Behind the White Coat

Vacatıon

So in haste I did not update the blog prior to my departure, but my month wıth the old sick folks has come to an end... In fact, all my medicine floor months as an intern has come to an end!  2 more weeks of real work ın the ICU untıl I am offıcıally a second year resıdent... Fınally..

For now, I hopped ın a plane with a friend and went across the globe for my vacation in Turkey... Yes I am here for ten days, (Day 2 at the moment), and so far so fun... Once I return you'll get all the stories.. Already have managed to hit up the Aya Sofıya, Blue Mosque, Suleyman Mosque, Grand and Spice Bazzar, and just had our Turkish Bath.. (ınterestıng ıt was). For now, my ınternet cafe time is a running out, so İ too will be running out... Ciao for now!

It's All About Shit

This month I Have gotten a shit load of patients with gastrointestinal issues (no pun intended). Probably because geriatrics are so demented that they don't realize how their bowel movements are, and they are often very constipated, and that leads to all kinds of problems with diarrhea, obstruction, and impaction.  Incidentally I have had a lot of younger people this month with various types of GI issues and bleeds as well.  So I thought I'd run down some of the stories... I must warn you, if you get disgusted easily, I would NOT read the rest of this post... It will be quite graphic and gruesome and is not for the faint hearted.... You have been warned!!

Take my Albanian lady of about 85 years old.  Mildly demented, and spoke not a word of English.. In fact she barely spoke Albanian, probably because she was almost deaf.  This lady was a whale, her stomach was just huge folds of fat rolling everywhere.  Anyway, she came in with an episode of bloody diarrhea.  Now many things can cause bloody diarrhea.  When it is bright red blood, it is usually something from the "lower GI tract", which is the colon, or large bowel.  The definitive test would be a colonscopy (sticking a camera all the way up the colon).  She came in with a very low hematocrit (blood count), and was scheduled for a colonscopy the next morning.  Until then we had to provide supportive care, maintaining her pressure with fluids, and blood count with transfusions.  When I came back into the room to check on her, she had a huge bowel movement.  A bloody one.  You could say it was "bloody big you ole bloke!" (sorry).  I saw her neighboring patients dash out of the room, gasping for air.  This was gonna be bad. I could smell it down the hall.  I walked in, and she was rolling around in the bed in a pool of bloody diarrhea.  I mean she and the bed were covered in it.  You could see the fumes of stench rising.  It was like seeing a hippo in a pile of blood and shit.  It was disgusting.  The whole day it kept coming. Luckily her pressure maintained and we got her blood fast enough.  The colonscopy showed ischemic colitis in her colon.  Basically blood was not getting adequately to portions of the colon, because of narrowing of the arteries and likely a low blood pressure, causing the tissue to get hypoxic and die.  Kind of like a heart attack, but involving the bowel.  She ended up doing well and going home.

Now the weirder problems happen in the really old and demented people.  Take the lady we had this past week.   A nursing home resident, and severely demented.  This lady didn't even know her name, let alone where she is or what the year is (apparently it was 1924).  She came in with abdominal pain and diarrhea.  So the first thought is she got some sort of diarrheal illness. Fine. But it's never that simple.  When we examined her, her belly was uber-distended.  I mean the thing was like huge, like she was about to give birth to quadruplets, it was tympanic, and the bowel sounds were high-pitched.  We did an x-ray of the belly, and the colon and bowel was crazy dialated, like 7 to 8 cm in width, and there was stool packed in the rectum.  What she likely had was the infamous fecal impaction.  Old people who are chronically constipated can get this problem, where feces just packs into the rectum, and pressrue just builds up behind it.  Then they get "overfow diarrhea", where it seeps out around the sides of the impaction.  So it is basically constipation that is so bad, that you get diarrhea.j  Often times it is so bad, that even when you get it disimpacted, the bowel never normalizes and you need a colstomy bag placed.  So what do you do to disimpact?  Occasionally laxatives can help, but in severe cases like this, you gotta go manual.  Lucky for us in this instance, it was the GI fellow who took the duty upon himself.  The manual disimpaction doesn't involve much, you basically get your finger up in the rectum, move it around to loosen the stool if you feel it, and stimulate the mucosa to "wake up".  Disgusting isn't it? Well whats worse is when you get a good response.  So in this case, the manual stimulation worked, and out came a rushing gush of stool.  It was like an explosion.  Karakatoa re-visited.  The shit heard round the world.  It exploded into the bed, even onto the windows, and on the poor GI fellow's pants and shoes.   We ended up putting a rectal tube in her, and eventually her belly decompressed amazingly.  Good times.

The list goes on…. Our 45 year old lady with HIV who vomited blood and had black melena bowel movements.. She had a mallory weiss tear of her esophagus, where a hole forms in your food-pipe and it bleeds like no tomorrow... We had another lady who had mounds of black diarrhea, whose hemoglobin dropped to 4.5 (normal is like 14, trust me it's low), she ended up having this huge gastric ulcer which looked like a fungating mass, which is probably a giant cancer.  Anyway... I think that's enough for now.... But needless to say I am pretty comfortable with dealing with all kinds of bloody shit....

Death

Death.  You deal with it a lot in the hospital, especialy as a medicine intern on a ward with seriously ill patients.  Sometimes it comes unexpectedly, in someone who has an acute illness, and decompensates severely, and dies fighting for their life.  Other times it is somebody who is chronically ill, perhaps on dialysis, or with severe heart failure, or mutliple other problems and of very old age.  Whether you expect it or not, it is still not easy to deal with--for the caregiver, or more importantly for the family.

