When you wish patients would die

I haven’t blogged in quite a while, and my husband was harassing me to post something new.  I’m currently in my third year of medical school rotating through various specialties in the hospital.  It’s not that I’m too busy to blog (though I’m quite busy between hospital scut work and studying), it’s just that this year feels like such a whirlwind of emotions sometimes that it’s hard to put them out into the blogosphere without feeling a little exposed.  But maybe those are the types of topics that make for the most interesting read.  So I give you a topic that reflects what was going through my mind a few days ago: when you wish patients would die.

Try not to read too much into that – I don’t want to harm or kill my patients.  But sometimes you see people who have been suffering for so long, that you wish for an end to their suffering.  Unfortunately for some people, the only end that would provide this is death.

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Those drug reps are good! (or…er…bad?)

I shadowed an internal medicine specialist last week, and as I was trailing behind him like a lost puppy (ah…the joys of being a clueless medical student) someone who appeared to be his buddy joined us as we reviewed charts and examined some imaging studies that had been ordered. The doctor and his buddy (who I presumed to be another doctor given that he was wearing a pair of blue scrubs) talked about their plans for the weekend, what topics should be presented at an upcoming conference, and then started discussing the pros/cons of various procedures and new techniques that might be helpful.

It was at this point that I got a closer look at the “buddy”, and noticed something inscribed on his scrubs that was neither his name nor the name of the hospital…it was the name of a drug company! Eek! I had been fooled! He was handsome, charming, and seemed to know the medical lingo (perhaps his good looks and perfect hair should have been the first clue?). He followed this doc around for a good 3 hours (maybe even more since I had to leave), including being present for a procedure on a patient, which seemed entirely unnecessary given that there was no “product” being used on this particular person. Drug reps definitely know which doctors respond to their attention, so the doc I was shadowing must have been a huge fan of their products.

It was weird to see the close relationship the two had, but did the patients know the physician was getting followed around all day like that? That he was getting paid to speak at conferences on behalf of this company? I don’t have a problem with drug reps per se…I understand products need to be marketed and sold, and I’m all in favor of competition…but if you publish a paper in a journal, you have to disclose all of your financial ties to show any potential bias you might have. Shouldn’t you do the same for your patients?

I’ve set a goal for myself for next year (my 3rd year of medical school, when I start rotations in the different specialties) – I’m going to see how long I can last without taking a single thing from a drug rep. No pens, no free lunches, no little gadgets…nothing. It’s mostly because I want to force myself to be aware of all the different ways the drug companies woo doctors/nurses/students…and because I like a good challenge. If I last a week, I’ll be proud…if I last a month, I’ll be amazed (free food is really hard to pass up when you’re poor and in a hurry). I’ll try and update the blog with all of the cool stuff I’m passing up, as well as how long it takes before I succumb to peer pressure. It’ll be fun! 😉

~ Lily

Thoughts on the John Ritter case

I was perusing my blog feed this morning and came across a CNN article discussing the wrongful-death lawsuit against doctors who treated the actor John Ritter. Ritter was treated for a heart attack, when in fact he was actually suffering from a “torn aorta” as the article puts it, which in more technical terms is an “aortic dissection.”

It’s tragic that he (or anyone for that matter) has to die at such a relatively young age – 54 is much to early to go. But for me the significance of the case is to serve as a great reminder of how non-scientific medicine can be. Don’t get me wrong – there’s a lot of science to medicine, and a lot of treatments are prescribed because of solid evidence and many years of research comparing different treatments with outcomes. You’d think by now we’d be experts at treating someone who comes to the emergency room complaining of “chest pain”, until you realize how many different problems can present themselves under that single descriptive term. We’re taught in medicine to come up with a list of possible diseases each time a patient complains of a certain ailment – we call this the “differential diagnosis” and it includes both what we think is likely to have occurred as well as a list of long-shots. For instance, if someone came to the hospital with “chest pain” a doctor would consider serious problems such as heart attack, pulmonary embolism (blood clot to the lung), aortic dissection (torn aorta), pneumothorax (collapsed lung), and cardiac tamponade (blood around the heart that limits its pumping ability)…but would also consider benign problems such as indigestion, esophageal spasm, etc. They then go through their list and try to target their questions to rule in/out the various conditions, focusing on the more serious ones first since those pose the most immediate threat. In the case of John Ritter, his family history of heart problems may have come into play. Medications, alcohol/tobacco use, or previous medical ailments might also influence which diagnosis you lean towards.

