Surgery, What's it like?

Morning round at 6:30 AM, end of shift 6PM if you're not on call, and the next day at 6PM if you're on call (36-hour duty), 6 days a week. What's up?

I've never felt or been so out of time for so long in my life. What's it like? Forget about having the slightest bit of time for anything unexpected like your car breaking down or your grandmother getting sick. These have no place in your loaded schedule and most days you have too little time to make a phone call or even to think about it!

On the floors, busy with more tasks than you can count, armed with a loud beeper that won't shut up or stop interrupting you, paged relentlessly by your numerous superiors and their ridiculous requests that could not come at worst times. You feel the need to be at 5, 6 places at the same time, and soon as the day goes by, like butter spread over too much bread.

You feel disrespected, unappreciated, and you want out. Out of the misery, the stress and humiliation. But somehow you pull through it all and get home almost too tired to get out of your clothes and crash on your undone bed and fall asleep to wake up a few hours later for it to start all over again. "Bring it!" seems like the only attitude to take if you are to have any chance of succeeding.

Here's what you do on the first year of a surgery residency.

First call on all your patients's issues.
Loads of paperwork.
Seeing and preparing all new admissions.
Keeping track on all occurrences and treatments done on patients in real time.
Making sure all the labs ordered on patients are within normal and making corrections as needed.
Handle incompetent nurses and be thankful that there are a few who want to help and actually know what they're doing.
Handle all of your superiors' scut work like ordering labs, getting consent forms signed, and transporting blood units or specimens back and forth between the OR and the pathology lab.
Keep track of everything your students are doing and making sure they don't screw up.
Dealing with obstinate and overconfident hypertalkative students, patients, and colleagues
Catering to every attending's immense ego.
Playing secretary and delivering messages between residents and attendings in the hospital who are just too stupid to talk to each other directly.

The list goes on. And the worst part of it is that you never get any form of recognition when you get all of this done right, but get reprimanded heavily at the slightest delay or bureaucratic mistake you make, to the demise of any shred of motivation you might still have had.

What a rush, what a time hole, making you appreciate your only off day in the week like someone starved for a year would appreciate a Big Mac. Wow.

But you know what? I love it! I love that feeling that no matter what happens this year, or the next, or the one after that, something is being built that seems to be worth all the crap you are forced to take. I have students under my supervision now. Students I have to teach, supervise, and help write progress notes. Students who - mostly - look up to their intern with respect and admiration.
And the single most rewarding feeling you have, that will make all of the above seem like a very small price to pay, is the recognition you get from your patients, who often are very sick people that you can help provide with a better life. And it's amazing just how grateful they can be, not because your attending surgeon just performed life saving surgery on them, but more because you devised a way for the dressing on their colostomy to stop leaking stool, the smell of which requires no description when it comes from s diseased colon, from their abdomen and onto their skin and bed sheets, keeping them awake at night. You do something like that, and you end up getting a disproportionate amount of gratitude, and that patient will smile every time you walk into her room.
This feeling, this gratitude, is worth more to me than the highest awards, from Penrose all the way to Alpha Omega Alpha (some of the most coveted awards), making them seem completely trivial once a sick patient calls you their guardian angel just because something you did helped them get a good night's sleep.
There's no beating that. And this mini surgeon is sticking round for more.

A Physician's Closest Enemy...

... is actually the patient's lifeline. That brilliant little invention called a Beeper or Pager that's designed and built to keep you alert and reachable,  and without which the phrase "on call" would have no practical meaning whatsoever.
That's all very nice. I mean it's really hard to conceive of a hospital functioning without pagers. Every single attempt at communication would invariably take longer, cost more, and be more burdensome on staff and patients alike. So here's how it should work:

1- Patient need something
2- Patient calls nurse
3- If nurse can handle it, stop here.
4- If nurse can't handle it:
5- Nurse picks up a phone and pages Dr. Fixit
6- Dr. Fixit shows up happily within minutes and sorts things out.

Great stuf right? 6 easy steps towards better patient care! Right? Well, only when it works!

BUT... (hehe) what happens when you mix needy and naggy patients, an incompetent nurse, and a doctor worn out by 14 hours of floor work during the day, and 3 hours of the same after sleeping hours? well things turn out a bit different... like so:

1- Patient needs attention = Patient nags about the lighting in the room
2- Patient calls nurse
3- Incompetent nurse prances in and freezes at such an impossible task as putting the patient to ease
4- Incompetent nurse freaks out, picks up a phone and pages Dr. Wornout at 3 AM
5- Dr. Wornout is bummed that the stupid pager's ringing again but humbly picks up a phone and responds
6- Incompetent nurse tells the story
7- Dr. Wornout cannot believe he's been woken up for such a lame story
8- Dr. Wornout screams and cusses out incompetent nurse
9- Dr. Wornout still might have to come over and talk to the patient or prescribe sedatives across the floor to get some peaceful sleep.

Ah, yes! This is perhaps a more accurate description of many of the calls we get on a night's duty. Thinking about it is funny. It really is! I can remember being paged for the dumbest stuff! And I swear all of these are true stories!

BEEP! 2:00 AM, 10 South: Doctor, doctor! The patient in 1026 refused to wear the face mask that was keeping him alive. He says it's too bulky, and his oxygen saturation went down to 70. But don't worry I called Inhalation Therapy and they convinced him. - "Wow good job, stupid male nurse! Thanks! "

BEEP! 5:00 AM 8 North: Doctor, Doctor! The patient in 823 Just called me and said she just had her period. - "OMG are you really calling me at 5 in the morning for this?! What do you want me to do, bring pads!?! Is this an emergency? Is she hemorrhaging?! - No - Well?!!? - ok thank you Doctor.

BEEP! 12:00 Midnight 9 North: Doctor the patient in 922 is ready for his blood transfusion, if you could bring up that unit? - Ok on my way - I get to the floor - Here's the unit, start the transfusion - Oh but Doctor the patient was taken down for his CT scan. - Is he coming back soon? - We don't know so we can't keep the blood unit here, in case it takes longer than expected; you have to take it back to the blood bank and check it out again when the patient comes back. - !@#%#$^$%&*^%$#!@#$#$@%@# You stupid MORON!!!!!!

