Thursday, June 26, 2008

Frustrations with giving medical care

I'm sure there are a many frustrating things during intern year, and I'm sure I will blog about quite a few of them. Here's one.

There are so many patients in the hospital who fight with you about their care. You're trying to do something for them which will make them better, and they don't want to go through with it. And I'm not talking about interventions that are risky, or have lots of side effects, or ones that we're not sure about or ones that don't matter that much. Sometimes they're life-saving interventions! Here's my example from intern year:

I had a patient who had a horrible infection - she needed IV antibiotics. She wasn't about to die just yet, but if she didn't get the IV antibiotics soon, she would get horribly sick. And we know this because we see it happen all the time. Sometimes we don't even know people have infections in the hospital yet until they're horribly sick - we got lucky and managed to catch this patient before they got to this point. She tried to refuse the IV antibiotics! She said vitamins or herbs might do just as well. Ridiculous. She also had made some really bad medical decisions that had got her in this situation in the first place. I spent close to an hour talking her into, first, letting us put an IV in her arm, and then second, getting the IV antibiotics. What if I had said, fine, don't get the IV then. She would have gotten seriously sick! But of course, I spend more than an hour arguing for her, and she got the IV and the IV antibiotics, which probably saved her life.

The problem is that it's very difficult for doctors to say something like oh well, it's your call, go ahead and die to a patient. First of all, they genuinely believe in the therapy and believe that they're right. Secondly, if they didn't try their absolute hardest to argue with the patient for their own good, doctors would be held liable. It's very frustrating, but I think we're stuck with it.

Blue Moon

I can't believe it. Blue Moon is a wheat beer, one I often order at bars and enjoy quite a bit. I just found out that it's not a microbrew, never even started as a microbrew, but in fact was created by one of the giant brewing companies. I'm sure had I known that before I started drinking it, I may have looked down on it a bit more.

But taste is taste - it's still a good beer.

Monday, June 23, 2008

George Carlin - anorexics and bulemics

Here's another one, much shorter than the first. It's about anorexics and bulemics. Man, that was a funny guy.

George Carlin video about swear words

Well, George Carlin died of heart failure today so of course this news is everywhere. I just watched this video for the first time. It's his famous bit about swear words. I'm not going to say much about him because I honestly didn't know him that well or watch him that much, but this is HILARIOUS.

Saturday, June 21, 2008

First Call - to Code or not to Code?

I had my first overnight call as an intern. It wasn't too bad. Pennsylvania Hospital is actually pretty nice to their interns. Typically, interns stop admitting around 1 or 2 am if they're on overnight call. Which means they probably get 3 or 4 hours of sleep, which is great! Of course, I spent about 2 hours with my resident doing a paracentesis (sticking a big needle in somebody's abdomen - you usually do it when fluid is building up abnormally in a patient's abdomen, making it all poofy. Yes that's a medical term. Poofy.) and trying to get IV access and blood drawn from a very difficult patient. So I didn't even start admitting until around midnight, and I felt bad, so I ended up doing 4 admissions, which lasted until about 4:30am. Plus there was a code - which is the thing I actually want to talk about that happened that night. I ended up getting only about an hour of sleep.

So the code was interesting - a resident and I are doing admissions in the ED, and suddenly a code call goes out across the hospital-wide PA system. "CRT... CRT... " and it told us the location. Apparently that means somebody was going through cardiac arrest. I found out later that this patient had been doing fine after his surgery and was being monitored by telemetry. That's where they attached a lot of electrodes to a patient's chest, it monitors their heart, and somebody in a centralized location watches a lot of monitors 24-7 to make sure all those hearts are working properly. This person noticed that at 1am, this patient's heart suddenly stopped working for some unknown reason and called the code. When my resident and I got in there, there were 4-5 people already there working on the patient and giving CPR. It turns out giving CPR (which at its most basic is simply chest compressions and giving breaths) is the most important thing in bringing someone back from the dead and giving them the best chance of survival afterwards. Somebody had already gotten IV access, and he was being pumped full of fluids, they were attaching a monitor to his chest. His heart was in ventricular fibrillation, which is a type of arrhythmia, that if left untreated, usually leads to death. They shocked him, and he immediately went into PEA, or pulseless electrical activity, which means the electrodes were sensing electrical activity by the heart, but it wasn't actually pumping, and the patient was pulseless. At this point, shocking doesn't help anymore, and you basically continue CPR and start giving all these different types of medications meant to jump-start your heart.

