Bellevue Hospital (or any hospital), these snapshots probably seem like a foreign world, a world left to overworked housestaff and television dramas.  However, to those who have worked the graveyard shift, these images hopefully remind you of a time you may not necessarily want back, but still remember fondly.

And to those working at Bellevue tonight, good luck.

Christopher Tully is a third year internal medicine resident at NYU Langone Medical Center and contributing editor to Clinical Correlations

A Tale of Olympic Survival

June 17, 2010

By David Chong, MD

 As the world watched the greatest athletes gather to compete in Vancouver, I was on a plane to Haiti.  Just getting on the plane was quite a feat.  After I received an urgent e-mail for volunteer doctors from the University of Miami’s Project Medishare field hospital in Port-au-Prince, Haiti late on a Friday night during an overnight shift at NY Presbyterian hospital, I began to send frantic requests for coverage for the week.  Slowly, I began to receive supportive responses but there was a lot to accomplish before departure.  As the Sunday deadline approached, I felt a strange peace.  Perhaps it was after talking to my wife, perhaps it was divine, but I really felt that I needed to go and that I had to help, no matter how small, in the tragedy that is Haiti.  The earthquake in Haiti affected one of the poorest nations in the western hemisphere and the estimates are more than 200,000 people perished in the span of 35 seconds.  It is a disaster that staggers the imagination and may be the single worst natural disaster in our lifetime.  It was bigger than the Asian Tsunami, Hurricane Katrina, and the Southern Chinese Earthquake.

 Although Haiti is only six hundred miles from Florida, it is a world and a distant culture away.  Thousands of Haitians call New York and America home, but Haiti remains desperately poor and many Americans consider it a “dangerous” country.  Images of black faces, corruption, HIV, and voodoo dominate our impressions.  I have to admit I didn’t know much about Haiti.  My high school French was long gone, and my Creole non-existent.  Nevertheless, I felt I needed to be there.  So close but yet so far away, it took me more than twelve hours to get to Haiti from New York.  The FAA restricted flights to Haiti and we all boarded the same flight in Miami loaded with tons of medical supplies.  When we finally arrived in Port-au-Prince, we had to unload all the cargo by ourselves.  I realized how much I took for granted when traveling.

 After arriving at the tent hospital on Sunday night, we got a quick tour from veterans who had arrived two days before.  We were lead to the staff tent and I picked an empty cot, grabbed some military rations, a bottle of water and used a port-a-potty to conclude a very long day.  On Monday, I met EM.  They had found him in the rubble of a flea market as people were scavenging for food or bodies.  He had been trapped under the rubble for 27 days, ever since the January 12th earthquake.  Dehydrated, starved, having lost 60 of his 140 lbs., but with obvious trauma, he was the longest survivor of any earthquake ever.  That morning, I had been assigned to the makeshift ICU in the corner of the OR.  When I met and examined him, he did have some burns to his feet, perhaps from when they pulled him out of the rubble, but otherwise he was intact.  He said that except for drinking some muddy water around him, he had no food for 27 days.  It was a miracle.  What happened next was surreal. 

 As EM began his recovery, the media frenzy began.  Someone had alerted the media, and so within the hour of EM’s arrival to the hospital, CNN, The New York Times, and Reuters were knocking at the door.  He began to tell his story to me.  EM explained that he had just finished selling rice for the day at the flea market on January 12th when the earthquake hit.  He said he was instantly trapped but could move a bit and he could hear people, but he couldn’t see them and more importantly, they couldn’t hear him.  He screamed until he lost his voice.  He then lost hope and assumed he would die.  27 days later, he was miraculously found alive.  

 When asked if he wanted to talk to the media, he repeatedly declined.   He explained that the miracle was not about him but that God had saved him, and that it was a testimony about the power of God.  He didn’t want to talk to CNN or the New York Times; he wanted to give his testimony to fellow Christians at his church.  Unfortunately, his church was destroyed in the earthquake.  Dignified, EM also said that if he told his story on television, it was look as if he was begging for money and he kept saying that his mother raised him better than that.  Proud and devout, EM epitomized the Haitian people.  This man who had no money, no home, and no food was not going to beg and risk dishonoring his mother or his faith.

