Monthly Archives: July 2008

Mulberry search terms

One WordPress feature not available on my old Blogspot URL is a better statistics feature.  It’s rather interesting to see monthly graphs of visits to my blog, and to note any correlation between the frequency of my posts and the number of views.  I can also easily see which posts are the most popular, most commented on, linked to, etc.

There’s another feature which displays search terms which lead to my blog.  I’m not sure if these represent “outside searches”, e.g., from Google; or WordPress blog searches.  Here are some of the more interesting ones over the last month which led, one way or another, to Mulberry Street.  They intrigue me, not only that they necessarily led to my webside, but by causing me to imagine exactly who creates these search terms:

  1. toradol on the street
  2. “daron dean”
  3. i power blogger
  4. mulberry sucker
  5. appetite suppressant mulberry
  6. sandwich mulberry street
  7. copper penny mosquito bites
  8. surgeon and bathroom breaks
  9. “lynn roselli”
  10. gasoline prices and prophecy
  11. patient crumping
  12. my favorit [sic] room
  13. what to know before internship medicine
  14. pronoun for government
  15. mulberry street constipation child
  16. chiari malformation george bush
  17. physical exam jake gyllenhaal

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Filed under Blogging introspection

Maybe I should get a desk job…

Editor’s note: I wrote this post some time ago, but waited an unspecified length of time to post it to protect patient privacy.  It should be noted that the post portrays graphic medical situations in raw, unedited detail, so readers with a delicate constitution may wish to stop reading here.

Yesterday afternoon’s code was one of the…shall we say…earthiest I’ve ever been to.  My friend Jen, carrying the code pager for the day, had grabbed the orange “arrest bag” which was stocked with medicines, airway equipment, and gloves and was headed out of the anesthesia workroom.  “Code blue, sixth floor,” she said tersely, “Want to come?”  Given that I find participating in codes strangely rewarding, I tailed her.  It’s satisfying to make a huge difference in the acute trajectory of a patient’s health, and once an endotracheal tube is successfully placed, one can sense the rest of the medical team breathing a collective sigh of relief.  I’ve also noticed that walking into a crowded room, assessing the situation, and taking charge and communicating effectively seem to restore a bit of order to the chaos.  It’s good practice for learning to function well in highly stressful situations.

As Jen and I rounded the corner, we saw a small gaggle of medical students clustered around a door near the nurses’ station.  They talked quietly in intense conversation among themselves, their short white coats’ pockets bulging with reflex hammers, pocket references, and “to do” lists.  We immediately headed toward that door.

We strode into the room that was packed with physicians, nurses, pharmacists, respiratory technicians, and the code cart.  Being nearly 6’4″, I had a decent view of the situation, but rather than seeing a patient, all I saw were white coats clustered around the bed amid a flurry of syringes and beeping.

“Anesthesia,” I announced loudly.  “Who’s the primary team?”

“Anesthesia, get in here and intubate this patient!” one of the surgery seniors commanded me.  A little taken aback by his tone, many thoughts quickly crossed my mind.  Why else were we here?  Tea and crumpets?  Of course we were going to intubate the patient, in the quickest and safest manner possible.  Jen and I were working our way to the head of the bed.

Rather than replying, “Can you communicate with me rather than barking orders at me?” I simply asked in a voice that carried across the crowded room, “Does he have any cardiac history?”  The surgeon didn’t seem to know.  Instead, in a more neutral tone, he said, “He aspirated.  He needs intubated.”  Aspiration is the medical term for when acidic stomach contents enter into the trachea (windpipe) and potentially cause grave damage to the lungs.  Most people who aspirate end up with in the ICU with lung injury; many die.

By this time, through the tight ring of white coats, I was able to see the patient at last.  They were doing chest compressions.  I looked at Jen and said, “Compressions.  We need to intubate.”  A true code–that is, a cardiac arrest–makes our job fairly simple.  No medicines are needed.  Just a laryngoscope and endotracheal tube.  And there’s really nothing worse than being already dead, so we don’t have to worry much about hurting the patient.  I’ve never heard of a patient saying, “Hey Doc, I wanted to thank you for saving my life, but I think you may have cut my lip in the process.”