I should add at this point that I’m not a doctor, let alone a cardiologist – I’m a medical student with a very introductory understanding of how this process works. Most emergency room doctors would have probably considered the various problems listed above, taken a detailed history of the patient, and then decide which course to pursue. If they suspected a heart problem, they would probably obtain a chest x-ray as well as an EKG to look for electrical abnormalities that might indicate a heart attack (and call the cardiologist to come down and examine the patient). But this is where it starts to get tricky – an EKG is a great tool, but will not always show electrical changes even if someone has had a heart attack or is on the verge of a heart attack. Thus if the patient’s history strongly suggests heart attack but is not confirmed by an EKG, the doctor might still treat as if it were so. I have no idea what happened in the case of John Ritter, but perhaps that is one possibility of what took place. The classic presentation of aortic dissection is sudden onset chest pain that migrates…if Ritter’s pain wasn’t radiating (or if the doctor didn’t ask whether it was radiating) that diagnosis might be missed – that doctor would not have ordered a CT scan to look for tearing of the aortic wall, and might go on to treat as if the patient had something else.

Even if it is caught, aortic dissection is a terrible diagnosis with a very high death rate – surgery is required to immediately fix the tear before it occludes blood flow to vital organs and causes permanent damage/death.

In summary, I’m not writing this post to make excuses for the doctors involved in the case – I have no idea as to the specifics involved and what was or wasn’t considered. I’m merely trying to provide insight into how this whole medical process works, since most people outside the system are entirely clueless. Medicine is a wonderful tool with the potential to have huge impacts on our health and quality of life…but it is a mix of science and art, with the two frequently so intertwined that it may be difficult to distinguish where one stops and the next begins. Fancy tests only tell you so much, and are generally meaningless without a thorough history of the patient (I wonder how much money we could save by simply providing more time for talking with the patient, which may then allow us to avoid having to use the fancy high-tech toys at our disposal). Regardless of whether John Ritter’s death was the result of a medical mistake or an inevitable outcome, it’s tragic that he had to die at a young age. Hopefully medicine will evolve to provide more accurate distinctions between the various types of “chest pain” so that such tragedies may be avoided in the future.

~Lily

CNN article

Daily dose of crazy – today’s winner

Let me start by saying that I live in a big city, with a lot of crazy people who like to shout at other people. I see men and women talking to themselves, or yelling at a random piece of trash on the sidewalk which, apparently, is talking back to them (I think there’s a lot of undiagnosed Schizophrenia in my city). But this was different. Both frightening and funny at the same time, it went something like this…

Me – walking along the sidewalk, minding my own business

Crazy man – about a block away, yelling at random women walking past

Me – within a few feet of crazy man

Crazy man turns to me, his new target, and says shrieks “Evil woman! Homosexuals exist because of evil women like you!”

Why anyone would move to the suburbs and miss out on gems like this is beyond me. Misogynistic and homophobic at the same time. To think that I, a heterosexual married woman, was responsible for all the gay men in the world. Who knew I had such power? Guess I should be more careful how I use it from now on, cause ya know…with great power comes great responsibility. (aw come on – you know you laughed a little at that one)

~ Lily

God killed my friend

or at the very least stood by doing nothing while she died, while allowing people like this and this to live on.

My friend, we’ll call her Rebecca, died this past weekend at the age of 25. She was diagnosed 3 years ago with a brain tumor, and had every type of surgery, radiation, and chemotherapy possible, but it was not enough to save her. She was sweet, caring, beautiful, and strong; she had recently gotten married and had a lifetime worth of goals and dreams ahead of her. Rebecca had planned on becoming a teacher, and eventually becoming a mother. She volunteered in her community and was kind to everyone she met, regardless of whether she personally liked them. She was active in her church, singing and sharing her many musical talents with anyone who asked.

Let me now add a disclaimer that I don’t believe in a God – there are a lot of things we don’t understand about the universe, and I don’t pretend to have any answers. But when my friend died, I couldn’t help but wonder how someone who believes in a God can justify what happened to her. It’s the classic question – “why do bad things happen to good people?” See, I understand that religious people generally believe in free will, so sometimes when bad things happen to us it’s a result of some action we took. For instance, if I drove my car to the grocery store while it was snowing and got into an accident injuring myself, it’s reasonable to assume that my choice to go for a drive while the roads were slippery played a role in my injuries. It was my choice, and I paid the consequences, despite how inherently good or bad I might be. I also understand that the definition of “good” or “bad” is going to vary between people.