 I had come to Haiti to help them, EM blessed me more that I could ever repay.  As the week drew to a close, Haiti commemorated the one-month anniversary of the Earthquake. The people of Haiti decided to make it day of prayer and fasting; this in a nation with no food, no shelter, and no basic services. 

 When it was time for me to leave at the end of the week, I went to EM to say my goodbyes and to give him my sleeping bag, my flashlight, a mirror with a picture of my daughter, and my business card. Upset and dismayed, EM kept saying that he wanted to go home with me.  He had become suspicious of everyone and stated that he only trusted me. Post Traumatic Stress Disorder (PTSD) is common during disasters and he was showing all the signs.  Leaving him was extremely difficult for me as well.  I desperately wanted to get him transferred to Columbia-Presbyterian Hospital, but I knew it was not possible.  When I left Haiti, my body departed but a very big part of my heart lingered.

 After coming home, I, too, experienced PTSD and fell into a depression.  I experienced extreme sadness, anger, restlessness, and insomnia.  I felt I needed to go back and there was still so much to do.  I thought of EM constantly.  Sharing my experiences was difficult.  I found solace in connecting with other Haiti Earthquake volunteers on Facebook.  Almost a month after returning, only now have I been able to share my feelings about Haiti.

 It angered me when people would respond so flippantly to the plight and suffering of Haitians. Haiti needs more than just money and supplies; they need real help every day. They need schools, homes, food, electricity and clean water. Recovery seems insurmountable.

 Why is it so hard to believe that anything good can happen in Haiti?  Are we that pessimistic about Haiti?  Have we already given up on Haiti?  The Vancouver Olympics showcased an amazing array of human athletic accomplishments.  I think it pales in comparison to EM and the daily Olympics of Survival, human spirit and dignity that is Haiti.

Dr. Chong is the Hospital Director of Critical Care Services, Columbia University Medical Center

Tales of Survival: The Rock’s Wife

January 8, 2010

20080311-bellevue-hospital-03John Trahanas

She was not my patient. Actually, she was nobody’s patient, she was just a wife; she was “the family.” She was a rough, stern looking woman, and with good reason as she had weathered many difficult times. Her husband had been severely demented for many years; however, it was only in the past few months that he required such intensive inpatient care. He was not conscious or communicative, but he was clearly in pain from the gaping, gangrenous sacral ulcer that his prolonged hospital stay had cost him. His hospital course consisted of trips to the operating room for more debridements and antibiotic treatment for subsequent re-infections. John Trahanas

As medical students we heard about him on rounds, but we had never actually seen him. He was just one of our “rocks;” there were more interesting cases with better teaching points that we could follow. I used to see her though. She would walk around the hallways, and I wanted to talk to her, to let her know that there was someone she could feel like she knew. I tried to say hello to her one day, in Greek, but I doubt that she heard my softly spoken “Good Morning.”

Her husband was scheduled for another debridement, and the team felt that it would be best if he could leave the hospital immediately following the procedure to avoid another multi-drug resistant infection. They also wanted to have a discussion with her about goals of care. Maybe it was time to start thinking about how this man could find peace. It made sense to me. So many healthcare resources and dollars are spent on patients who can no longer benefit or be improved, despite our best efforts. Families need to realize that when their loved ones can no longer respond and cannot be salvaged, that the battle has been lost. Sometimes, everything should not be done.