BEEP! 1:00 AM 10 South: Doctor? I was wondering why the patient in 1036 is taking Methotrexate? - Ok I'll go along with this, He has scleroderma, to satisfy your hunger for knowledge at this hour of night... - Ooh ok, and Why are you giving him Tazocin? - For his pneumonia honey what's up? - Oooh true but why not Tavanic? and since he has pneumonia, why didn't you order him an incentive spirometer? - Hmm are you really calling me to suggest medical management is incorrect? Can I !@#$ing go back to sleep now?! Promise we'll talk in the morning!

No disrespect to nurses, but please help us out with our crazy duties! There are things you can handle, and things you can't, know which is which!
It's funny remembering all this stuff and I'd like to take a moment to say that not all nurses are like this! I've worked with a few nurses who had excellent judgment, knew how to talk to patients and resolve issues like lighting and air conditioning, but also comforted their patients for a peaceful night's sleep without the need for Lexotanyl! Some admittedly knew more about medicine than I did and they have my full respect and admiration. You make our lives easier.

Cheers to a completed Internal Medicine rotation! 

The Bitter End

They called me to your room, I saw you for myself

I saw you, and my self was torn

Who you remind me of, I dare not say

The consequences I dare not see

Your habit, got the best of you

But you of it, have the worst end

And they will be there, to hold your hand

Your loved ones, till the bitter end

Themselves miles more torn than me

Written for a dying mother...

It all starts with a nodule...

We are taught by life to greet people with courtesy; always smile and say something nice, always ask how people are doing. You enter a sick patient's room on the morning rounds and say something like: "Hello sir, how are we doing today?", and hope for some optimism and a smile in return. Try doing that on the oncology wards. On a few of my first patient visits on the oncology floor, I was caught off guard by a 38 year old patient with a body torn up, on the inside, by a uterine cancer. Now in the terminal stages of her disease, N. answered my question in a way I was never ready to handle.
- Me, entering the room for the first time, smiling: "How are you today Mrs. [...] ?"
- Her, stating the obvious, pointing at her distended, asymmetric, diseased abdomen: "Well, how do you think I'm doing?"
Realizing the retrospective absurdity of my question to a woman with a mass the size of a basketball inside her, and many other little ones scattered around her frail and broken body, I froze for a second, and nodded, with my stupid, embarrased smile still stuck to my face, and proceeded to interview and examine her, gathering a few pieces of information to write my stupid little note in her chart.
How? How can you be pleasant to a dying person? I'm still learning here... perhaps learning that oncology is the single most impossible specialty for me to work in. Oncology, cancer, that indiscriminate, slow killer that catches persons and tosses their bodies around for seeming ages.
Cancer means you see your patient on Friday and think he's doing a bit better:
- Mr. H, a nice and unfortunate old man: "Thank you doctor for coming to see me, it makes me stronger"
and then you go away for the weekend and on Monday you hear the news that Mr. H passed away on Saturday, his son's wedding day. They tell you that Mr. H's son had been pushing since thursday for a discharge so that his father can die in his hometown, and to kindle a glimmer of hope that his father would get a chance to see his son get married, even if he has to feel this fatherly pride in a wheelchair. No such luck.

It's too much for me to handle. Too much to see this losing battle day in day out, too much to see so much suffering. Too much to see so much harm coming from what started as a small nodule, a small blip on a chest radiograph... Not for me.

The ER Delivers...

Bring it ER, Bring it Med IV... That was the closing sentence in my Beginning of the End post. Excitement and ambition.

I have to say that today, the ER delivered. Today, I couldn't help but think that what was happening was some kind of response to what I wrote and felt a few days ago when I was just starting out...
The ER never faltered, even in the med III ER rotation, in showing us how little we knew, and how completely unprepared we can be for handling situations and patients beyond our qualifications.

Modern Medicine and Cruelty... The Positives?

Read Cruel Discussion and Modern Medicine.

I've talked and talked and rambled on about the disillusionment one stands to feel during one's progression in physician training over the years. My avid readers will remember the "Ladies and Gentlemen, Your Future Doctors!" 'saga'. If you don't, check out Part I and Part II. (Does time fly or what?).

Anyways in the second part I go on about how you lose this sense of idealism, this cleanliness, if you will, that people commonly associate with medicine. Now some one and a half years down the line, this incident comes and reshuffles my perception of the world of medicine and what it all stands for.

In the OPD (Out Patient Department) we care for patients on a visit-to-visit basis. It is usually the least expensive form of healthcare, and so inevitably we get to see the less fortunate patients who are paying petty fees for consults with doctors in a high-ranking hospital. The ramifications of this, which I will save for another -long- post, and the experience of such 'encounters' sometimes shakes you to your core. The socioeconomic aspect that we never really come to face on the ward floors with high class (I hate to say it) patients is a rude awakening to say the least. So one of my last patients in the OPD Pediatrics rotation was K. an 11 year-old boy whose chart (We view charts before meeting with patients) said that he had growth failure. As I read more and more pages, and came across more and more test results and differential diagnoses, I got to the note that was written when K. had last visited the OPD clinic. At the time (some 2 years ago) he was diagnosed with Laron-type dwarfism. In brief, Laron type dwarfism (also Laron Syndrome) results from a mutation of the Growth Hormone receptor, and a subsequent Growth Hormone insensitivity leading to failure of growth due to severe IGF1 deficiency (IGF1 mediates the action of Growth Hormone).

The Visit

K. walked into the room and I immediately saw his prominent foreheaed (typical of the syndrome). To me he looked like a 4-5 year-old toddler, physically, and somehow even though I knew about his condition, I was still dumbfounded when he greeted me with a noisy low-5 followed by a firm handshake worthy of a grown man. Or when I heard his 11 year-old voice and his 11 year-old vocabulary. Or as I saw his 11 year-old movements manifest in a 4 year-old body. His 11 year-old self confidence, assertiveness, and demand of autonomy also struck me as he insistently forbid his mother from answering my questions for him. I think I've stressed it enough, it was one hell of a surprise, despite the fact that I knew about it.

