Tuesday, October 31, 2006

Ghouls and Ghost Stories

Yes, I backdated my post to October. Suzan-Lori Parks may have been able to write a play a day for a year, but I know I’m not up to writing even a decent post a day for a month, so I don’t want to imply that I’m doing so by posting on November 1st.

Yesterday I supervised the residents for outpatient office hours. I mostly enjoy this part of my job; it’s a perfect opportunity to teach the art of medicine. There are all kinds of techniques for giving patients what they need and want AND being efficient. Sitting down when talking to them, asking “What else?” and “What else?” and “What else?” until they can’t think of anything more, asking “What questions do you have?” at the end of the visit instead of “Do you have any questions?” Explaining that something “isn’t dangerous” rather than saying “it’s not serious.” Oh, I’ve got tons of cute tricks up my sleeve.

Yesterday got a little out of control, however. We saw 17 patients between 2 and 5 pm, and most of these patients were not 10 minute visit types. A couple of them were very appropriate for Halloween, and haunted my thoughts all night. (Some details altered to shield identities.)

One was a patient I’ve been following for a couple of years; she got put on the resident schedule because I was out of town last week. This patient is truly horrifying. She’s an alcoholic, but not a flunked-a-couple-CAGE-questions alcoholic; no, she’s an old-school, drink-yourself-to-a-miserable-death alcoholic. She used to have a real job and a real life, but has lost it all. She has developed almost every sequela of alcoholism there is—heart damage, liver damage, brain damage, nerve damage—but most frightening is that she keeps falling down and damaging her flesh and bones. She drags herself into my office about every two months for follow-up from a visit to the ER with another horrifying injury. She fell flat on her face and smashed her nose in. She fell and bit through her lip, almost severing the whole bottom lip off. She’s broken both arms several times. She’s so malnourished at this point that she can’t heal properly. She’s a trembling, emaciated, misshapen wraith. And she’s always furious. Furious that she’s in pain all the time (and that I won’t give her narcotics, though she usually has plenty left over from the ER and the orthopedic surgeons). Furious that everyone is “shitty” to her. Furious that she has no life. And especially furious that everyone keeps “implying” that her problems are due to drinking, because she DOESN’T HAVE A PROBLEM, GODDAMMIT. She cries and shakes and fills the room with the fumes of whatever she had to steady her nerves that morning and licks her scarred lips with her cracked, swollen, vitamin-deficient tongue. And begs for sleeping pills.

My poor resident was terrified. I ended up doing most of the talking, because at least I’m used to her. There’s really not much to say; I just agree and express sympathy about the fact that her life is hell, and then decline to write prescriptions for mind-altering substances, explaining that I’m concerned they could make her fall even more often. I’m not sure why she keeps coming back. I don’t know how to help her. So that was the only lesson I could give the resident: sometimes there’s nothing you can do.

The second frightening patient seemed only perplexing at first. He was a new patient, a mild-mannered elderly man. He spoke only Albanian, so everything had to be said through the phone interpreter, and even the interpreter seemed to have difficulty figuring out what he was saying. He came with a “case worker” who knew absolutely nothing about him (and definitely didn’t speak Albanian). He presented with papers from prison stating that he had some medical problems and some psychiatric problems. He’d been released several months ago, and had been able to fill his regular meds, but not his psych ones.

The resident came out of the room and explained all this to me. “Someone has to know the story,” I said. “Talk to the case worker and find a number we can call.” She seemed skeptical, but returned to the room.

Turns out that this patient had been in prison for 25 years after becoming psychotic and strangling his mother. He’d been treated in prison with monthly injections of antipsychotic meds, which apparently worked well enough that he was released to a halfway house. Off his meds. The pharmacy hadn’t filled the prescription for the injection because they didn’t carry it.

We slowly and carefully went back in the room and got on the phone with the Albanian translator again, determined that the patient was not interested in harming anyone at present, and explained that we would be starting him on some new pills that he must take every day. (We also got him an appointment with psychiatry, but in our institution that takes a month or so.)

The last scary patient was frightening in what she had rather than who she was. She’s a sweet little white-haired 85-year-old woman who was recently admitted for a possible stroke. As they often do, the neurologists had sent a test for syphilis as part of her workup. The initial test came back positive, but they assumed it was a false positive, and discharged her with instructions to follow up with me and get the results of the confirmatory test.