She did not agree, didn’t want to talk about it. She was not being cooperative. The team thought it might be because she simply did not understand. Perhaps if someone could explain our reasoning to her in her own language, then she would be more receptive. “Hey John, you speak Greek, right?” Sure, I thought. True, I didn’t know medical terms, but I was fluent. I’ll just explain to her that this was the worse place for him to be, that we could only make him worse while he was here in the hospital. It made sense, we just needed to explain it to her.
She saw me walk in and gave me the look of disapproval she had been sharing with most of the staff since the development of her husband’s ulcer. I think it startled her to hear her own language come out of my mouth instead of something only vaguely familiar. She opened up like a floodgate. She hadn’t had anyone to talk to and now, she finally had someone who could listen. She told me her husband’s whole story: how he had finished college in Greece; how they moved to the U.S. together but still visited in the summers; how they had opened a diner in Long Island. I knew this story, it was my family’s story, the same story of so many other immigrants. I felt like I knew her, and it made it that much harder for me to listen to her tell me, with tears streaming down her cheek, about the Parkinson’s disease and the pneumonias and the puddle of bloody urine that had leaked onto the bed but was ignored by our staff.

She explained to me how guilty she felt for bringing her husband to the hospital. If she had never brought him here, he would have never gotten the ulcer, and then she could have taken care of him at home. Now, she had nowhere to take him. She told me how the doctors told her he was at his end, and that more treatment would only prolong his suffering. She told me how the doctors didn’t care that he would still perk up when he heard his daughter’s voice, or her voice. They thought she was being difficult when she refused to talk about the goals of care for the man who had treated her so well for so many years. She told me that no one acknowledged the fact that it was in this hospital that he had gotten the ulcer that was eroding his body and her spirit, and instead of wanting to continue helping him, they had given up. They wanted to send him away and wash their hands clean of him. She told me all the things the doctors had said to her, the same things I had come to say.

I knew that we were not as heartless as she made us sound, and that what we wanted was not to be rid of the man, but to make sure he didn’t get infected. It was logical, it made sense. But instead of getting through to her, she got through to me. I realized that it was me, us, that didn’t understand her. This scared woman was desperate for her husband to be treated right and not to be abandoned. I’m sure that’s what all families want, not to be abandoned when the end really is near. That’s why she did not want to speak with palliative care, and why she wanted everything possible done for her unresponsive spouse.

Logic may tell us that our efforts our futile; however, for the first time I realized how hard it can be to justify that standpoint when looking into the pleading eyes of frightened families. I saw how one might feel the same obligation to treat their pain as much as the patient’s. I haven’t seen any guidelines for this situation in any of my pathology, pharmacology, or physiology books, and I imagine that in the future, I will have to use my own judgment to balance science and empathy. What I do know is that we as the medical team could have done a better job of making her feel less deserted while she struggled through her husband’s hospitalization. I don’t know if that would have helped her to see past her fears, to realize that we did not want to abandon her or her husband, but that we only wanted what was medically best for him. I can only hope that my talk with her, however brief, had given her a chance to reflect and express her grief.

Tales of Survival: The Bellevue Clap

December 24, 2009

bellevueamb2Bellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those stories.

Christopher Tully, MD

The entrance to Bellevue Hospital is a spacious, I.M. Pei-designed Ambulatory Care Building consisting of five floors of exam rooms enclosing a sun-drenched marble atrium, all capped by a glass-and-black-beamed ceiling.  This addition skillfully and seamlessly drapes across the now-ancient appearing previous entrance to this historic hospital, its classic red brick and columnar facade now hidden beneath its modern appendage.  I generally don’t spend much time in this intersection between the new and old Bellevue as I am usually scurrying across the expanse to get my signout, not wanting to be the last intern to show up and receive the passive-aggressive ire of the intern night float.  The end of the day, however, tends to be a slower trip.  My feet drag a bit more, my thoughts from the day distract me, and my general fatigue from being an intern is most evident.

It was during one of these slow walks that I first noticed the Bellevue Clap.  It is a clap with the essence removed.  My hands come together like any normal clap, but it is like the sound gets sucked away and flattened.  We all know the sound of a clap.  The cupped fullness of hands slapping together in such a way as to produce a noise that echoes, startles and excites.  I am not sure how or when I found it, but much like the factory workers of old, the clap has become my whistle signaling the end of the workday.   It silences the constant ringing of patient call bells, pagers, telephones, and telemetry stations.  It quiets the sonorous, almost rhythmic chirping of a patient coughing on a ventilator and eliminates the constant chatter of nurses and housestaff.  It ends a day full of Spanish, Bengali, Mandarin, Cantonese, and Polish; the melting pot of languages is now silent.  After the Bellevue Clap, my hospital day ends and I enter the world of New York City.