K. was without a doubt the most pleasant patient I've had during this rotation. He had a persistent contagious smile that revealed a set of run down, crooked and decay nibbled teeth. He made jokes, played with my stethoscope, and everything else he could find in the room. The whole interview and physical exam took place in a light atmosphere and in the best possible conditions. NOT to be soon forgotten.

Of The Sadness of Reality
One promising modality for the treatment of Laron Syndrome is recombinant IGF1 (marketed under the name Increlex in the U.S.), which can bypass the action of GH on its deficient receptor, thereby restoring growth satisfactorily if treatment is initiated in a timely fashion.
Sadly, Increlex is unavailable in Lebanon. And apparently it is a very expensive drug, which as you might have concluded makes it a problem for an OPD patient struggling to pay even the LBP 10,000 OPD fee.
As documented in K'.s chart, K.'s mother was told about this treatment when they had last visited OPD. She was also told that it was not available and that there was no way she could afford it even if it were. She was coming a couple of years after that visit in the hope (in her own words) that "Dr. N had something new for her and her son".
- Dr. N: There still are no significant efforts to market the drug in Lebanon.
- Mother: Oh.
- Dr. N: As I told you last time we are trying but your son's condition is so rare that it's hard to find proper treatment here. And the expenses would be just impossible.

Dr. N once again sent K. and his mother home empty-handed. I could not tell whether the expression on the mother's face was one of disappointment, helplessness and resignation, or of expectation.

My Reactions and Thoughts

I was deeply saddened by this outcome and for a brief moment I felt helpless and ashamed that we had to send a patient home after telling him in no uncertain terms: "there is a drug for what you have, we're sorry but you just can't have it". So what are the issues here? I mean after stepping out of that personal, humane, human, emotional roller coaster ride of a first reaction, what are the circumstances that need to be discussed?

We hear a lot every day about how medicine has been commercialized to a degree where incidents such as these are possible. We also hear about how shameful it is that medicine is a financially driven institution. And what we hear most are the sad individual stories such as the one I've told you in my long and by now surely boring account. But what is the bottom line? If anyone knows me they know I'm a bottom line kind of person. So what is it in this case?

Well the bottom line, stripped of all emotion, all sentience, and all humanity, is a sad realization that money is and always will be a major, major factor in the drive for research of all kind. Putting all of this baggage aside, a patient is buying a product (in this case a drug that is the result of years and years of expensive research and trials), in order to use that product for personal reasons.

This is how impersonal and desolate the bottom line of modern medicine has become. And to me that's all that matters because there simply is no point trying to discuss how and why it comes down to this. So is it correct to assume that my disillusionment has surpassed all the good that medicine has brought and is bringing to this world? That in the end it can be boiled down to a simple transaction between a care provider, a pharmaceutical company, and an ill person?

The answer is a resounding NO. To me there is always a positive side to this. One positive side that will not be affected by the source of motivation of pharmaceutical companies, is that no matter what happens, medicine will always strive toward a common goal. And that common goal (besides, of course, the financial rewards) being what it is, which ranges from the curative eradication of disease to the palliative nature of the most trivial of pain medication, I can confidently say that medicine does more good than harm.

Sure, unfortunate patients will benefit less than others and K. here is a prime example. But if we consider the long term outcome of the situation, we are hard-pressed to see that had there not been this monetary incentive for research, Increlex would have probably never seen the light of day! But the bottom line is that it HAS. As a result of this, we HAVE a drug, it IS helping SOME people and maybe one day this drug WILL be available to everyone. I will go out on a limb here and say that an inevitable period during the life of this drug (and this applies to all drugs and forms of medical treatment or diagnostic tools one can think of) when it will be administered in a discriminate fashion among patients is only an obstacle, a hurdle that we will overcome in our drive toward global availability and affordability of the drug. This situation now is better, in my humble opinion, than not having any drug at all, and I would be surprised if anyone argues otherwise.

Sad. But true.

Cruel Discussion and Modern Medicine

Overheard at the OPD Pediatrics Clinic between physician and a patient's mother.

Mother: What can we do Dr. N?

Dr. N: There is a new and effective drug for what your son has. But it's too expensive. Neither you nor I can afford it.

Mother: So what's the solution?

Dr. N: ..........................................

P.S. I will elaborate on the case soon.

Drafts from the Past

For a few days now, I'd been wondering how to get back on the blogging track. For me it's one of those times when you have a lot to write, but not enough time. So much to write you can't just cram it into one post and expect it to make sense... So I thought why not see what I had been up to before my unjustified hiatus...

Here's to fishing a few drafts from the past, a few posts that were never posted. Figured we'd go from there!

August 22, 2009 - A Med Student's First Patient Crush

"Well here it is. It finally happened... It had to, I guess it was only a matter of time. I guess it's always only a matter of time before any med student gets infatuated with one of his patients. I had to check on a total of 6 patients yesterday, and these include two patients from my previous post.

So after a long on-call day at the hospital, I get beeped for my last admission of the day. I thought to myself, "here we go. One more intestinal obstruction or jaundiced patient and I'll be on my way..." And so I got to 7 South. I saw Dr. K (one of our residents) and R. (a visiting student from Syria) at the end of the long hallway leading to the desk. As I got closer, I started hearing tidbits of what they were saying, and the little that I could put together was "She's status post whipple procedure in 2007".

When I heard this, I tought "ok, here comes another 90 year-old... [end of draft]"

September 26, 2009 - Enraged Med Student Slays Many in Elevator Frenzy.

"What is wrong with people? What is wrong with Lebanese literacy? what is wrong with normal psychomotor and cognitive development?

You're probably wondering why I'm asking these questions... Well let's see. In order of appearance and respectively, here's what they... [end of draft]"

November 6, 2009 - Some Will Never Learn...