The rule of thumb is that you don't continue to code a person past 10 or 15 minutes because (1) the chance of survival is way too low after that period of time and (2) even if you bring them back to life, they've been "dead" for too long, and their functionality is horrible. There's a good chance they'll code and die again before they leave the hospital. However, in reality, codes often go on for 20-40 minutes, especially in patients where it is unexpected. Time goes super fast in a code, and people are reluctant to give up. This code had gone on for about 17 minutes... people were starting to give up, they'd loss IV access (I actually managed to put a new one in on the foot that lasted about 2 seconds). And then all of a sudden, someone says "I've got a pulse." Crazy. This guy was dead for 17-18 minutes, and then all of a sudden his heart starts working again. And the monitor shows that his rhythm, although not idea, is a workable rhythm, and he's "alive" again, and somewhat stable. All this activity starts up again and he eventually gets intubated (a breathing tube shoved down his throat) and transferred to the ICU. I don't know what happened to him after that - I guess if you follow statistics, there was a good chance he coded again and died.

Afterwards, I finally found out the rest of his story. This patient has esophageal cancer, one of the worst cancers to have. The treatment is surgery - they take out your whole esophagus, which is an extremely hard surgery to live through. Then afterwards, many patients have to go through chemotherapy and radiation, which is definitely no joke either. And after all of that, there's a good chance of it coming back anyways! So even if this patient lived and was stabilized, first of all, he would probably have little to no brain function since he got very little oxygen to his brain for 17 minutes. He'd be a zombie, on life support, for the rest of his life. Even if a miracle happened and he woke up, he'd die of his esophageal cancer pretty soon, or have to go through chemotherapy or radiation, which might kill him too.

So my question is... should he really have been coded? If I were the patient, I would not have wanted that. But not many people think of these things when they're going in for surgery anymore. In many countries, they trust the doctors to make these decisions, but in this country, and in the era of litigation, that's just not possible. Because of this, we waste millions of dollars on codes and life support and everything else. But more importantly, it leads to horrible situations that families have to deal with.

Wednesday, June 18, 2008

Faith in American patients

Today may have restored my faith in American patients. Way back when, I posted about how much better African patients were than American patients. Today was my first day of internship and I was prepared. I was prepared for the gripes from the patients: "My cable TV isn't working!" "I asked for mashed potatoes for dinner, not broccoli!" "I refuse to take that medicine!" "I demand a private room!" And of course, I was not expecting any gratitude or help with the patient care from the families. I was not even expecting the patients or their families to know anything about their own illnesses. I expected a lot of drug addicts, HIV patients, gun-shot wound patients, people with no family support, rudeness, impatience, an air of presumption and expecting things they should expect.

I was surprised. Three of my patients or their families expressed extreme gratitude for my help. Some of them were pretty demanding, but in the end they were grateful for all that I did. A fourth patient started out pretty surly and unfriendly. To be fair, he's been in the hospital for close to 3 weeks, and he's not that much better yet. But after talking to him and joking around with him for a few minutes, he warmed up, and even thanked me at the end for talking to him.

