Medical Urban Legends

As medical students, we whispered about it. Residency. We had read the books: The House of God, which chronicled one young intern's loss of everything that made him human as residency beat him down. The Intern Blues and Rotations, two books that followed peds residents through their first year of internship. We knew that they had no life outside of the hospital and that on the odd time they TRIED to socialize they would commit some horrible social blunder like falling asleep at a family wedding. We knew that would soon be us. We knew that clerkship was no measure of what residency would be like. As clerks, we got called to do consults in emerg... but when issues arose on the floor, the nurses would page the people whose signature meant something... the residents. So we would often get to sleep, at least for a few hours. We knew it would get worse.

But even though we had begun mentally preparing ourselves for the stresses of residency, there were still the whispered rumours that circulated among the medical students. One surgery program in the province was allegedly known for its 100% divorce rate among it's residents. Another was notorious for putting their residents on 1 in 2 call... and submitting dummy call schedules to the union so as not to get reprimanded. We knew the stories. They were repeated time and time again as a warning not to enjoy life too much-- if would soon get pulled out from under us.

There was one story, though, that made even the most naive medical student raise an incredulous eyebrow.

"Didja hear? An ortho resident at Big Name University Hospital had a STEMI."

"Yeah?"

"He was 31."

"No."

"Dude. Swear to God. I heard it from my senior, whose staff works with the nurse who knows the guy's clerk. He almost died. Stress. Lifestyle. It's crazy."

"Heh. Does ortho let you leave at noon post-call if you have a STEMI?"

"Doubtful."

Ortho is the ironman of residency programs. Only for the hardest of the hard-core. Big men (for the most part) wielding saws, hammers and drills in the OR. Long hours, long patient lists... short marriages, and apparently, according to recent lore, short lives. An ortho resident (as is the case with most residents) simply cannot maintain a healthy lifestyle. The work week lasts 120 hours. Call is 1 in 3, and is usually without sleep. Rounds start at 6am so that they're done in time for the OR at 8am. The OR ends at 6pm, when it's back to the ward to deal with the scut. Then, if you're one of the few lucky enough to be going home that day, you're out by 8pm. Usually. Exercise? Please. Eating right? Eating at all is an impressive feat, and it's usually cafeteria fare shoved unceremoniously down the orthopod's throat while the OR is being turned over between patients. Downtime? Stress relief? You've got to be kidding me.

I was a disbeliever. I thought that residency was only as bad as you make it. I brushed aside tales such as that of the 31-year-old orthopod with the STEMI as urban legend, passed on to strike fear in the hearts of medical students everywhere.

Fast forward to the present day.

I'm sitting at the nursing station on the internal medicine floor writing in a chart. Sitting next to me is a fellow junior resident, whom I'll call Steve in a half-hearted attempt at anonymity. Steve was post-call, and was dressed in the shapeless green pyjamas that residents have been trying to pass of as real clothes since the dawn of medicine. This is significant because scrubs have short sleeves. Usually, on internal medicine, guys wear dress shirts. Long sleeves. While chatting with Steve, I happen to glance down at his exposed forearm. A prominant scar marked his inner arm, extending from his elbow to his wrist. Steve caught me staring.

"Impressive, eh?"

"Bar fight?" I asked, jokingly.

"CABG."

"Pardon you?"

"Yeah. I had a STEMI in my second year of residency." He said it nonchalantly, as though he told the story on a daily basis.

"Oh! I thought you were first year internal." Obviously, I was at a loss as to the appropriate response when someone catches you staring at their deeply scarred forearm. Because what year his was in was OBVIOUSLY the important thing, here. Sigh.

"I am. But I used to be ortho. I had the STEMI in my second year, when I was 31. I had to take a leave of absence, and I transferred to internal medicine. I probably wouldn't have survived ortho if I'd gone back to it."

"Um, wow."

Less-than-brilliant response aside, I am now a believer.


P.S. A STEMI, by the way, is an ST-elevation myocardial infarction. For the purposes of this story just think of it as a VERY bad heart attack. CABG is a coronary artery bypass graft (pronounced "cabbage").

A Comedy of Errors...

...only none of them were funny. I was on Friday-Sunday call this weekend. So I went into the hospital on Friday morning, didn't leave until Saturday noon, went back on Sunday morning and didn't leave until Monday noon. Not the nicest way to spend my long weekend, but at least I get a "lieu" day for working on the stat holiday.

Last night was busy for internal medicine. We got flooded with referrals from emerg, nearly all of which required admission into hospital. There were many of the usual suspects-- MI's, COPD exacerbations, CHF exacerbations, and the parade of confused eldery people usually found to be suffering from pneumonia or urosepsis. There were a few more interesting cases, too-- and a few that should have been routine but became more interested through gross mismanagement.

