The Ethics Committee 2

I'm following up on the ethics case that I wrote about a couple weeks ago, but it seems that one dilemma leads to another, and another, and another... What I find so interesting in this case (as in many of the ethical scenarios that we've been presented) is the issue of "justice." Who deserves our care? I think answering that question unfortunately depends so much on where you were born, where you grew up, who did this-or-that to you, etc. So much happens to us as children, things that we cannot control, that affects the rest of our lives. And then who are we to sit here and judge someone in the moment? This person gets another chance; you don't. We'll pay for your complex discharge, but not that other guy or gal's. When we really delve into some of these issues, I'm wrought with guilt. How did I get so lucky to be educated, to be loved, to not grow up in an environment wrecked with drugs and alcohol, to not be molested, to not have a serious psychiatric disease, to not have been physically abused... the list goes on.

In this case specifically, we have a patient who's undocumented. We don't know why he came to America. He's unemployed. He has no family. I don't know his story; I don't know what he's had to go through in his life. With the opportunities I've been given, it's unlikely that unemployment will be an issue I will struggle with (knock on wood), or that my family will disappear. I will always have a network of colleagues, a group of individuals that will pretty much guarantee me health care as long as I keep in touch. In our society, this undocumented person only gets emergent care. Is that just? We, who never have had to deal with these issues, make the decisions concerning allocations of resources. Who gets what, and when.

But, note the other side of the coin: the hospital in this scenario has a limited amount of money that can be used to provide services for patients just like these: persons with no insurance, no means of paying for care, no resources. Let's say it's 2 million dollars (and forget the question about whether this could be waaaay more money, because that's another whole "justice" question entirely). What if this single patient takes up a large percentage of that $2 million? What if his cost for care precludes other patients from getting care? Doesn't one have to start thinking about "justice" in a different way when many other people could be helped with that money?

This is one dilemma I've really struggled with during our bout with ethics this year. I see it as ethics in a vacuum vs. situational ethics. One option for this gentleman is to look for care in his country of origin (Tanzania), and then pay to fly him there. No follow-up, no problem. Much cheaper to the hospital than emergency dialysis three times a week. For some, that's good enough. In my mind, that raises a number of red flags. That solution is certainly good enough for the hospital, but is that necessarily the best for the patient? What if that country can't meet his needs after 1 week? Are we just packing up this man and sending him to his death? What if the plane is diverted and he dies en route?

But say this patient is taking up $1 million a year, half of the year's budget for these patients. How many other patients who are also desperately in need of care, are we missing? Do we give up on this one since there are so many in need? I just don't see a win-win situation in this scenario.

I think that's what I've enjoyed so much about our ethics curriculum: it's more questions than answers. My banter back and forth on this scenario does not do its complexity justice; I would defer to my more erudite colleagues. But, there's so much at stake when you're talking about patients' lives, and there are so many back stories, and we don't ever really get beyond the tip of the iceberg. I just think it is so easy to turn one's back to a patient in need and say, "Hey, just fix yourself. Why can't you be more like Joe-Schmo? He's doing just fine." It's just more complicated than that.

It's an issue of justice.

Short White Coat Syndrome

Being a third year medical student is awkward. There's the short, stubby little white coat (which I refuse to wear; it's heinous); there's the fact that I look like I'm a 12 year old trapped in a 6'5'' frame; and then there's the constant, honest struggle that all of us face between providing care and knowing our limitations. This year is all about learning, and part of that learning is doing things for the first time. Sometimes this means asking the right questions or discovering a new physical exam finding, but often it means counseling a patient on different ways of quitting smoking, or even giving a patient his or her diagnosis. But from the patients' perspective, who are we to care for them? Who are we to tell them they have dementia? Two years of Anatomy and Physiology, Biochemistry and Pathophysiology certainly don't qualify us to give advice. But we have to learn sometime.

Even something as simple as introducing oneself I find extremely complicated. I have tried a number of approaches, each with varying degrees of success. I've walked in with, "Hi, my name's Robert. I'm a medical student working with Dr. So-and-so." Casual, honest, and to the point. However, I've also discovered that I get less information from a patient with this approach. Often an attending will ask the exact same question to a patient, and he or she will give a more detailed (or even completely different) response. Patients are much less willing to discuss issues such as mental and sexual health when I'm "just a medical student."

On the other hand, I've tried to enter with, "Hi, my name's Robert. I'm working with Dr. So-and-so. What brings you into the office today?" I have found with this approach, I often get a better story for the patient. I am more likely to address real issues, and often patients are more forthcoming. But did I lie? Although I didn't introduce myself as a medical student, there it is plain and simple on my ID badge (see for yourself!). But often patients now think I am a doctor. They know I'm not the doctor in charge (not their doctor), but they think I'm a physician nonetheless.