I am sure many of you have noticed this little quirk of Bellevue, and by no means do I take credit for its creation or its discovery.  While I am a bit hesitant to share my little ritual with everyone, I figure we all need a bit of help ending our crazy days.  So if you want to experience the Bellevue Clap for yourself, simply find the final letter A on your way out of Bellevue Hospital, and with one swing, let it all fade away.

Christopher Tully is now a second year resident in internal medicine at NYU Medical Center.

Tales of Survival: A Formidable Foe

September 12, 2009

bellevue.jpgBellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those stories.

Judith Brenner MD

Many years have passed since I was first an intern on the Bellevue wards. The details are blurred into a hodgepodge of images: running to codes, drawing blood, beepers, waiting for elevators. But for me, the particulars that emerge are always about patients. Patients are the greatest teachers and the hospital wards and clinics, the best classrooms. The first MI, the first PE, the first sepsis-we learn medicine one patient at a time. The experiences never fade, but rather crystalize and forever influence the way we approach disease. Enter, pneumococcus…

It started off innocently enough. I was an intern and we were called to the Bellevue Hospital ER at a time when the ER was more of a makeshift trailer, where a curtain separated the main treatment area from “the slot” and which came as close to being “in the trenches” while still remaining on US soil. “We’re admitting a patient with pneumonia” my resident said. As is not uncommon, before meeting my patient, I saw his x-ray. Indeed, there was an opacity overlying the RML. We walked into a room with 3 other patients, each one separated from his neighbor by a sheet. We pulled the curtain back and met a young man. He was 24 years old, handsome and appeared to be in no acute distress. His chart told us that he had been febrile, very febrile to 104F earlier, but acetaminophen had worked its magic and he looked fine. As he spoke, we heard the paroxysms of cough that interrupted his story.

“I’ve had a fever and a bad cough for 3 days”

“Yes, the cough was productive” he answered to our questions. In fact, he actually used the word “rusty” to describe the sputum. His exam could have come out of Bates’-increased tactile fremitus, dullness to percussion and ‘e’ magically transformed to ‘a’ as we examined his RML.

We walked away from the patient and discussed the next step, which in the early 1990’s meant going to the lab with the patient’s sputum and trying to make a diagnosis under the microscope. And so we did, gram stain and all, and found gram positive cocci in pairs and chains with PMNs all over the slide.

My hands were still purple from the stains as, almost giddy, I told my resident: “Our patient must have read Harrison’s. This is why I love medicine”. We couldn’t have been prouder of ourselves for making this diagnosis. We half-heartedly discussed options for antibiotics. Should we treat broadly or should we be elegant and treat with penicillin for the diagnosis we were confident in? We remained resolute and wrote the order for penicillin. Yes, penicillin! This was the era when resistance was just emerging and “broad treatment” would have been appropriate had we not been sure of our diagnosis.

The patient was safely tucked into his bed on 16N when we went home that night.

Walking out the door, I felt really good-probably too good, bordering on smug-at having outsmarted pneumococcus.

But pneumococcus proved to be a menacing opponent. The next day, our patient remained febrile. As we rounded that morning, we made note of his temperature of 102 F, but told each other that “he looked good”. My memory is clouded now-what exactly did “he looked good” mean? I know that his vital signs were stable, but clearly, his “guest” was still present. Did I wonder about making a change in his management? Again, that’s a question that’s clouded now by the events that followed.

By day 3, we walked in and were told that he remained febrile to 103 F overnight. A sick feeling came over me as I walked toward the doctor’s station to meet my team. The words were about to come out of my mouth when my thoughts were interrupted by a page—oh no, it’s the 16W nurse’s station. As we turned the corner, our patient was standing at the elevator, IV pole in hand, pulling at the IV’s and tubing attached to his arms.