The “fairly simple” task, however, became a bit more complicated as I got a better view.  The bed was only about two feet off the floor, making it more difficult to get a close view.  The patient had a huge stomach, which is usually associated with a thick neck and a difficult time performing adequate laryngoscopy.  In addition, he had a full beard.

“Move the bed out,” I ordered.  As the bed rolled forward, I noticed not puddles, but small lakes of brown liquid covering the floor at the head of the bed.  The white sheets covering the mattress were saturated with particulate brown fluid.  Donning gloves, I scarcely had time to process it before the respiratory therapist told me, “I’m having trouble moving air.”  With that, she removed the ambu bag and I saw the source of the effluvium.  It was erupting from the patient’s mouth with every compression of his chest.

“This’ll be tough, Jen,” I said, looking at my fellow senior resident.  “Do you want to do this?”  She shook her head no as I removed the head board and grabbed the suction tubing with the Yankauer tip.  This attachment quickly clogged with the particulate matter, so I removed it and placed the larger tubing directly in the patient’s mouth while the internists continued compression and rounds of epinephrine and atropine.

After thirty seconds, I realized that whatever I suctioned out was being replaced with more fluid from deep, deep inside this poor patient.  His mouth was like a storm sewer overflowing after an afternoon deluge.  If we didn’t get oxygen into his lungs soon, there would be no hope of resuscitating him.  I tried to think about my options: a fiberoptic scope would be useless with all the liquid, and it was downstairs anyway.  A laryngeal mask airway might help get oxygen in, but it wouldn’t prevent more fluid from entering the lungs.  I don’t feel qualified to do a slash-tracheotomy, and a needle cricoidotomy would be silly in this setting.  He needed a definitive airway–an endotracheal tube–and our main way of placing it–by direct sight–was impossible with the copious runny stool being forced up by the impossibly large gut.  My sense of smell, taste, and hearing didn’t seem to help me here.  This left me with one obvious answer.

“Jen, could you hand me a bougie?”  This somewhat rigid yet flexible tool saves lives daily in the operating room.  Its curved tip is designed to bounce on the cartilaginous tracheal rings, providing tactile confirmation that the bougie is within the trachea and not the esophagus.  Once in, an endotracheal tube can be slid over the bougie, the cuff inflated, and the bougie removed.

I grabbed the laryngoscope and pried open the patient’s mouth, while brown chunks seeped out the corners of the lips.  Advancing the laryngoscope by feel rather than sight, I knew that it would help me by lifting soft tissue out of the way, rather than providing a line of sight.  I took the bougie in my right hand and plunged it into the small pool in the patient’s mouth.  It met some resistance as I advanced, so I twisted and redirected a couple times before it finally sped forward.  I felt a subtle bump or two, suggesting tracheal rings.

Raising my eyebrows at Jen, I steadied the bougie while she advanced the endotracheal tube over it.  With deft hands, we inflated the cuff, pulled out the bougie, attached the carbon-dioxide sensor, and applied a few breaths with the ambu bag within seconds.  The sensor turned a reassuring yellow, and one of the keen internists called out, “Bilateral breath sounds!”  The tube was miraculously in place.

I called for a soft suction catheter, knowing if the patient stood any chance of survival I’d have to remove as much fluid as possible from the lungs.  As I removed the ambu bag, however, I didn’t anticipate the geyser of fluid pumped from the lungs, up the tube, and out onto Jen’s scrubs and a nearby internist’s white coat as another medicine doc continued forcible compressions.  We quickly suctioned and continued ventilating while rounds of epinephrine, atropine, lidocaine, and calicium were poured into the femoral line.