In our hospital it's not unusual for patients to spend a day or more in the emergency room after being "admitted" (on paper, anyway) waiting for a bed. The emergency room is a busy place, and it isn't the nicest place to be hanging around all night. Plus, the nurses are busy and the care that our patients get isn't the same as if they were on the floor. Usually, this is just inconvenient. This night, however, it became downright ridiculous.

At around 11pm I saw an 18-year-old kid with diabetic ketoacidosis. This is a serious complication of (usually) Type I diabetes that has a 5% fatality rate. So it's taken pretty seriously. I had actually asked to see this referral as I had never managed a DKA before and wanted the experience. I had admit orders (instructions to the nurses on how to manage the patient) within 30 minutes of seeing him. They included close monitoring, an insulin drip, correction of his hypokalemia (low blood potassium, can cause heart arrhythmias if not treated), blood sugars measured every hour, electrolytes measured every two hours... the usual. By 5am, not only had the orders not been implemented, but the night nurse had allowed the patient to take his usual dose of long-acting insulin. You don't have to necessarily understand the medical management of acid-base disorders to appreciate the bottom line-- this delay in treatment could have killed this kid. Luckily, he wasn't all that acidotic (it's the acidosis that kills, not the blood sugar per se) and was fine the next morning. But things could have easily turned out much worse.

One of the other residents saw a young (early 40's) healthy guy who had a spell of atrial fibrillation (a heart arrhythmia) after finishing a 5k run that afternoon. First of all, it didn't need to be referred to internal medicine-- he was stable, and could have easily been started on medication and followed up as an outpatient. But he got referred, so we saw him. The other resident ordered some anti-arrhythmic medications and decided to keep him overnight on telemetry (constant vital sign monitoring). Good thing. Her orders weren't carried out either-- he never got his meds, and ended up going into atrial flutter (a worse arrthymia) in the middle of the night.

At midnight, already snowed by admissions and referrals (including a very rare blood disease, the management of which was a mystery to everyone including the thrombo attending on call) the R5 (emergency medicine resident in his fifth and final year of residency training) dumped three referrals on us that hadn't even been worked up. His explanation?

"Well, they're three old ladies that are confused and short of breath, so whatever the cause they'll end up going to your service anyway."

Um, thanks. This is the kind of bullshit that gives emergency medicine a bad name with other services. I took one of them-- an 88-year-old woman with severe Alzheimer's dementia who was non-verbal. All I knew was that the nursing home had thought her to have a decreased level of consciousness that afternoon and sent her in by ambulance. The resident hadn't even ordered a CBC (the most basic of blood tests).

To add to the confusion, the computer system went down inexplicably sometime after 1am. So we had no access to lab values, x-rays... and perhaps most importantly when dealing with demented elderly patients who can't tell you about their medical history, their old notes and files. Information was passed by phone calls from the lab and the stressed radiology resident, and was then relayed through a twisted game of broken telephone until it reached us and could be translated into a diagnosis and treatment plan. In many cases, it was easier to give up on nailing a diagnosis and just start everyone with nonspecific fever on broad-spectrum antibiotics and delay the more formal workup until the morning.

I guess that night was the perfect storm of problems-- some of them, like the computer problems, being nobody's fault. Others, like the mass referral of patients without workup, the resident's fault. But the delay in receiving treatment that some of our patients experienced last night was downright dangerous. If it had been my family member, you can be damn sure I'd be demanding answers. Not enough nurses? Not enough beds on the floor? Complete incompetence of the health care team in general? Maybe a little of each. But it's definitely not a night I'd like to repeat.

But maybe I'm naive in thinking that this was an unusual scenario.

Back on Call



And believe it or not, I'm not complaining about it. Why would I? After my first week of internal medicine, I've come to realize that when I'm on call is the only time I'm going to get a chance to do any real medicine. Sigh.

Honest, I'm not complaining. Thankfully, it looks like my experience in Internal Medicine is gearing up to be WAY better as a resident than it was as a medical student. For starters, I'm now working in a centre with much less of an emphasis on "shame-based learning" as we affectionately refer to the art of pimping. People seem more interested in making sure you learn something than they are in publicly humiliating you for what you don't already know. Second, my team rocks. I have an attending who is so nice that she often has trouble convincing people that she's an internist. My senior is very non-initmidating, reasonable and approachable. I haven't met the other junior yet... she's on vacation this week. But so far, so good...

The teaching on this service is amazing. We get a minimum of two one-hour teaching sessions a day. Very different from family medicine, where I got... well, none. So far I've learned about aortic stenosis, aortic sclerosis, toxic epidermal necrolysis, nonspecific elevations in liver enzymes, what those clotting tests we order ACTUALLY measure, atrial fibrillation, asthma, rheumatoid arthritis and a bunch of other topics that I've probably forgotten already.