"Ever wonder why you seem to keep making the same mistakes... [end of draft]"

December 24, 2009 - Wandering Attention, You're Welcome

It's 2 am and I'm awake, wondering what it is that drives the seemingly coincidental encounters, the apparently arbitrary events, large and small, that seem to just explode in apparent randomness until they inevitably crash back together and make up that mess that we call life... [end of draft]

I had been thinking about a few of these posts, the few worth posting, that is, and wishing I had posted them when I remembered more of what made them worth writing. But I have to say that while a bunch of fine-script details are lost to hazy recall, some memories are tenacious and come out vividly as soon as they are elicited.

Like L., my 26 year-old patient with not only the most intriguing and sorrow-inspiring medical history and problems, but also with the most unforgettable face and big blue eyes and out of this world sweetness one could imagine. One of the many patients I will never forget.

Or that insane feeling I get everytime I get in the elevator at AUH and people start pushing and shoving to get in before anyone has a chance to get out. When they look in at some of us 'elevator insiders' and ask: "Going up?" with that bewildered look on their faces! And finally, when stuck in a packed elevator for 10 floors with a stop at each and every single floor with agonizing slowness and the same sketch of pushing, shoving, and moronic questions, the nice feel of less-than perfect hygiene: the 9 out of 10 people with breath odors prompting the eloquent question: "WTF???" and let's not forget the 8 out of 10 people with body odors worthy of wildebeest! I used to think about that frenzy every day! "LOOK OUTSIDE YOU MORON! THERE'S A LARGE ARROW POINTING EITHER UP OR DOWN! AND GUESS WHERE THAT !@@#$% ELEVATOR'S GOING!! AND TAKE A GOD!@#$ SHOWER AND BRUSH YOUR GOD AWFUL TEETH!" Oh that felt good!

As for the last two drafts, I can't seem to remember what I was on about. I'm sure it would have been interesting though!

Ok so there was my flashback. My way of dotting the i's and crossing the t's paving the way for a few more memories fished from the past as I catch up.

No Comment...

No comment, because I can't say how it feels to connect with someone like you do when that someone is your patient. And even less when you spend hours in that room talking and talking and end up wondering if you'd ever meet someone as interesting, as insightful as them, and with a story as captivating as theirs...

There's no describing it. Much like there's no describing what it felt like when I got this note after saying goodbye to Mel, who was leaving the country for good. It felt like saying goodbye to an old friend.

Goodbye Mel, All the best.

First LVAD implant in Lebanon - The misconceptions surrounding a highly successful operation

"A team of AUH surgeons has successfully carried out the first artificial heart implant operation in Lebanon, saving the life of a 37 year-old man and father of four".

That is the claim of many renowned media sources in Lebanon. Click here to read the official AUB article by Maha al-Azar.

I'm currently, and incidentally, on the Cardiothoracic surgery rotation at AUH. Yey me. I was surprised by a phone call on Thursday night and a friend screaming at me for not telling them that the first "Heart Transplant" in Lebanon was performed at AUH. Shocked, I thought to myself, there's no way I didn't hear about that one!! Then came another call, another newspaper article, another overheard conversation... All with one, or two, or three things in common... The misconceptions, the misconceptions, and the misconceptions. I just thought there were too many scientific blunders on the part of the media and their reports have been massively misleading at best. The following is a roundup of the misconceptions I thought people should be aware of...

Misconception 1 - This is NOT a Heart Transplant...

...And even if it were, it would not be the first one in Lebanon. The first heart transplant in Lebanon (a real heart transplant) was performed at the Hammoud hospital in 1999. Click here to read about that.
This is an LVAD, or Left Ventricular Assist Device (more on that later) implant. The original heart is still in place!

Misconception 2 - This is NOT and Artificial Heart Implant...

This is an LVAD (Click here), NOT an artificial heart. Let me explain. An LVAD, as its name implies, is a pump that merely assists the biologic heart in its function. It neither takes over its function nor does it replace it or completely take over its role. It ONLY assists it in its function by taking some of the work off its back... The biologic heart is still in place, functioning properly with the help of an assistant, if you will.

The implanted LVAD.

An Artificial heart, the Jarvik.

In contrast, an "Artificial Heart" is... well... an artificial heart! It is a complete heart-like pump that replaces the biologic heart, which is taken out of the patient on the OR table. It is still an experimental technology with only limited success in the United States.

Misconception 3 - This is NOT a life-saving device...

The AUB article also states that the operation saved the life of the 37 year-old patient. I am sad to point out that this is not the case. An LVAD implantation is what we call a "bridge to recovery" or "bridge to transplantation" procedure. This device is designed to help keep cardiac performance at an acceptable level for a limited amount of time pending one of two events:

- The recovery of a mildly diseased heart as a result of decreased workload afforded by the LVAD: Bridge to Recovery.
Or:
- The availability of a matching donor heart for transplantation: Bridge to Transplantation.

The LVAD used in this case was the Heartmate II by the Thoratec corporation and is claimed by Thoratec themselves to be able to provide circulatory support for only up to ten years. Now keeping in mind that these ten years are the result of the most optimistic and optimized calculations, it is clear that we should be expecting 5 to 10 years, more realistically, before there is a need for a new intervention. And we would still be optimistic in that we are neglecting all the possible complications that the poor guy could face.

I am not trying to rain on anyone's parade, and least of all the patient himself or the thousands of others with heart problems. I just think it's a shame how the media are having a field day with his story and modeling it, be it willingly or unknowingly out of lack of scientific knowledge, to fit the textbook picture of a world-class achievement in medicine, or that of the wonderful doctor or hospital saving lives by the millions. That this life has been saved is simply not true, and while I am truly ecstatic that this operation took place where I work, and even more ecstatic to see its success and the time it gave our 37 year-old father of four, I cannot emphasize enough how much of a temporary solution this is for our patient, who is, at the end of the day, whom we should think about before anyone or anything else. I can only hope he and his family know what the future holds for them.