The story ends, sadly, as many codes do.  We were unable to restore a heart rhythm.  The code was “called” as no pulse was attained.  The room emptied in what seemed like seconds leaving Jen and me, with spinning heads, alone with the patient and our orange bag.  We wandered back downstairs to change scrubs and sit down for a few minutes of peace to restore our sanity.

In retrospect, I cannot think of much we’d do differently.  Attempting mask ventilation can force more fluid into the lungs in a patient with such copious gastrointestinal regurgitation.  We should have put on masks with face shields first thing for our own protection.  But in reality, I knew that our chances of bringing this fellow back were next to nothing with such massive aspiration.  Here is a situation where the patient is clearly objectified, as he should be in that moment.  He becomes a task, a problem, a challenge.  We solved it.  And even if saving his life was practically impossible, by restoring oxygen to the lungs, we at least gave a sense of closure to the medical professionals.  Everything that could be done had been done.

Images of those minutes kept coming into my mind during the remainder of the afternoon and as I tried to go to sleep last night.  Nearly every sense was saturated with input: slippery floors, shouted orders, red blood & brown stool, ringing pages, splatters, needles, cracking ribs.  And I wondered, “What kind of job do I have?  What would it be like to sit behind a desk, sip coffee, and sort through e-mail and messages?”  In medicine, we tweak the inner workings of an amazing machine, our finesse guided by thousands of years of experience, by the scientific method, by love, by art.  But in the crucial times, practicing medicine rams together the raw, animalistic, sloppy, dirt-under-your-nails sort of gritty survival instinct with placid, cerebral, transcendent rationalism.  And I marvel that this is all starting to become normal.

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Filed under Musings, Work

Wordle

Since I’ve added the “Category Cloud” and “Tag Cloud” widgets in my side bar, my sister Charity suggested I check out wordle.net.  This website will create artistic clouds of commonly used words on a website.  This image, created from the last three days’ posts, gives a good flavor of my week.

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Filed under Blogging introspection

An open letter

General Manager

New York Yankees

Bronx, New York

 

Dear Sir or Madam,

I enjoyed my first outing to Yankee Stadium last night to see the home team beat the visiting Tampa Rays.  While the weather was hot and humid during the day, the temperature seemed to drop enough by early evening to be tolerable; the ambient air was not nearly as comfortable as the Metropolitan Opera’s perfectly conditioned red velvet interior, however.  In order to keep attendance up in comparison to rival city institutions, I suggest you factor this in.

I have to say, although my friend who accompanied me was surprised by my naivete when it comes to domestic beers, I also enjoyed my first Genuine Miller Draft, plastic bottle and all, a relative steal at $8.50 for 16oz.  It seemed to be a recyclable container, which comes with an added safety benefit: were I to inadvertently throw the bottle onto the field, fewer people would be hurt than by the bat that was nearly hurled into the seats close to third base.

I was also impressed by the accessibility to public transportation.  The B and the 4,5,6 line all stopped on the corner, adding to the feel of community as fans traveled to and from the stadium.

Speaking of the stadium, as this is the last season in the “House that Ruth Built”, I was a little disappointed by the renovations–apparently done in the 1970s–that effectively destroyed the structure’s character and charm.  The plastic seating, the electronic banners, the tacky refurbished ceiling made me wonder what, apart from spirits and legends, was worth seeing.  I am hopeful that the $1.3 billion of public and private money you are spending on the adjacent new stadium will provide a little more distinction.  And perhaps now is not the time to question why public funds are being used to build a stadium replete with luxury boxes and marble.

I cannot remember the last time I enjoyed a $5 hot dog so much.  How nice, too, that the spicy mustard came free.

And how surprised I was when, after displaying my ticket at the entrance, I was directed to another security guard who told me that my compact shoulder bag was not allowed inside, even though it clearly contained only books and paperwork.  I suppose I was just confused because I saw women carrying in purses the size of my bag.  Your security guard seemed almost huffy when I asked if it were true that women could carry purses in, but I couldn’t carry my shoulder bag in.  “I don’t make up the rules,” with an aggressive posture really didn’t answer my question, so I rephrased it, “No, I’m asking you.  Is it true that women can carry in purses?”  Hearing the affirmative somehow made me feel better as I carried my bag across the street to the $5 bag check at the bowling alley.  In fact, I was thankful for this opportunity as I was able to appreciate actual examples of substantial architecture.