I think in the end, you get what you put into the patients. They may be very demanding (especially compared to Botswana patients), but if you really care and try to help out, they'll see that in you and be appreciative. If you don't care about them, of course they're going to realize that and see that in you. Maybe American patients aren't so bad after all. Or maybe it's my first day and I'm still being naive. :)

The first day of internship

Today was my first day of internship at Pennsylvania Hospital! There were a few hitches - we didn't have our own long white coats (the universal symbol of being a doctor), so we had to borrow other people's. Not a big deal - we put tape over their names, which are stitched over the pocket. A few of us also didn't have our logins or passwords to one of the main computer programs used in the hospital. Without it, we couldn't enter electronic orders, or really check labs on patients. It took a couple hours to sort it out, so that definitely ate into our working time. Also, I still don't have my email account. Oh well - hopefully nothing crucial was sent to us! All this was a little annoying, because you would think these things would all be taken care of weeks ahead of time, since we found out we were going there in May. But it's not a big deal.

Despite it being the first day, I think it went relatively well! I had 7 patients to start, and 3 of them were discharged. My resident helped me out, as well as the other intern on the team quite a bit since we didn't know these patients at all. We were also lucky - my co-intern (Christina) and I both know the programs and the system relatively well, so we were able to do things much more efficiently (I imagine) than some of the other new interns. Some of the newbies definitely had frazzled looks on their faces. :)

Tomorrow will be much harder for us - we're on call. Christina has to stay until 10pm, and I am staying overnight until the next day at 1pm, and we are taking patients during most of that time. That means not only will we be busy with the patients we already have, but we will also be admitting patients from the ER, which takes on average 1 - 1.5 hours per patient. We can each take up to 5 new patients, in addition to the ones we already have. It's gonna be interesting!

Sunday, June 15, 2008

The Making of the Lubangs

I just got married!

We had a crazy 3 weeks, starting with my graduation. You'd think this would be a bigger deal since I spent 9 years trying to get this diploma, but it got a bit eclipsed with the wedding. But it was still a good time - my parents came into town, as did Pete's mom. We had a nice dinner that night, and the next night, my parents through a big banquet dinner for me and my friends. It was so nice of everyone to come!

That next week we spent getting ready for our wedding, which takes way more time than you might think. I can't even remember what I was doing anymore, but every day was super busy doing super important wedding stuff. Plus we were picking people up from train stations and airports and my brother his girlfriend, and my sister and her boyfriend were staying with us.

The wedding itself was so much fun for us! We started with photos to get them out of the way, and then it was on to the ceremony. My brother Bruce was our officiant, with Karen, my sister, as my maid of honor, and Ben, Pete's brother, was his best man. We had Ben's two twin sons, Jacob and Aaron, as our ring bearers. During the rehearsal they were so cute, in their tuxes carrying the ring pillows. I wish I could have seen it myself, but I hear during the actual ceremony, they did great! And of course, there are probably a bazillion pictures documenting their cuteness. :)

Bruce did an awe job as the officiant. I'm lucky he let me read a draft of his talk the day before, because when I read it I was bawling, and that probably would not have been the best thing to do during the ceremony. He made it very personalized for Pete and I, which was great. You know those parts of ceremonies where you almost fall asleep? Well completely objectively-speaking, there were none of those parts during our ceremony. I for one, did not fall asleep. :) Tons of people came up to us afterwards though and told us what a wonderful job Bruce did. There were even a few requests for Bruce at other weddings!

Afterwards came the cocktail hour. We holed ourselves up in our private room for 30 minutes or so then stepped outside for some socializing. The private room was great - family members came in to see us, we played with the twins for a bit, and we even had our own food! I didn't have many of them, but people said the appetizers were great. We had a table with lox and whitefish and bagel fixings, a table of cheeses, olives, and crackers, as well as an assortment of butlered hors d'ouvres brought around to guests: shrimp tempura, wild mushroom phyllo, scallops wrapped in bacon, coconut chicken, beef tenderloin with eggplant, asparagus with goat cheese, peking duck rolls, and crab cakes. And, of course, it was open bar.