Of course, the second test was positive too.

The resident was panicked. “How am I supposed to tell her?” he asked. “Her daughter is in the room!”

So I went in with him. First I asked if the patient understood why she was there.

“For the test results,” she said.

“And do you know what the tests were for?”


So I politely asked the daughter to step out for a minute, then dropped the bomb.

She sat for a moment, her eyes narrowing. Finally she said, “That brings back some bad memories. That no-good son of a bitch. My mother told me I shouldn’t marry him!”

Turns out her husband had cheated on her some forty years ago, and she found out because he’d given her syphilis. She’d been treated, but she didn’t remember how, since she was allergic to penicillin.

“That’s why I kicked him out,” she said. “He’s dead now, and it’s a good thing, because if he weren’t I’d throttle him myself. I thought this was over and done with.”

By the time I got home last night, HellBoy had already gone out trick-or-treating and come home—he’d had enough after just one house. He was having a good time sitting on the stoop with his dad greeting all the other kids.

I didn’t stay out there long. I’d had enough of ghouls and ghost stories for the day.

Wednesday, October 18, 2006

Are You On Drugs or Something?

In response to my prior post, some people have requested specifics about the medications.

My first was sertraline (Z*l*ft), an SSRI. Started at 25mg daily, then 50, and eventually 100. Worked great. Felt like myself again, except that I didn’t get depressed and I was no longer afraid of spiders. (I still had some trouble talking on the phone—another phobia of mine—but it was a lot better.) Side effects were entirely manageable, not unlike having had an extra cup of coffee … with the exception of that one pesky thing. Libido wasn’t so much the issue. I could open negotiations, I just had a hard time sealing the deal. I enjoyed casting, but I didn’t reel one in very often. I could crank the starter, but the engine didn’t always turn over. The water got hot, but the pot wouldn’t boil. I could paddle the surfboard, but it was hard to catch a wave. I had a nice time mountain climbing, but had to turn back before the summit. If I were Cracklin’ Rosie, even Neil Diamond might have run out of time.

What’s that? Get to the point? I couldn’t, that’s the point.

It didn’t matter too much at first, because I was busy and single. But then I met my future husband, and I began to long for what I was missing. I’d never been a zero-to-60 in four seconds kind of girl to begin with, and we didn’t have that much free time. So, as I described previously, I stopped. But being happy in the sack doesn’t make up for being clinically depressed, as it turns out.

The next medication I went on was buproprion (W*llb*trin), 150mg twice a day. It’s in a completely different class than sertraline. Worked great for the depression, and practically no side effects. Its one drawback is that it doesn’t have any effect on anxiety; SSRIs are really the only ones available that work for that. So spiders started to freak me out again, and it got harder to start conversations with people I didn’t know. But overall a good choice.

Enter infertility treatment. Much stress, much anxiety, not much sleep. Then a new job on top of that. I started to feel as if I was overloading the buproprion. I got a new psychiatrist finally (I had been seeing my PCP, who was great, but not, obviously, a specialist in tweaking these meds). And he said, you know, the sexual side effects of SSRIs are dose-related, and you were taking a relatively high dose. How about we leave you on the buproprion, but add a whiff of sertraline back?

Simple but brilliant. I added 25mg of sertraline, with no appreciable effect on my sex life but a definite dampening of the anxiety.

I was, naturally, worried about what to do if I ever did manage to get pregnant. When I broached the subject with my husband, I was relieved to find he had a strong opinion that it was much riskier to go off meds during such a stressful time than to expose a baby to medication that has not been shown to do any real harm. We decided that since the real issue was depression, once/if I actually got pregnant, I’d taper off the sertraline, just to decrease any possible risk. In fact, I upped the sertraline to 50mg during the worst of the IVF treatment and left it there until we’d seen a heartbeat, then tapered off. I continued buproprion during pregnancy and restarted 25mg of sertraline once the baby was born. (Buproprion does get into breastmilk, but again we decided that the benefits clearly outweighed the risks.)