This is a milestone in the practice of Cardiothoracic surgery in Lebanon, one that I am proud to witness during my young career. I just can't stand it being taken out of context in this manner. The authors of these articles and their sources shoud be reviewed.

The Emergency Room... Oh the Anarchy!

If I had one word to sum up the ER and what comes through there in a day, it would be Chaos. But it's amazing. Challenging in a way I could never have imagined. It took me 2 days to realize that what you can learn in one day of an ER clerkship really amounts to more than you will learn in 2 weeks of patient care and follow up on the ward floors. There is no comparison. You can see, examine, process, and discharge 10, 15 patients a day with ranges of problems so varied it'll make your head spin!

On any typical day you can see:

-The prissy church choir girl (girl being a serious misnomer here, seeing as how she was 74, but hey...) who "burnt" her hand trying to put out a blanket, placed a bit too close to a candle, caught on fire near the church store room. She had two of her fingers covered with melted nylon which stuck after cooling down. She came to the ER not because she had a burn, but because she had no idea how to remove this thing of DEATH that had entrapped her silly fingers!!!

And then minutes later...

-The poor 24 year-old construction worker (A.) who had a 6-kg rock fall over his head from the top of a 9-storey building while he was out for a walk on his break. He sustained multiple fractures of the skull, and was brought to the ER with his mashed brains pouring out the top of his head. Scientifically speaking, and to put things in perspective for my med readers, the brain CT report was significant for multiple skull fractures reaching the base of the skull, severe depression of a part of the calvarium deep into the brain causing midline shift, trans-tentorial herniation, and severely increased intracranial pressure with all of its sequelae.

We stabilized his vitals after 3h of fighting and 4 L of I.V. fluids.

The poor guy died in the ER exactly 48 hours later.

This is a small idea of the spectrum of sights and colors we see on a day at the ER. But what struck me the most is surprisingly not the patients. It was not the drama, the excitement, the rush of dealing with life and death. It was the patients' families. Why? It became apparent to me how everyone saw nothing but themselves, nothing but their own, and just dismissed everything and everyone else in complete and utter disregard.

As poor A. was expiring in Trauma 1., we were also handling a patient (in S2) with mild head trauma. He had been hit by a car at low speed and hit his head against the windshield. He was awake and oriented, and his studies all came back negative, so basically he was fine. All he had left was a small laceration on his forearm that we had to suture before we could send him home. Naturally when the alarms went off on A.'s monitor screaming that he was going into severe tachycardia and O2 desaturation, we all left S2 to go check on A. and see if there was anything that could be done. Obviously there wasn't.

Now imagine this. Coming out of Trauma 1, heavy with heartache and shaken to your core by your first ever encounter with death and a patient who slowly died in your hands, you and your resident take a tough walk out to the ER waiting room and make sure the parents know that their worst nightmares have come true; "we are truly sorry to have to tell you that your son passed away 2 minutes ago. There was nothing more we could have done."

Now imagine walking back into the ER, in that state of mind, to find an obnoxious old lady, S2's grandmother, in a panic, screaming at you and yelling all sorts of nonsense asking you how it was possible for "doctors" to leave his wound uncleaned, knowing that she was coming to see him. She hates the sight of blood apparently.

How could we? how could we have such disregard for her great presence and not have wrapped him up before we tried to help a truly dying person? I don't have an answer to that.

This was even more destabilizing to me when I thought back at A.'s parents' reaction when we told them what had happened. Actually it was not in any way worse than the old lady's panic. No. Even less dramatic in my opinion.

So is worrying about a loved one an all-or-none sentiment? Can anyone worry, but at the same time have as little as an ounce of consideration? Can anyone worry, but realize that there are priorities and that there are always people who are worse off??

The answer is, YES, worrying is an all-or-none sentiment. From the stupid prissy choir girl who came for a hand-cleaning session, to the exceedingly unfortunate A., rest his soul, brought in by the Red Cross with only a few breaths of life left in him, and to the mind-twistingly annoying and naggy fat boy who twisted his ankle and had no signs of injury remotely indicating even as much as an X-Ray, you will be surprised to see that the parents all act in the same craze, the same insanity, and the same "treat-my child-first" attitude. You will be surprised to know that sometimes it is even reversed, that families of patients in dire emergencies will seem more composed and cohesive than families of patients with petty scratches not even worthy of a band aid. And for now, this is what makes the ER stand out.

Patients: for a change...

I am happy to report that the long awaited feelings of gratification, satisfaction, and sweet fulfillment have come through during these two past weeks of hospital clerkship (the first two weeks in Med III). This is it. What I have been waiting for since I graduated from high school, and even a few years before that, if you will deem meaningful the idealism of a foolish teenager and his noble aspirations to save the world one patient at a time. This quest, this mission, now surely tarnished by disillusionment and eroded by its relentless and savage conflict with the grit of reality, this enthusiasm, and idealism, or what's left of them, is what I am trying to salvage at this time in my life and career. The fact is, I can proudly say that at last, at long last, I have the power to do something about it. I, your dedicated and enthusiastic medical student, now have enough to work with to impact people's lives, no matter how limited that impact may be. Flashback 3 weeks ago: I was just another student in a classroom counting the seconds before it was time to head back home or to the pub for a few drinks. Now, for a fast change, things are different. Let me tell you the story of a patient who made me realize that.

N. is a sweet old lady patient I was following up. She was one sick lady, with heart problems, kidney problems, and diabetes. One of the many, many long term complications of diabetes is peripheral vascular disease. simply put, this means that diabetics have problems in their blood circulation and as a result, there is impaired blood supply to the lower extremities. Impaired blood flow means impaired oxygenation, impaired eventual wound healing, and impaired immunity in the affected area. This is why you see 'informed' diabetics and think that they're anal about foot hygiene. It's simply because they've been informed that even the smallest abrasion or cut to the skin of their feet could result in devastatingly painful ulcerations and invasive infections that could ultimately warrant the amputation of a toe, or even the entire foot or leg in severe cases. What makes it worse is Diabetic Neuropathy, another complication of Diabetes that impairs sensation in the lower extremities, meaning that any wound, abrasion, or developing infection in a hidden area could go undiscovered for months, without the patient feeling so much as a tingle. Read more about The Diabetic Foot and Diabetic Foot Care.