But believe it or not, call was good. And not only because I actually got some sleep (although those of you who have been reading my blog since my surgery rotation can understand what a difference an hour or so makes) but because I got to practice medicine. See, internal medicine isn't exactly medicine. Or at least it isn't medicine if you're the JMR (Junior Medical Resident). My days are spent 'managing my patients'. In plain English, this means chasing down lab results, filling out paperwork, attending endless "meetings" to plan discharges for people who are just taking up acute care beds with no acute medical issues.

At night, however, things are different. And not bad different. Rather than being left on my own to sink or swim with dozens of very sick patients with no backup (yes, referring to that damn surgery rotation again), I am part of a team. I have someone to refer to if I feel like I'm in over my head managing the ward. In addition, I get to see the consults to medicine from the emergency room. Some interesting stuff comes through there. My night on call saw two acute coronary syndromes (one STEMI and one NSTEMI), a post-ictal (after a complex partial seizure), a superior vena cava syndrome from a huge goiter, a new-onset SVT in a cancer patient, a COPD exacerbation and a rule-out Guillain-Barre. Pretty interesting stuff.

Internal medicine call. Interesting. I must be losing my mind.

Bring on the codes.

A Woman's REAL Right to Choose

Did you think that I was going to talk about abortion? Wrong. I'm talking about a woman's right to choose how she gives birth.

I know I've touched on this topic briefly before, particuarly when I was doing my obstetrics rotation in a tertiary care centre. I saw so many bad outcomes in both high and low risk pregnancies, it seriously biased my view of childbirth. For quite some time, I thought that if I were currently pregnant I would chose an elective c-section over labouring. For me, I prefered the idea of predictible risk against the idea of unpredictible risk. A c-section is a higher risk procedure than uncomplicated vaginal birth overall, to be certain. But an elective c-section is a lower risk procedure than an emergency c-section (meaning any c-section done for medical indications after labour has started) and it's impossible to predict beforehand if your birth will be one of the uncomplicated vaginal ones or if it will get complicated as your labour progresses.

In Chatelaine magazine this month (did I mention I'm a total magazine whore?) columnist (I refuse to call her a journalist) Rebecca Eckler waxes poetic about her elective c-section. People, for the most part, are horrified that she is 'too posh to push'. I have to disagree. Why mock her motivation for chosing a c-section? No where in the article does she say that she doesn't want to mess up her eye makeup by labouring or anything that implies that she made her choice based on aesthetics alone. Granted, some of the 'pros' to elective c-sections that she mentions do seem a little superficial (like knowing exactly when she'd be giving birth, being able to plan her mat leave accurately, knowing when her mother should come and visit) but who are we to judge?

I'm all about giving patients the choice. Like when it comes to Vioxx. Vioxx was a drug that gave many people with osteoarthritis a new lease on life. Finally, their pain was under control and let them be active with far fewer gastrointestinal side effects than many of the earlier drugs for OA. Then it was pulled from the market under fears of cardiovascular disease. I know for a fact that many people would gladly accept a higher risk of cardiovascular events for the improvement in their quality of life that this medication offered. I also know that I'm not alone in wishing that this medication were still available so that patients would have the choice.

But I'm going off on a tangent. I know, so unlike me.

The health care system has evolved far beyond the days when the doctor would decide what's best for the patient and the patient wouldn't have any say. Why shouldn't the patient get to decide if they prefer the predictibility of a c-section over the experience of a vaginal birth?

Sure, a c-section has it's drawbacks. It's major surgery-- the recovery period is longer, there are risks associated with any surgery, and there is the threat of wound healing problems. But there are risks associated with childbirth, period-- and the complication rate of elective c-section in low-risk pregnancies is very comperable to the risks associated with vaginal birth. Vaginal birth carries the risk leaving women with urinary incontinence, fecal incontinence, sexual dysfunction, uterine prolapse-- some studies suggest that these complications are less likely in women who were sectioned. And the tearing... ugh! I've seen tears that have ranged from what we affectionately refer to as 'skid marks', superficial tears that don't require closure, to fourth degree tears that penetrate the anal mucosa. And that's if you're lucky enough to tear downwards. Clitoral tearing is also a possibility. Then there's always the potential for the stellate tear (I'll give you a hint... stellate means "star-shaped") and the ever-horrifying perineal blowout.

Sure, natural childbirth can be a beautiful thing. But that's not a guarantee.

I know I'm singing a different verse of the same old song. But if the pros and cons are laid out for expectant women in a non-biased way, why shouldn't they have the right to chose?

Now if only I could figure out how to reconcile the increased costs to our overburdened health-care system that c-sections would carry...

Murphy's Law of Blogging

The number of things that you have in your head to write about is inversely proportional to the amount of time you have to spend writing. A few weeks ago, when I was full of ideas, stories and opinions, I didn't have two minutes to rub together. This week I'm on vacation and have nothing BUT time... and can't think of a damn thing to say. Sigh.

So instead of pithy commentary on the world of medicine, here are some gratuitous dog pictures. Pretty soon, I'll be giving Stacie (my favorite dog-blogger) a run for her money.