What is even more intriguing to me is that sometimes it doesn't even matter how I introduce myself. I can tell them I'm a "medical student," and then the patient will leave the room saying, "Thank you, Doctor!" Or a patient may be on the phone when I knock, and they will tell whoever it is on the phone that they have to go because "the doctor is here." I affirm that I am just a medical student, and that seems to make not one iota of a difference.

Thank you, Doctor.

Explaining what a "medical student" is, is oddly difficult. Correcting a patient, telling him or her that you are not a physician is actually very time consuming, and has irritated a number of patients I've met. Numerous times at the beginning of the year I would spend several minutes with some people describing what my role was within the health care team. This was either very complicated to some, or I'm just a flat out poor communicator. Most patients really didn't understand it, which honestly is a testament to the complexity of our health care system. You aren't a doctor but you still provide care? You can't write prescriptions but you can enter medical records? You can counsel me about my health but can't sign off on it? It does seem a bit odd.

I guess the reason I'm spending so much time on this is twofold, 1) Is not introducing yourself as a "medical student" a lie of omission, and 2) Do the benefits outweigh the risks?

My initial reaction to Question #1 is "yes." Question #2, I'm not sure. I think it's tricky because I have noticed such a distinct difference between the two approaches (keep in mind I would never say that I am a doctor, and when asked, I always give an honest response). Patients are more willing to answer my questions, allow me to perform other aspects of the physical exam, and much more likely to listen when I counsel them on their plan of care. Family Medicine is a great example: I am expected at the end of each visit to wrap up the encounter with the patient. This means I tell them what the plan will be, including what medications we need to change, what referrals we need to make, what tests we will order, etc. Learning how to do these things well is so critical to our education.

On the other hand, I'm not a doctor.

Ultimately, I've decided to err on the side of caution. I guess there will be plenty of years ahead of me when I am a doctor and still in training. Or maybe I'm just over-thinking this whole dilemma. Maybe it's different for third years at large teacher hospitals where their role is more defined. Simpler. I'm not sure. That's why I think this year is somewhat "awkward." What am I?

Next time maybe I'll just say, "I'm not doctor, but I do play one on TV."

The Champagne Tap

According to some random website that I found on the internet, a champagne tap is defined as "a successful lumbar puncture with no red blood cells found, which means it is as clean as possible. Upon completion of the maneuver, the supervising resident has to, by custom, buy the student a bottle of champagne." I am gloating today because, by custom, my attending Emergency Medicine physician just bought me a bottle of champagne. (Insert huge smiley face here).

For those of you not of the medical persuasion, a "lumbar puncture" (or "spinal tap") is a procedure usually done to assess a patient's cerebrospinal fluid (CSF). This is the clear/yellowish liquid that encases your brain and spinal cord. A needle is inserted into a patient's lower back, just between two vertebra of the spine, and right below where the spinal cord ends. Fluid is extracted, and then analyzed in the lab. There are a number of reasons to perform an "LP," but one common example is testing for meningitis. This is a very serious medical condition caused by inflammation of the protective coverings of your brain and spinal cord. An LP can determine whether this infection may be due to a bacterium or a virus, among other etiologies.

As you might have gathered from the description above, an LP is not an atraumatic procedure. The patient curls into a ball to open up the vertebral bodies, the area is prepped with antimicrobrial ointment, and a large needle is stuck through the skin and spinal ligaments until you hit the space with all the fluid. There are plenty of opportunities to cause bleeding along the way. The champange tap then, is when there is no blood in your sample. Usually that means there was no blood in the cerebrospinal fluid (CSF), and none encountered along the way. So it's not impossible to get a clear tap, but apparently it's not always routine. And thus when you get your first one, the doc in charge buys you a bottle o' bubbly.

So my bottle of Jaume Serra Christalino is now sitting proudly on my desk at home.

It was beginners' luck; I have to admit that. It certainly wasn't perfect technique or years of experience. I just simply got lucky, but I'll take it! And as Dr. Mitchell told me, hopefully I can earn myself another bottle during residency (if I don't tell them I already popped my first during medical school).

The Emergency Department (ED) is where we get to do most of our procedures. Here, we learn to start IVs, do lumbar punctures, and intubate, among other things. We see a ton of patients and a ton of pathology. This is where I remember seeing my first case of shingles, and my first necrotizing fasciitis. It is a very interesting place. Some of you might be wondering whatever happened to my interest in Emergency Medicine. I have to admit, it certainly was number one on my list of potential specialities going into this year (Surgery wasn't even in my top 3!). With my experiences in EMS, it seemed like a plausible next step. I guess three things happened, 1) I fell in love with Surgery; 2) I always find myself wanting to follow my patients one step further after the ED; and 3) the pace in the ED is a wee bit faster than at which I want to operate.