N. had had diabetes for many years, and after an ulcer between her toes failed to heal and got infected, she lost her little toe, which was amputated to prevent the infection from spreading further up her leg with dire consequences. The first time I examined N., she immediately reminded me of my grandmother (Read); an exceedingly sweet, but obviously worried old lady, more open to suggestion than anyone could imagine. Even long years of fighting with chronic disease, life saving operations, and medications, along with a roughed up body both inside and out, had failed to embitter this inspiring character. The best of it all is that all she had to do was smile.

After this introduction it's time I got back to the point I was trying to make. People like N., with limited resources, bad or no insurance, are usually treated and let go as soon as possible. This is the sad reality of health care today, and is something that I'll be sure to write about when time and inspiration permit. The bottom line is that after a successful operation, N. was about to be sent home with her foot well on its way to a full recovery. Sadly, no one really took the time to sit down with N. for a few minutes and explain to her what steps needed to be taken to avoid another visit to the operating room. My group and I (Myself, M, and G.) felt that we could do it. Why not? It is now our duty to care for our patients, examine them, and help in their treatment and convalescence. Why would we not be responsible of raising some awareness and help them also by preventive measures? We went to N.'s room and gave her a talk with a few crucial instructions on how to care for her feet. And yes, this is the essence of what I've been rambling about for the past 3,000 words or so. We did that, and I like to think that we DID make a difference in N's life. Only time will tell, but things are looking up.

M. told me a similar story about one of her patients. She felt the same as I did, but the feeling is a bit new to us. It's something that, deep down, you know is right and that you are 100% sure that you're doing the right thing, but that still feels awkward, for some reason, and you're always worried that it's not your place. Well, I think it is. And I'm sure that if we don't do it, no one will. If we somehow lose this enthusiasm, this 'flame' that sadly has burned itself out in all but the newest blood in the health care system, we can be sure that no one, especially not the hardened veterans with their cynicism, will kindle it back to life. And it is the patients that will ultimately pay the price. Who else?

I said goodbye to N. with a few last minute instructions and reminders, and she told me how grateful she was, and the last words she said before I left will stay with me for a long time.

"Ra7 a3mel metel ma eltelle ya 7akim!"(I will do exactly what you told me to, Doctor!) - said a proud and emotional N. ...

And So It Begins...

One week into Med III and I've been wondering how it would be possible to sum up a whole week in one post. And not just any week. The first Med III week,the first week in med school remotely resembling anything that even comes close to being a physician.

Well in fact, sometimes when I think about it I feel that I haven't done anything quite so significant yet. But at other times, I also feel that every small step, be it the patient you so much as greet in the hallway, or the first EKG you set up, or every Once-In-A-Lifetime Choledochal Cyst (1 case per 2,000,000 Live Births in the U.S) Roux en Y Hepatico-Jejunostomy (Yeah never mind... Just something fancy ) you witness in the OR is now a decent step forward, a landmark, a mini checkpoint, if you will, along the way to becoming a fully developed physician. It's really hard to describe, but what I can say is that it's a whole new world, that's for sure, and there is absolutely no way of comparing it to the previous two years of classes and bookworm-ism so I'm not even going to try.

Getting ready for tomorrow, the 8th day into Med III and the General Surgery rotation we incidentally started out with, and already, I'm (and when I say "I" I mean "we") already feeling more familiar with the system. There's a certain satisfaction to it, to becoming one of the microscopic cogs on one of the tiny wheels in the at-best marginally well-oiled, Willy-Wonka-esque machine that is our hospital. We meet with and examine patients, write admission notes, follow up on patients after their operations, write progress notes, and suggest management plans that will be a new point of reference in the patient's chart. And the new in it all, I mean besides the contact and all, is that it feels useful. What I'm doing with what I've learned and what I'm learning is actually being used by my peers and superiors, to benefit someone in the end. I think that's the best way of describing what it feels like. In one word: just grandiose. And it's only when you realize just how much more there is to learn, how much more there is to accomplish, that your head starts spinning and you let it spin back down to earth and get on with what you're doing.

I just paused for a second, and thought about all the stuff I want to write here. There is no way this could all fit into one post. So if somehow I've managed to grasp your attention and interest, come back soon for more...

Pediatrics... Uh-Oh!

I've been wanting to write this for a while now but it's just been a hectic couple of weeks what with the classes, both skipped and attended, the exams, both near misses and lucky escapes.
So here's another foray into the earliest clinical experiences and their impact on a confused med student shopping for a marginally successful career.

I've always struggled to understand kids. I'm only consoled by the mutuality of this feeling when it comes to my younger brother and sister, my younger cousins etc... There's always been animosity and for a reason. I don't seem to get them. Trouble inexorably ensued!! For me, as far as kids are concerned, no one could have said it better than the late Bernie Mac: "...Oh shit come help me babysit these m*****f******s..."! I know that to the baby lovers and kid huggers among you I'm gonna sound like a Neanderthal but I'm banking on an outside chance of a few of you feeling about the same way that I do; so I'm out on a limb I guess...

10:15 am - Visit # 1 - The Regular Checkup for the Obnoxious Fat Boy
Phase 1 - 5 year-old kid walks in with his mom. A 2-minute dialogue between the physician and the kid's mom about diet, playtime habits, and vaccines follows.
Phase 2 - Physician invites kid and mom into exam room.
Phase 3 - Kid enters battle mode and seems to latch on to his mother's leg in a grip worthy of the most intractable centipede dead-locks!
Phase 4 - Kid is now on the exam table - don't ask how that happened - screaming his little butt off while physician desperately tries to hear something in between the groans and moans with the stethoscope, as the kid gasps for breath.
Phase 5 - Physical complete. Physician calls for the nurse with the vaccines (I named her the Shoot'em'up lady).
Phase 6 - Shoot'em'up lady comes in, tray in hand, with 2 shots worth of vaccines. "One in each arm please", says physician.
Phase 7 - All hell breaks loose as Shoot'em'up lady pricks the kid once and another time. Me watching, worried that the little demon's gonna fidget one time too many and break the needle off in his flesh with dire consequences. Shoot'em'up lady's job? Not for the faint hearted!
Phase 8 - Shoot'em'up lady in the sweetest of voices: "there all done! That was not that bad now was it?" Me in the corner, trying not to puke.
Phase 9 - Physician declares the session over, gives the kid a lollipop. On to the next one!