I find it interesting that a lot of people are afraid to try antidepressants, not because they might not work, but because they might. If you start and find out that you feel like a completely different person, what then? Are you stuck forever? It’s hard to explain why this doesn’t really make sense, because you won’t truly understand unless you try it. What I tell my patients is that if the antidepressants work, you will feel—normal. Not a different person, just yourself, the person that you can remember being, though perhaps long ago. As testament to this, most people who are on antidepressants for a long time eventually get to a point where they feel like the meds aren’t working, because they feel utterly normal. And a lot of people can eventually go off while continuing to hold on to their normal self. The reason I can’t is that it is very likely that if I were not to continue antidepressants for the rest of my life, I could expect the episodes of depression to come more frequently and become more intense. Some people have episodes every once in a blue moon and can use antidepressants as needed, but my last depression came with so little warning and so little provocation that I don’t want to risk it.

And as long as I can make the sale, catch some fish, start the car, boil some water, catch a wave, and get to the top of the mountain, I’m good.

Wednesday, October 11, 2006

The MICU: How I Know Antidepressants Work

A student recently asked me, “When did you get to the point where you weren’t scared about seeing patients?”

That’s an easy one.

By the time a medical trainee gets to the point of making independent decisions about a patient and has the power to carry out these decisions—the first year of residency, or internship year—they have been through four years of medical school training (generally two years in the classroom and two years in a clinical setting). Most interns are reasonably well equipped to assess a patient and make initial management decisions. This is not to say that they are not absolutely terrified. The first month of internship is a heady time, but an anxious one. The first time a nurse pages you in the middle of the night demanding that you assess a patient in trouble, your heart starts to beat like a cornered stoat. I’ll never forget my first such call, that a patient was having “rigors.” As I descended the stairs to her floor, I went over the causes of rigors. Fever? Medication reaction? When I got to the room, however, I realized that the patient was not having rigors; she was simply shaking. I examined her and talked to her, but nothing obvious emerged as a cause. Finally she made the confession that unlocked the mystery: she had panhandled for change in the cafeteria, then called her connection to come to her room, and the two of them had smoked crack in the bathroom.

That explained the shaking, but what to do about it? This is how raw I was: I actually pulled out my little intern’s pocket guide, called something like “How Not to Make A Complete Ass of Yourself on the Medicine Floors,” and tried to look up what to do when your patient has smoked crack in the hospital.

Over the months, as the call nights add up and your experience grows, the initial white-knuckle terror fades, but a sick patient can still give you a little frisson of fear. What if I can’t figure out what’s wrong? What if I do something stupid and kill her?

Then you become a second-year resident and are placed in charge of the MICU (the Medical Intensive Care Unit, pronounced “Mick You”). This is the place for the sickest of the sick. If you train in a large tertiary-care hospital, as I did, it’s the place for the sickest of the sickest of the sickest of the sick, from miles around. And I do mean in charge. Sure, there’s an attending and a fellow who are technically your superiors. But they don’t spend the night. When dinnertime rolls around and your team is on call, everyone drains out of the unit like tepid bathwater and you are left In Charge.

(I should note here that I trained several years ago, when fellows NEVER spent the night in the MICU. They’d paid their dues, now you pay yours, page them if you need them and they might step out of the movie theater to tell you “Sounds like you’re doing all the right things! See you tomorrow!” These days I have reason to believe that this is less common. I dearly hope this is true, in case I ever end up in intensive care.)

Twenty-four beds, stocked with the most amazingly ill people you’ve ever seen in your life. People who shouldn’t be alive. People who really aren’t alive as that term is conventionally understood. People who have been on machines for months, who are yellow, bloated to the point of splitting, and have mold eating away at their noses and ears. Twenty-four beds, two raw interns, and you. (Also a handful of the baddest of the bad-asses, the ICU nurses. In some ways they are the ones In Charge, and the good ones will save your sorry know-nothing ass, but you do not know yet which ones are the good ones and which ones simply enjoy watching helpless doctors squirm. Not to mention the fact that there are many, many brand-new nurses—if you think doctoring can burn a person out, try nursing.)