The best example I can use to illustrate point #2 is a recent case I saw on the A side (where the crazy-ish goes down). A 50-60 year old man was transported to the ED after having an episode that his friends described as a grand mal seizure with a substantial post-ictal period. He meandered in on his own two feet with a temperature of 105 degrees F, heart rate of 150 beats per minute (that's fast), and a normal blood pressure. All his labs were normal. No evidence of infection (CBC was within normal limits), drug toxicology screen was negative, and LP was clean. He had never had a seizure before. It was just a peculiar story.

The patient was admitted to the hospital after I left, but I desperately wanted to know what was going on with him. I ended up following this patient to his story's conclusion, which was very satisfying, but I just don't like letting these cases go. I want to be on the other side of the coin: either being the one to figure out what's wrong, or fixing it.

I don't know. Maybe that's not a good reason, but I'm often left wanting more. If that isn't a good reason, loving Surgery is. So I'll stick to that.

Pop a bottle to that notion.

Tuesdays

This picture really has nothing to do with medicine (or Tuesdays for that matter), but it's one of the first pictures that pops up on Google Images when you search the word, "Tuesdays." I thought it was cute, so there we go. Anywho, before I start weighing in on last week's ethical dilemma, I want to get back to some of my bread and butter. Two things that I've been behind on are 1) profiling my fellow medical school classmates, and 2) going through a typical week to talk about our program's design. I'll start with the latter today, but since my post about Dan "The Man" White, I haven't done any in depth investigative reporting on my Asheville compatriots. We'll get there.

Onto Tuesdays. These are my "lite" days. Every other week I work the afternoon in Cardiology, but I'm scheduled to have the whole morning off each week. This works well for continuity clinics and spending half-days in other offices. I've had the opportunity to sit in the Radiology reading room looking at pretty (and not so pretty...) pictures, as well as drilling holes in people's femurs in the OR. Here is a brief list of a few of the specialties I've seen:

• Cardiology - Every other week I try my hand at "Cards." From 1pm to 3pm, we rotate through different aspects of cardiology, then hop on over to an hour and a half of "heart" lectures. I have spent a few hours with the Echo techs (they take souped-up images of a person's heart using ultrasound), a day working with the EKG techs in the Emergency Department obtaining bedside heart graphs (looking for MIs, arrhythmias, etc.), and working in the clinic taking care of outpatients. This latter experience is my favorite, because I get to hear a whole bunch of different "murmurs." These are extra heart sounds in the cardiac cycle that I can hear whilst listening to someone's chest through my stethoscope. Usually, one should only hear the classic "lub-dub, lub-dub, lub-dub." But sometimes I can hear "KEN-tuck-eee, KEN-tuck-eee, KEN-tuck-eee" or "lub-WOOOOSH-dub, lub-WOOOOSH-dub." Weird, huh? Now you wonder what your heart sounds like...
• Radiology - Pretty pictures. This is always a very satisfying half-day. What's awesome is that I get to see each image, come up with my own impression of said image, and then immediately have the answer presented by the attending. This is what I see when I look at this abdomen; see this [insert pathology here]? You can't miss that! I get to see appendicitis after appendicitis, chest x-ray after chest x-ray. It's the repetition, as I try to build a catalog of images in my brain for future reference. Picture, impression, answer. Picture, impression, answer. The radiologist immediately dictates his or her report on vocal recognition software, so I can hear exactly how the picture should be interpreted. Like I said, very satisfying.
• Orthopaedic Trauma Surgery - Another very satisfying field, because in this one I get to put screws in people's bones. Literally. I had the opportunity to take electric drills and screw in plates of steel (or some kind of metal) into broken femurs and elbows and ribs and clavicles. It is very meticulous for a specialty notorious for its brute strength. Everything is so precise: there has to be a certain amount of strain this way, and a little bit of stress that-a-way to make sure the patient's leg isn't turned 90 degrees when the patient wakes up the next morning. I also like Ortho because, instead of just wearing the shoes' coverings, I wear the moon-space boots that cover my scrubs all the way up to my knees. It makes me look uber-cool when I waltz into the cafeteria...
• ENT - "Ears, Nose, and Throat." It's an awesome field with a great mix of outpatient and surgery, pediatrics and geriatrics. Ultimately though, I just don't like the ears all that much. Too much wax...
• Neurosurgery - A very interesting specialty that I am definitely going to have to spend more time in. One of the docs I worked with does "deep brain stimulation," which means he actually inserts an electrical device into someone's brain and then it sends out all these stimuli. I've mostly seen it used in patients with Parkinson Disease, but I think there are a lot of indications for it. I've only seen a couple chronic neck pain cases, so I'm definitely going to have to go back for some brain drilling. Ultimately, I think I enjoy the abdomen much more, but it's worth a second look.
• Continuity - same old, same old. Taking two patients from the ER straight to the OR was the latest and greatest I've done.

I also have half-days in Pediatric Endocrinology and rural General Surgery to look forward to (I hope!) in the near future. So next we'll tackle the ethics issue presented last week, and then hopefully some class profiles to follow.