10:35 am - Visit # 2 - The Regular Checkup for the Demonic little girl
Same as above. Please replace "5-year old" with "4-year old", "mom" with "dad", "his, he, him..." with "her, she, her...", and "all hell breaks loose" with "My eardrums burst" and that's about it, all the rest is essentially unchanged.

10:50 am - Visit # 3 - The Regular Checkup for the Sweetest Thing that Has Ever Existed (now that's a change of pace!)
A 2 month-old baby girl with the face of an angel. Brought in by her mom and grandmother. Onto the exam table after the formalities of phases 1 and 2, she lay silent, her fists clenched and her tiny arms and legs twitching from time to time. Her big grey eyes desperately looking for something to focus on apart from the bright overhead light. The physician examined her, looked at me and said suggestively: "she has a very faint murmur you should hear." Even her guardians were nice and joked around, and actually acknowledged my presence, something no other parent/guardian managed to pull off, the physician's failure to introduce me as his apprentice notwithstanding, talk about professionalism! Would it be too much of an effort to say this is R., He's going to be learning with us today, please don't be freaked out by his curious eyes... but I digress... So here I was, awestruck, in front of a silent pediatrics patient, until, you guessed it, Shoot'em'up lady came in and screwed everything up with one little prick.

11:05 am - Visit # 4 - The Regular Checkup for the 2 Girls From Hell
This one was a bit funny, I have to admit. The older of the two went first. After a typical phase 1, phase 2, and phase 3, came a rather peculiar phase 4:
-Physician: "Let's see what's in your ears now all right?"
-Little girl, tears in her eyes, pouts and answers: "no. there's nothing there I checked!" I cracked a smile.
After going through phases 1 through 8, with the ruckus and the rivers of tears I had now adapted to, she looked at her sister (now in phase 4, the worst) who was screaming so hard that I was afraid her eyes were going to pop out. And then, in a condescending tone, one that flaunted her newly acquired wisdom to her sister, she quipped: "khalas! ma 3am ya3mellik shi! lesh 3am tebke??" translation: "Stop crying! what's the problem they're not doing anything to you!" I couldn't help but laugh, look at the Dad and say "oh, now she's wise!". The dad nodded, threw a fake smile my way and went on to talk to the doctor.

That visit ended at around 11:45. Another short uneventful visit (uneventful only meaning not any more eventful than the other visits, because you may imagine that there is no such thing as an uneventful visit to the pediatrician's!) and it was time for me to head out. And as I was getting ready to do so, the attending, having noticed my expressions of boredom and anguish, smiled and said: "It's a lot of repetition, this specialty." So I smiled back and said nothing. What could I say? "Yeah Doc it was nice watching you play and toss your stethoscope up and down while the nurse did all the real work" ? hehe no, I don't think so.

For me, it was an interesting experience, to be honest. Sure, for the most part all I could do is think about the best ways to shut the kids up, and these included hammers, fists, screaming in anger, but also, I have to admit that a nice strawberry lollipop and a reassuring kiss on the forehead went a long way sometimes. So what am I saying here? Hold on... I'm not so sure anymore! I mean when I started concocting this thing you're reading I imagined it ending very differently. Somewhere along the lines of "Kill the bastards", or "Fucking kids!" or... you get the drift... But as it turns out, I am just realizing now, as I'm typing, maybe I don't hate the little buggers as much as I used to... Maybe I did think that the little wise-ass girl was funny and cute, or that the helpless silent baby girl was just to die for... I must be growing up. Go figure. Well some of my closest friends would say: "it's about time"...

The First Clinical Experiences

Towards the middle/beginning of the end of Med II, medical students are supposed to go on these so called 'Shadowing' sessions with the practitioners of health care; their mentors, superiors, attending physicians, whatever you want to call them. This is some kind of apprenticeship for more clarity... Needless to say, almost all medical students are tired of sitting in class and sitting for exam after exam after exam every week by that time of the curriculum (Med II is the last predominantly didactic year in the med curriculum). So these eagerly awaited sessions are the very first opportunities we get to see actual patients, and understand and witness how, and sometimes whether, what we learn in the classroom is brought to fruition in the real world.
I thought I'd share my experience with my first few 'encounters'...

Med Students and General Trends

So these sessions are generally very rewarding for med students. Well at least they should be. After all, these are the first few times we are exposed to the workings of the health care system and get a chance to experience a touch of what it feels like to be a "Doctor". Remembering the day of our absolute first PD (Physical Diagnosis) rotation, it was a day like no other! Everyone was dressed to impress, the ties, the suits, and the button down shirts -why? we have a formal dress code in our Medical Center (MC) - made it feel more like going to a wedding reception than to class! Right then and there the impressions began to rush into my mind as the personalities, values and norms became more and more public in our prided med students. I can't help but smile as I type this, because I'm remembering my thought process as I saw and analyzed the reactions and moods among the students (myself and my own included, see below). A select few couldn't care less, and it was just another day at the office for them; "...to hell with the dress code I'm wearing my sneakers today!". To others it meant a slight bit more, as I could tell from the tidiness with which their ties were tied, how neatly their shirts were tucked under their pants; nothing too excessive here, just a different mood you don't see everyday. Still others made a complete, full-fledged rite of passage of the matter and there was a billboard above their heads, piloned to their shoulders, that said "M.D." That stayed on long after the rotation was concluded. The billboard, naturally, came with the awfully unusual and unexpectedly excessive and outright creepy fake friendliness they greeted other, more 'normal' people as well as their colleagues with, not to mention their glue-on, fake, arrogantly proud, or maybe proudly arrogant ear to ear smiles that lasted for hours on end... Some found it would be cute to dangle their stethoscopes around their collars, even among those who were on the dermatology or ophthalmology rotations. Of course, these same students also thought it would be even cuter to keep their lab coats on after they left the hospital, and to flaunt their newly found glory and self-satisfaction and self-approval at the university's main gate and around the better part of the whole campus. Id tags and stethoscopes dangling from lab coat and shirt collars, respectively-and here you err into the nature and discussion of pride, status and meaning of the white apron and stethoscope, the social impressions, the implications and how fake and stupid they may be, but I digress...