Still, it’s puzzling that an institution that accepts public funds can so flagrantly practice gender discrimination.  Maybe someday, when the old laminated stadium has been razed, we can talk this over in one of the calf-skin upholstered luxury boxes over a nice glass of pinot noir and some bruschetta, or perhaps jalapeno cheez-whiz nachos.

Very truly, a satisfied patron and fan,

Jonathan

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Filed under Around town, Irony

Red up, blue up, volume in

Such is the chatter I pick up going on between the cardiac surgeons and the perfusionists.  The simplicity and efficiency of the lingo belie the complexity of the cardiopulmonary bypass machine.

My first month in cardiac anesthesiology nearly a year ago was rather stressful, with often difficult arterial and central venous lines, intense and dynamic physiological perturbations, and a general haze of confusion when it came to knowing exactly what was happening when.  One would think that that a major surgical event like, say, unclamping the aorta, would be heralded with a clear pronouncement, if not a chime, a blast from the trumpeter in the corner of the operating room, the unfurling of a scarlet “Aorta Unclamped” banner, and a few turns of the disco ball above.

Not quite.  In the midst of the rocky course of coaxing an octogenarian’s heart off bypass, dealing with hypothermia, metabolic derangement, coagulopathies, and blood volume shifts, I must pick up on quickly uttered words like, “Pressure down, off.”

As a whole, however, I’m enjoying this month much more than before.  Knowing the basics already of how to do straightforward bypass graft and valve surgery, I feel like I’m able to pick up on more details, like nuances of induction of anesthesia, performing transesophageal echocardiography, how to better communicate with the surgeons and the perfusionists, and pearls and pitfalls when it comes to coming off cardiopulmonary bypass.  Transporting an intubated patient with multiple intravenous infusions in a large ICU bed can still be challenging, but at least now I don’t feel overwhelmed by just setting foot in the cardiothoracic ICU.  Having rotated through six months ago, many of the nurses are friendly faces.

Even medical situations that used to be daunting now seem fairly routine.  The patient’s on 6 mcg/min of norepinephrine and 4 units/hr of vasopressin?  A little nitroglycerin?  No big deal.  Pulmonary pressures a little high? Let’s start some nitric oxide.  And I know it’s bound to come to an end at some point, but my hands have been golden this month.  Bright red arterial blood flashes back in my catheter with no redirection; the catheter slides right into the artery.  Central lines slip into the neck like slipping my fingers between the sofa cushions.  Difficult view on intubation?  I’ll just ease a narrow bougie into the trachea and glide the endotracheal tube over that.  So that’s at least been rewarding.

My biggest difficulty has come consistently toward the end of a run on bypass, when the circulating blood must be reheated in order to bring the patient’s body temperature back closer to a physiologic temperature.  (The patient is cooled during bypass to help decrease the brain’s and heart’s metabolic demands.)  Around this time, I page my attending to announce, “We’re rewarming.”  That’s the hardest thing to say, with all those R’s and W’s.  I’ve even tried coalescing the two R’s into one (“Weereewarming”), but I’m thinking of just shortening the message to “Rewarming.”  Or maybe just “Warming,” since, unlike leftovers, this is only the first time I’ve brought the patient’s temperature up.  I’ll try some of these out, and let you know what works best.

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Filed under Work

I’m a fan of methadone

One of the more interesting parts of spending time on the pain management services was getting more comfortable using methadone.  Methadone is a synthetic opioid (mu-receptor agonist) which was developed in Germany in the 1930s since there were predictions of opium shortages.  Methadone has a very long duration of action (making it well-suited for recovering addicts) and it also is a NMDA-receptor antagonist.  This means it may help prevent some tolerance to opioids, and it can quell central nervous system responses to pain.