I have had a few people die on me this year.  I'd say most of them I could predict it coming, but there were a few that came unexpectadly.  Sometimes it is kind of in between, where it is not necessarily expected, but should not be a huge surprise.  Take my last person who I had die on my service.  It was a very elderly man, about 91 years old, but for his age, he looked pretty decent.  However if you are that old, when you get sick, you are always sicker than the same disease in a 50 year old.  This particular gentleman came in with bacterial lobar pneumonia.  You often hear of elderly people passing away from pneumonia, because when you are that old, your body has a much more difficult time fighting a bacterial illness, especially when it is in the lungs and it compromises your oxygenation and breathing, and their bodies just have a harder time coping and holding on.  These bad infections always gets the old folks unfortunately.  So anyway, his family was very involved, and quite respectable and educated people.  They were very impressed with me because I told them I would see them in 30 minutes, and somehow I was right on the dot.  I spent some time and answered all their questions and concerns, and they were so thrilled with that alone, they thought I was the best doctor ever.  (It makes me wonder the kind of doctors they have dealt with in the past).  They were very realistic too, since the patient's wife recently died of pneumonia, they knew the prognosis was not great at his age.  The patient was doing OK for the first few days, getting antibiotics and hanging in there.  I was telling the family that the prognosis is difficult to say, but he could do better, or could do worse, time will tell.  I was optomistic though since he looked pretty decent. 

The next day, he was dead.  More or less out of the blue, but given his age and the size of his pneumonia, it should not have been a huge surprise.  Nevertheless, calling the family wasn't a good feeling, particularly since I established quite a good relationship with them.  They were saddened and taken aback, but they took it very well, despite me having told them that he was doin pretty well, and could recover (which was the truth at the time).  The conversation ended with the son thanking me for the care I provided, and said after all the doctors he has dealt with over the years, I was the one of the best most concerning and communicative doctors he has interacted with.  I think having slipped that comment in there after just having told him his father had died meant quite a lot to me.  The patient was sick, but even though he didn't make it, I feel I had still succeeded, since I had in some way dampened the burden for the family, making their father's death comfortable for him and for them, by simply taking the extra few minutes communicating with them and letting them know he was "in good hands."  That's all families really ask for, a few sincere minutes of your time.   The son's last words to me on the phone still leave me wondering the many other phsyicians he has dealt with, and how we often become jaded and forget what small simple things we need to do to make a difference to the people we care for, and their families.... After all, that is at least part of the reason we are all doin what we do.

My B-Day

So I went out with my friends for my birthday this weekend, and I must say it was quite the fun night....  Dinner was at Cuba, on Thompson and Bleeker.  A smallish place with a second bar and seating downstairs, but a great vibe.  The mojitos were strong and you could order them by the pitcher.  A guy sat at a table in the front rollin fresh cigars, complimentary for the taking, and a live band sat in the corner upstairs playing some latin tunes to go with dinner.  Very tasty food too.  After that, we head to the party, and that's when it gets a little blurrier. 

The party we had at Double Happiness (not Happy Ending as everyone confuses it with), which is on Mott and Broome. Pretty much at the foot of chinatown.  To a sultry downstairs lounge, it was a pretty cool place of medium size, tables and seating, and 2 bars to get drinks.  The crowd was nice and mixed, at least half were with our party I am guessing.  I am pretty sure we had lots of girls too, but somewhere between the patron shot, and my last vodka redbull, I lost track of time... And all memory.

I woke up in my bed at noon on Sunday, fully clothed, alone.  On the table was some plates, and empty pizza boxes, there were at least 4 or 5 glasses lying around, and empty bottles of booze.  What exactly happened?? I later learned that I was taken home at like 3:30am (and I wasn't even sick, I was just drank so much, and was so tired, I pretty much fell asleep).  Apparently like 4 of my friends who brought me home hung out at my apt for about 2 hours, until 5:15am or so, drinking, eating, and chilling.  There was an after party at my apartment, and I wasn't even invited!  Amazing...

Anyway, I was all good in the morning, and was fully functional to enjoy the day.  So quite the fun time. Thank to everyone for partying it up!  There are some parts of the night that are good stories to tell, but a little too high profile. So you can grab me aside to get the details ;)

Now I am back on the wards, with my old geriatric patients. (Yes I have the "geriatric" team this month).  The average age of my census is somewhere in the high 80s... Stay tuned for some stories...

MRI Results

A herniated lumbar disc.  That is what I have.  There is a shot at my Lumbar Spine MRI.  There you can my L5-S1 disc extruding posteriorly into the cord canal, and on the first image you can see it creeping up superiorly as well.  Well looks like there is the reason I have had unremitting back pain for the past 2 months.  Though I somehow I feel it may have herniated back in medical school the first time I screwd up my back, and this instance maybe just worsened it.  Who knows, regardless, it is goin gto suck trying to get my back into normal shape.

Lucky for me it is not impinging the spinal cord causing neurologic symptoms like muscle weakness, sensation loss, or something dreaded like urinary incontinence!  The most I get aside from the back pain is some sciatica pain radiating down the leg.  So treatment options are basically physical therapy, spinal injections, or surgery...

So obviously the conservative route is the one of choice at first.  The non-invasive route of physical rehab and pain killers (some that I'd prefer to others) seems to benefit a lot of people.  I just hope I find the time to do I don't know how many weeks of physical therapy amidst my schedule!  The steroid injection option sounds tempting though, but it probably should not be the first choice.  Especially since I am guessing PT could potentially improve the disc herniation itself instead of just treating the symptoms. I hope at least.  Surgery would be a last resort.  Luckily it is not immediately bad to necessitate surgery, but I hope it don't get worse in the future.  I don't want no orthopod comin near my spine!

The gimp signing off....

On another note, I turned 28 yesterday, and trust me when I say I am beginning to feel old.. With the back pain to match...