My Personal Experience; and a Bit of Introspection to Go...

That morning, I woke up a bit earlier than usual. I can't deny the excitement, the expectations that I had on a day that was a bit more... important?... no... perhaps I should say, a bit different than other days. I put on my new shirt, my new tie, with the pants that I wore to my uncle's wedding some year or two ago. Here's a dead giveaway; my tie was very tidily tied, after all "A well tied tie is the first serious step in life" according to Oscar Wilde! So I left home in a mood that felt brand new. A mood that just seemed to put everything else that was going on at that time on hold. The stressors, the studying, the few nearly failed exams and the financial troubles; everything that had been restlessly gnawing at my brain since even before the day I started med school, was simply swept aside as the new order of the day was to discover what this excitement was all about. Also on my mind was what it would be like to see the inner workings of our MC, to see patients and cases from that new perspective! I can't remember ever starting a day like that before. After a serene 6:00 AM drive to university, a one-hour session of caffeine-kick starting to my system, and an Immunology lecture from 8:00 to 9:00, it was finally time to go to the Ophthalmology department at the AUB MC!

Here, I would have loved to say that the session was a fantastic, life altering experience because not only would that have been wonderful for me to write about, and for you to read, but it would also have been a perfect culmination to everything I've said before. But sadly it would be a lie. The fact is that it was a 35-minute session of show and tell. The ophthalmologist in charge of our group just sat there and force-fed us a review of the anatomy and histology of the eye... and then showed us around saying "oh this machine does this, that one does that..." and a bit of "I know so much more than you do!"... such a disappointment, especially when we got to see the other groups coming right out of Cardiology, ENT (Ear Nose Throat), etc... with their stories and now-even-wider fake smiles! The stuff that I do wanna write about, however, came in subsequent rotations so let's skip to those!
There are two patient encounters that really stuck with me. Two patients that made me realize how thirsty for knowledge we medical students are. Let me start from the end and say that as we got out of the respective rotations in ENT and Dermatology, we were blown away. Blown away, yes, but why? Because in the words of the human embodiment of high-end refinement that is the medical student and future Healer, "it was so cool. it was so interesting, a great case to start off with!" It is here, and after long thought, that I felt something was off and I lost a bit more faith in the medical community... Why? one would ask what the big deal was... I mean I've been rambling about how these experiences are what we've been looking forward to for years and years, why is is such a problem that they turned out 'cool and interesting'? Let me put things into perspective:

Case 1: the very cool case in ENT
A 5 month old baby girl referred to the OPD because she had intranasal obstruction and externally visible swelling over the upper part of the nose. After clear fluid started dripping from her nostrils, an MRI was requested and revealed an invasive mass that had worked its way up through the cribriform plate and into her brain, which explained the Cerebro-Spinal Fluid (CSF) drainage.

Case 2: the very interesting case in Dermatology
A 25 year old man (M.S.) that had a Bone Marrow Transplant (BMT) came to the OPD accompanied by his mother with a generalized exfoliative rash. One of the first signs of Graft Versus Host Disease (GVHD). In his own words: "I had a BMT exactly 120 days ago and this rash has developed lately [...] I'm worried about GVHD and we need to take biopsies[...]".

The implications of these problems/complications that the patients encountered are devastating. Really I don't think I have to explain to the lay person that a tumor reaching and invading the brain is bad. On the other hand GVHD is a complication of immune competent cell transplantation (Bone Marrow and sometimes blood transfusions) in which the grafted/transplanted cells mount an immune response against host tissue, often resulting in multiple organ failure and death. And to see M.S. and how he was handling something he knew so much about was a sobering experience to say the least. He started talking about his condition and throwing the acronyms around, telling the doctor which meds he was on by active ingredient and mode of action! It took me a few minutes to reach back into my rusty and dusty immunology memory and figure out what the hell he was talking about! I was afraid to make an ass of myself if the doctor asked me a question! Skinny M.S. looked tired, and when he undressed to show his rash, the scars scattered on his spent body told the tale of the time he spent on the operating tables. The dermatologist added two more as he biopsied his skin in two places. "I'll call you in a few days and let you know what turns up!" he said to MS. I left the clinic and never heard about MS again.
And there we were, a few hours later, with our "cool" and "interesting" and ooh my case was more interesting and bloody than yours, about life threatening and life altering complications that destroyed lives of patients and their families. That's right, I finally know what a GVHD rash and patient look like, and how a tumor can work its indiscriminate murderous magic! But it's the meagerness of our reactions to these catastrophes, and just how insipid and trivial we made them seem, that gets to me...

The Girl in Gray

It was a beautiful morning, and I had found myself a seat next to a 7th floor hospital window to peer out of. The city looked small, with only a few rooftops carving into the horizon. The intense, yet hypnotizing turquoise hue of the Mediterranean was playing with my senses. The voices and clatter in the crowded room seemed to fade as I started to imagine stories and serendipities for the minuscule people. I gazed and wondered... What's that down there? Oh look, up there! a plane! I wonder where they're going...
And there she was. Way down there, tiny, and making an easy, yet elegant stride of what any other woman would make a complete mess of, holding more scholar paraphernalia than one would care to describe. She caught my eye, her charming gray outfit contrasting against the yellow tiles as she made her way through the plaza. I wonder where she's going...
She holds her phone to her ear and disappears into the crowd... Is my phone ringing?