“What are you doing out here” I asked? “You should be in bed.”He looked at me strangely with barely a hint of recognition.
“Who are you?””Where am I?”
“Get me out of here!!!!”

Within a few minutes, the hospital police arrived and escorted our patient back to his bed. He eventually moved to the ICU after the LP revealed meningitis and stayed with us in the hospital for weeks after his endocarditis was diagnosed and successfully treated.

The patient was ultimately cured of his Austrian syndrome, the triad of pneumonia, endocarditis and meningitis caused by Streptococcus pneumoniae. He was intact, but what he left behind were doctors humbled and forever changed after caring for him.

What did I learn from this experience? Circa 1994, our initial management was sound, but pneumococcus is indeed a fierce opponent that may appear relatively innocuous on the surface, but indeed is not. Pneumococcus gave us clues that we failed to recognize, but should have reacted to. We labeled the patient as “he looks good”-a three word phrase that is filled with meaning for a house officer. When someone is labeled as “looking good”, we allow the gestault to guide our management rather than attend to the small details which we should have: the fever that’s still present, the white count that’s not quite at baseline.

Our team was rightly humbled by this experience. I remember discharging him, so pleased that he was returning to his family and the life that he knew before admission to Bellevue. What I didn’t understand at the time was the influence his case would have on the way I treated other patients. I didn’t appreciate that talk of “pneumococcus” would forever conjure up the image of this patient and the battle we fought in conquering his disease. I never imagined that I might still be thinking about him 15 years later. Were others saved because of the experience of “my first pneumococcus”? I have to believe that’s possible.

So, the morals of the story: Pneumococcus is a formidable foe. Medicine is learned one patient at a time.

Dr. Judith Brenner is an Associate Program Director and Associate Editor, Clinical Correlations

Musher Daniel M, “Chapter 128. Pneumococcal Infections” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2867097.

Dalal A, Ahmad H. Austrian Syndrome: A Case Report. American Journal of the Medical Sciences. 336(4):354-5, 2008 Oct.

Tales of Survival: Hot Air

August 20, 2009

bellevue.jpgBellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those stories.

Benjamin Bergman MD

 

Sometimes surviving a hospital stay is not so easy and the reasons are not so obvious. This is the story of how I realized that doctors frequently don’t have the time or the creativity (some would say lunacy) to consider weird diagnoses. 

I was accepting a transfer from the ICU to the medical floors, an ill woman with immunodeficiency, who had been unfortunate enough to fall down and suffer a deep laceration on her right cheek. It was really a very sad story; her social worker described her as a chronically stressed individual under significant financial hardship. It turns out the reason she fell was that she was rushing around making appointments to sort out her money problems. The wound subsequently got infected and the infection spread to her brain – meningitis. She was treated in the ICU and eventually improved, however, she continued to spike very high fevers. The cause of the fevers was unknown. It was at this point that I became her physician.

The details of her voluminous chart were overwhelming. She had been treated for the right bacteria which caused her meningitis. Most recently she had been spiking fevers for weeks with an associated severe diarrhea. The obvious players had already been ruled out. She was immunocompromised, so she could really have any infectious disease out there. For all I knew she could have some fishborne flesh eating bug or MRSA of clostridium or pseudomonas or herpes or fungal infection–the list was pretty much endless.

As I started perusing her chart, I noticed she had had an intra-aortic counterpulsation balloon pump, at least as read by the ultrasound technician during a routine abominal ultrasound. She had about fifty seven x-rays of her chest and abdomen done over the prior weeks for the workup of infection. I looked at a few of them, mangled images with fluid everywhere with roadmaps of electrical wires strewn across her chest and intravenous wires mapping her large veins.

When I looked at her, she was struggling to breathe through a tracheostomy, she was hot as a firebrand with an ocean of sweat on her face. She had lesions on her back; were they bedsores or herpes or heat rash or fungal infection? The dermatologists were unable to shed any light. She was spiking temperatures as high as 105 to 106 Fahrenheit. These fevers necessitated a full-time cooling blanket, around the clock Tylenol. We were no closer to an answer.