Time went so fast! Before we knew it, it was time to go into the reception hall. Bruce went in and was announced first, followed by my parents (Phillip and Catherine Jang) and Pete's mom (Carol Lubetsky). Then we were announced as Mr. and Mrs. Lubang! It was such an amazing feeling to go into that room with everyone cheering and applauding. After our entrance, we went right into our first dance. I know this is what everyone wants to see, so here, courtesy of Jen (my sister-in-law, Ben's wife, and mother of Jacob and Aaron), is a video of our first dance on youtube. We had it choreographed to Let's Get it Started, by the Black Eyed Peas.

The first dance led right into the hora, which was the best idea ever because all the energy from that was transferred into the hora. I've never been lifted or pumped in a chair before, but it's great!! I can't believe they even got my parents up there. And everyone said my dad looked so good in his yarmulke. :) After that, there we had toasts from Ben, Catherine (and Phillip) and Carol. And then we started dinner! Even though we didn't get to eat too much of it, everyone told us the food was so good! I think it was just as good as when we tried it at the tasting dinner. Just because food is my thing, this is what the guests were served:

Butternut squash soup (delicious!!!)
Caesar salad

Main entree: Guests had a choice of
(1) sweet potato-encrusted NY strip steak grilled medium rare with roasted potatoes and julienned vegetables,
(2) chicken olympia (seared European chicken breast topped with sauteed spinach, roasted red peppers, and feta cheese in a lemon-thyme sauce) with garlic mashed potatoes and julienned vegetables, or

(3) a vegetarian option that I -believe- consisted of tortellini. I guess this shows how much
we cared about the vegetarian entree... :)
Kids got something like chicken fingers and fries.

Dessert: wedding cake! (with coffee or tea) The wedding cake was a layer of vanilla and a layer of chocolate, separated by a coffee ganache and a raspberry layer. The wedding cake was awesome - we got it from Dough Main Bakery. Pete keeps talking about how he wants to order another cake from them. :)

The rest of the wedding was fantastic! We had a father-daughter and mother-son dance, which ended up with all of us dancing together. We did cake cutting and a few more pictures. We talked to so many people, although not nearly as many as I wanted to. At some point we tried to make it around to all the tables, but we probably didn't even get to half of them! I felt really bad about not talking to some people, so I figured it out... the entire reception was 5 hours, but we spent half of the cocktail hour alone, then there were the different dances. Also cake cutting, toasts, etc. - so there were really only about 3 hours to socialize. If you divide that by the number of guests, each guest would only get a little more than a minute! So if I talk to someone for 5 minutes, I shaft 3 to 4 other people! So no wonder I didn't get to talk to everyone - I'm justified by math. And yes, this is pretty nerdy. :)

It was a wonderful day and I think it set the tone for a wonderful life.

Friday, June 13, 2008

The beginning of intern year

Yesterday marked the beginning of my intern year at Pennsylvania Hospital. I haven't done anything clinical really since September when I was in Botswana. I guess I took a radiology elective, but really, I didn't work too hard. I had to get up at 6am! I know, it's a tough life. I'm hoping to be able to blog about life as an intern throughout this year with some stories and insights into hospital life, but this being intern year, we'll see how much time I have for that.

For these first two days we have ACLS training. That is, Advanced Cardiac Life Support. We learn to run codes, which are when somebody suddenly dies, and you go through the appropriate steps to try to resuscitate them. Have you ever seen an emergency situation on a show like ER? And they yell out orders and give medications, and maybe eventually shock a patient with electric paddes? It's like that. Exactly.