One of my patients was a young man with sickle cell disease, which leads to painful “vaso-occlusive” crises.  These crises happen when the shape of the red blood cells becomes distorted, leading to obstruction of small vessels.  Patients typically develop pain in their chest, shoulders, hips, and knees.

This particular patient had been in the hospital for nearly two weeks by the time I inherited him (as I came on the Chronic Pain Service on a Tuesday).  He’d been intermittently refusing his long-acting oral morphine and insisted on using his substantial intravenous patient-controlled analgesia (PCA)  pump.  When I asked him why he refused his oral medications, he said they didn’t work for him.  I explained that I believed the oral medicine did work for him, because when he took his medicine consistently, he required less intravenous medicine.  The morphine was long-acting, so it didn’t produce a “rush” or “high”, but I explained that it provided a baseline level of pain control.  He still seemed doubtful.  I also told him that my goal was to get him off intravenous medications by the next day, and I was able to get him to agree to take his oral medicine.

Sure enough, by the next day, he’d refused a couple more doses of morphine.  The cynic found within all pain specialists may interpret this as a sly move to exchange the pain control afforded by long-acting medicines for the euphoria of intravenous medications.  Since one side-effect of opioids is sedation, if a patient is too sedated, he won’t push the pump’s button.  This is the elegant safety feature inherent to PCAs.  If a patient refuses long-acting medicine, that means he can get more intravenous medicine more frequently without becoming sedated.

At this point, I called the pain fellow to make sure he was on the same page as me, and then I lay down the law.  No more intravenous medications.  We’re starting methadone.  The patient would have shorter-acting oral medicines available too, but only if he took his methadone.  With the fellow, I did a multi-step conversion to determine the appropriate starting dose.

I was in for a surprise when I went to see the patient by the next day.  He had received three doses of methadone by that point (one dose every eight hours).  I’d double checked the nursing medication administration record to make sure he hadn’t refused them.  And then I walked into his room.  The patient was sitting in bed, awake, alert, and smiling.  He stated that this was the first day in two weeks that he wasn’t in pain.  Not only that, but since starting the methadone, he had not required any additional doses of shorter-acting oral medication.

Given the long half-life of the medication, it could potentially be building up in his system for days, so I titrated the dose down a tad.  He was still comfortable the next day, so I recommended that he was okay for discharge with close follow-up with his hematologist.

Another satisfying success story for methadone!

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Citizen activists

I’m so glad I decided to take the bus home today.

This was a departure from my usual trip by subway.  As I left the hospital, I noticed a bus that stops a mere fifty feet from my building’s front door.  Hopping on, I knew that the trip would take a little longer, but it seemed a nice change of pace to ride above ground.  That, and I avoided the awful elevators at the subway station.

I quietly read this week’s edition of The Economist at the back of the bus for the majority of the trip.  I was startled out of an article about Robert Mugabe, however, by a surprisingly stern and assertive woman’s voice.

“Sir. Sir! You shouldn’t throw your trash on the floor.”

I looked up and saw a middle-aged woman holding a copy of the New Yorker and dressed in a wide-brimmed hat and linen blouse, gesturing to a small paper carton lying at the feet of a nearby man who was sitting with his wife and child.

He mildly explained, “It wasn’t mine.  It was sitting on that seat.”

More than slightly irritated, she responded, “Well, who’s going to pick it up down there?”

I was surprised when he leaned over, picked up the paper carton, and set it back in the seat, evidently the same place he’d brushed it from just moments earlier.  And I was even more surprised when, a few stops later, he picked it up when departing the bus, presumably to throw it away in one of New York City’s many public litter baskets.

I half-wondered what this aggressive citizen would have done when confronted with the brazen olive oil double-dipper I described last year.

The best part is that I was able to surreptitiously snap a photo of her with my cell phone camera, while pretending to listen to messages.  I applaud you, Woman With A Wide Brimmed Hat Who Reads The New Yorker.

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Filed under Around town, The Economist