I myself was becoming frustrated by these problems. Everything had been considered: colonoscopy was performed which was unrevealing, an infectious disease consult had ordered as many blood cultures as coffees I had drank from the Bellevue Cafe, her urine was clean, the lungs seemed interminably infested with resistant bugs, thought she did not seem to have pneumonia, all of her intravenous lines had been pulled…yet the fevers continued unabated.

I realized I had to make a choice: 1. figure it out on my own why was she having these fevers,  2. defer to the infectious disease consult to figure it out, or 3. let her sink into the quagmire of a complicated Bellevue medical patient with the dubious diagnosis of “fever of unknown origin,” or FUO.  An FUO is a beastly diagnosis with a differential diagnosis longer than an encyclopedia–essentially every intern’s nightmare, full of mind-numbing hours of transport to and from bone scans, surreptitious blood cultures, sputum cultures, a plethora of sendout tests, stool scrapings, and all else that keeps your knuckles to the grindstone. I reluctantly decided to dig in and figure it out.

I now had to step into the patient’s messy and painful sickness, and take responsibility for either success or failure. I might decide to go down one pathway that could lead me astray for days or weeks or months. Sometimes we forget, but there was a person who was suffering from this illness. I spoke with her daughter who described her mother as really not doing very well prior to the fall with stress, anxiety, and depression. I felt that this was so awful that it happened this way that I wanted to make it right again.

To make an already long story a bit shorter, after looking at all her countless labs and CT scans and x-rays, I became obsessed with this one straight line on her chest X-ray. This strange, absolutely straight white line seemed to come from below the field of view of the x-ray. I figured it was some tube or wire she had been laying on, maybe it was part of the bed itself. It turned out–after lengthy discussions with multiple radiologists and attending physicians, and vehement denials, that she had a retained wire in her aorta. I was baffled at how this could have happened: she had never had an aortic balloon pump as the radiologist thought, she had had central lines including femoral arterial lines, but this metal wire was much longer than the wires that come inside central line kits; she did not have any interventional radiology procedures which could have left a wire there. I decided that this wire was what was giving her the fevers. I had figured it out!

I then spent the better part of an entire Saturday convincing the on-call interventional radiologist that I was not insane, but that she did in fact have a retained wire. I used just about every swear word I could muster to convince him to come in and remove the line. In the end, he used some really cool tools and was able to successfully remove the wire from her aorta. I hated him afterwards because he put up such a fight, but at least he got the job done.

So that was that. The wire was out, but two days later she was still spiking these fevers, albeit now only 102-103. So I kept at it. Maybe the wire, despite how ridiculous and wrong it was, was not the only thing wrong. I started over, looked at all her cultures, examined her skin, looked at those lesions on her back…and wait a minute… either I was spiking a fever myself, or I was wearing my grandmother’s fur coat by accident, but as I leaned over the patient to listen to her coarse breath sounds, I broke out in a sweat. Hot from below, hot from above, it seemed my patient’s bed was emanating a desert-like heat wave. I put my hands on the patient, hot like an iguana bathing on sandstone. I place my gloved hands beneath her body…the bed was literally baking her! I tore off the sheets. I stopped and listened, a sinister hum in the room clued me in. She had been, for weeks now, on the same mattress, which I confirmed with the nurse, transported her from the ICU with a special inflatable mattress with an air pump attached. I pulled the air hose off and unbelievably, the air coming out of that thing was volcanic. I checked the gauge on the machine, it was set to OFF, meaning no heat.  Yet it was pumping out HOT AIR. I ripped the hose off, called the nurse, asked her to get engineering in there and turn off this sinister bed heater which was literally cooking my patient.

Two days later – no diarrhea, no fevers, wire removed from aorta, the patient was still in trouble from all her issues, but she was out of bed, no longer sweating, the rash on her back now resolving and most importantly she was afebrile.

In the end, it was not any natural disease that was trying to take my patient’s life. The hospital system itself was to blame. No physician in the prior month of her hospitalization had had the time or the creativity, some would say lunacy, to consider weird diagnoses.