It's actually pretty complicated. Depending what's wrong with the patient, you have to give different medications, treat them differently, order different labs. CONTRARY to what you do see on ER, you don't shock every patient and not every patient gets epi (epinephrine, also known as pure ol' adrenaline). And everything is happening pretty fast - the patient is getting bagged or intubated (getting a breathing tube shoved down their throat), they're getting put on the monitor, somebody is inserting an IV or two into the patient, someone else is drawing labs, someone is giving medications, someone is giving CPR and doing chest compressions, someone is monitoring their heart rate, blood pressure, and a few other things. Not to mention all the bystanders there either just looking on, or trying to be available to help. So there are probably 10-20 people crammed into this small room with the leader yelling out instructions, and sometimes it can be pretty difficult under pressure to remember all the things you have to do, and to communicate effectively with all the people.

That's what all the new interns got certified in today. This is certainly not an unknown issue, but it's a little scary to think of new interns practicing a medicine, much less running a code. I don't think we would be bad, but almost certainly slower. But interns have a huge learning curve. I think by the second week, people are usually up and running, and while the knowledge base is still building, interns can get things done pretty effectively.

I think I would feel relatively confident running a code. Maybe not perfect, but ok, and I'm sure that will improve. I think many of the interns were a little worried or scared about running a code. Thankfully, usually it is a senior resident (a 2nd or 3rd year resident) who runs a code. The interns usually just help out, and when they have enough experience, then they run the code. I know this is a horrible thing to say - I guess that's why I'm in medicine - but I'm a little excited to take part in my first code! Look at it like this - I don't want anybody to die, I just want to help bring someone back to life! :)

Thursday, June 12, 2008

The absurdity of the airline industry

I've been traveling a lot over the last year and I've had to spend a lot of time in airports. Of course, everyone has gripes about traveling. But lately I feel it's been getting absurd. Take a story that my mom told me.

My parents had to be in Boston for a wedding, so I arranged all their travel plans for them - their flights, the rental car, hotel, etc. My parents aren't poor, so instead of going for the cheapest flight, which is usually a red-eye or leaves at an insane hour, I book a reasonable return flight for them going from Boston to Sacramento, which leaves at something like 9am in the morning, has an hour and a half layover, and makes it to Sacramento around 2pm. About a month later, I get an email notice from this un-named airline (but which rhymes with Smelta) telling me that their flight has been changed. Not only does the flight now leave at 7am, but now there are -two- layovers, one of which is 30 minutes long (yeah right, my parents would never make that), and now they don't get home until 6pm at night (9pm EST). This is important because they need rest. My dad is asleep usually by 9pm, and moreover, they were picking up more family at the Sacramento airport the next day from China, Taiwan, and Hong Kong to show them a good time in ol' Sacramento. Anyways, so I call, raise hell, and eventually they rebook my parents - they still have to leave at 7am, but now they only have one layover (45 minutes, still tight), and get back to Sacramento around 1pm.

So the day of their return flight, my mom calls me around 11am. Of course, I'm assuming that it's during their layover, but noooo. My parents made it to the airport around 5:45am - a good hour and 15 minutes before their flight takes off. I would have thought that at 7am, probably the first flight of the morning, this would have been plenty of time. Unbeknownst to them, Smelta apparently has around 7 or 8 flights leaving all at 7am from Logan International. The lines were horrendous and since everyone was in the same boat, they were not letting anybody skip ahead to make flights. My parents finally make it past security with a couple minutes to spare and my mom makes a run for it - my dad was a little slower since he had to put shoes back on and he's old, so he has to sit for that, and tie his shoes and everything. My mom actually makes it to the gate, it was still open, and they were letting in 4 more people. She pleads with the woman and says her husband is coming up right behind her. The gate woman says sorry, it's too late, and closes the doors. Literally a minute later my dad comes running up as well, and she wouldn't open the door for them even though the other people had just gone through and probably were still in line on the bridgeway to get it their seats. It was 7:01am.

How ridiculous is that? Do you know how many times I've been kept waiting by airlines? Not even for weather reasons. For cleaning reasons, mechanical reasons, reasons not explained to us, the customers. These delays have over my lifetime probably cost me days and days of time. If I said, oops, sorry, you were a minute late, I'm not paying - how do you think they would take that? Probably not well.