Adding to my stress was the fact that when I started my second-year rotation in the MICU, I was slogging through the tar pit of a fairly bad depression, one which had come upon me with almost no warning. Some background: episodes of depression since childhood, some worse than others, always lasting months, usually but not always precipitated by a stressful event. Finally started on antidepressants during my last year of medical school while I was not in fact depressed, just not great and trying to extricate myself from a bad relationship. Worked brilliantly, stayed on them through internship year “just in case”and was truly happy that year. Then started going out with my running partner, and given the fact that the pills made getting to my own private Idaho a near-impossibility, I decided to go off of them. Without telling my boyfriend. My sex life improved, and I felt fine! Hey, I don’t need those silly pills! They’re for wusses! Until the morning I woke up and felt like I couldn’t, well, anything. I managed to hide it for a week or two until I couldn’t anymore. At which point my boyfriend made me promise never to go off my meds again without warning him first. (He was absolutely awesome about the whole thing, further cementing my belief that he was My Mensch.) So I got to my doctor, got some slightly different pills, and started on them just as I started in the MICU.

It’s hard for a normal person to stay sane on an ICU rotation. You’re on call every third night, for starters. This means: Arriving early Monday morning, working all day, staying up all or most of the night admitting or managing people who are trying their best to die, working all the next day, and finally going home about 35 hours later. Then you collapse into sleep, wake up, and come in for your one “normal” day. Go home, collapse into sleep, wake up, and come in for your next call day. I counted one week: I worked 108 hours, exactly one of them spent sleeping.

So the situation is tough. In a way, going into it depressed didn’t seem inappropriate. But it did make it harder. And by far the hardest part was getting the calls after everyone had gone home telling me that a patient was being helicoptered in from an outside hospital. This patient was coming to ME. Of all the people in the whole tri-state area, I was supposed to save them. As I got the information, I literally could feel cold sweat trickling down my sides from my armpits. Up till then, I’d thought that was just a figure of speech.

There were two kinds of patients choppered in. The first kind were outrageously well, but something in their test results had freaked out the other hospital so much that they thought the person was about to die. These people were kind of like the full-term infants brought to the NICU for observation: the contrast between them and the truly critically ill folks was surreal. They were also more annoying in some ways, because they could talk and demand sandwiches and want to know why they were there.

The second kind, well. These were the ones that warranted my sweat. They were so sick, so unstable, that it was hard to know where to start first. I once put a central line in a patient’s femoral vein that, when the patient began to develop a blood pressure again, turned out to be in the femoral artery. (And I left it in, because a good arterial line is hard to get.) But the scariest thing of all was: although I could (and was expected to) call the fellow to discuss the case, if I didn’t know what was important enough to tell her—if I didn’t recognize the important physical sign, the critical lab result—I could easily miss something and kill the patient.

After a few weeks of this, a pattern started to emerge. Hey, I’ve admitted scores of sick patients, and I haven’t killed any of them. Some died, sure—the mortality rate was something like 50% overall—but the ones who could be saved, were (along with a few who probably shouldn’t have been). And I got very, very good at looking at a patient and knowing whether they were Sick or Not Sick. It is very hard to kill a Not Sick patient, and there are a limited number of ways to fix a Sick one.

And about three weeks in, I was strolling through the unit one evening humming a little tune.

“You’re in a good mood tonight!” the intern said.

“Yes, I am,” I said. And then I stopped in my tracks. I’m in a good mood. I’m on call in the MICU and I’m IN A GOOD MOOD.

Shit, those drugs work.

I never stopped them again.

And once I left the MICU, I never panicked about any patient ever again, because I’d seen Sick, and the vast majority of patients are Not Sick. As for the rare Sick ones, there are medications that can keep a lump of hamburger alive for a few hours—long enough to get them to … the MICU.

Sunday, October 08, 2006

I Would Miss My Water If My Well Ran Dry

A quick word on water.

In my earlier post on the subject, I may not have made it clear that I love water. When I want a non-caffeinated, nonalcoholic beverage, it is my drink of choice. I drink it before and after running. I drink it with lunch. I drink it first thing in the morning upon arising (granted, I need it at that time to swallow my pills, but it tastes good too). Until HellBoy was old enough to snatch at it, I drank it whenever nursing. And it's what I keep in HB's sippy cup.

Please, if you are thirsty, by all means drink water. If you are thirsty, you need it, and it's far better for you than anything else you'll find in the cooler at the 7-11.

My only objection to water is that people keep spreading the myth that you should drink more of it than you're thirsty for.

So drink up! (If you're thirsty.)