However, I’m not sure of anyone that would consider an early death, like what Rebecca had to endure, a good thing. And I don’t think her brain tumor had anything to do with a choice she made (in contrast to some cancers, like lung, which are often caused by an action like smoking). There was nothing she could have done or put into her body that caused that brain tumor – it was some sort of perverse accident, a deadly combination of genetics and environmental factors beyond her control. So then I ask, if you believe in God, what is your justification for this occurrence? Why did God give Rebecca a brain tumor (or allow her to die of a brain tumor) while letting serial rapists live? Why did God allow a tsunami to kill over 200,000 people in 2004, while doing nothing to stop a repeat child-molester? Is it because “God works in mysterious ways”? That response always seemed like a bit of a cop-out – if you don’t know the answer, say so. Did my friend sin, and this was her punishment? I don’t buy that – she wasn’t perfect (no one is), but there are many people in this world far worse. Did God smite her just for his own amusement? Or it is possible, just maybe, that God had nothing to do with any of this – that sometimes life sucks and good people pay the consequence? If God is loving and all-powerful, then he would have saved my friend. He wouldn’t have let her die before her parents, leaving behind a husband who is now contemplating what goals he has left that didn’t involve a lifetime with her. The world is a worse place today, because Rebecca is no longer here to share her love and talents with the rest of us.

~ Lily

Praying to ace an exam

I’m a medical student, and my classmates and I have an exam coming up. It’s not uncommon for students to send out study guides, flashcards, mistakes in lecture notes, etc to the entire class via our listserv – we’re generally a cooperative bunch and like to help out fellow classmates and save each other time. There are also occasions in which different school organizations send emails to the class advertising meetings, events, etc. Some of these organizations are strictly medical (interest groups related to every medical specialty imaginable), and others are religious or political in nature – “Catholic Medical Students Association”, “Med Students for Choice”, “Jewish Medical Students Association” – you name it, we’ve probably got a group for it. I’m an atheist, but generally am not bothered when these religious groups advertise to the entire class. They’re an organization, and it’s the easiest way to reach everyone until you have your first few meetings and narrow down your list of interested individuals.

But the most recent email I received was different. It was from a few of my Christian classmates who were advertising an hour long “prayer session.” I’m not sure how to explain it, but the email felt weird. They weren’t trying to be exclusive – indeed they specifically mentioned it didn’t matter whether you were “Christian or not” – but it still came across that way. It still made me feel like an outsider – a reminder that the majority of this country (some of my family members included) think I’m destined for hell, or that I’m the equivalent of a murderer or rapist. Maybe it wasn’t the tone of the email, but the fact that these classmates in particular like to conspicuously “advertise” themselves as Christian – one frequently has the word “Jesus” displayed quite prominently when he comes to class. When I see that, I can’t help but think he doesn’t want to pray with anyone “Christian or not”, but rather for them – to save their soul. Is this true? Maybe I’m wrong. They’re very nice people, but I still feel like they are judging me for my (lack of) beliefs.

Moving on from my initial impression, what also bothered me was what they wanted to gather and pray about. We’re in the middle of an infectious disease course, learning about all of these viruses and bacteria that cause death and destruction around the world. We learned about rotavirus, which kills around 650,000 children every year. Were they praying that children in developing countries could have access to sanitary water or a vaccine to prevent this infection? No! Part of our local patient population includes many poor and homeless people. Were they praying that these families would not have to worry about paying their next bill? No! Were they praying that the homeless man on the corner could get access to mental health-care and a safe place to sleep? No! They were praying so they could do well on our upcoming exam. That may reflect more on their personalities or the fact that they’re medical students rather than their religious background, but it came across as incredibly selfish.

I don’t even believe in the power of prayer to change outcomes (most recent evidence here), but I do think it can be beneficial for the person praying (as a form of meditation) or a person who knows that loved ones are praying for them (as a form of emotional support). However, regardless of whether it works or not, I must ask my classmates – seriously? Out of all the things you pray for, and you choose an exam?! Are you an idiot?! Do you not care about other people in the world?! Are you really that selfish?! And now, until they prove otherwise, my answer is…yes. They are that selfish. They would rather pray for a good grade then for a decrease in human suffering around the world. They would rather spend an hour praying to do well on an exam, than an hour studying (which is guaranteed to help them on the test). They would rather pray for an hour than spend an hour volunteering at a local homeless shelter and making a tangible difference in the life of a person. Maybe I’m crazy…but it seems like they’ve got their priorities wrong.

/rant

~ Lily

Shingles – to vaccinate or not to vaccinate (and my experience)

That’s what’s being discussed by a NY Times article today, titled “A Vaccine as an Option to Keep Shingles at Bay.” Unfortunately the vaccine is new, so a lot of the effects are unknown – that is, no one really knows how long the immunity lasts, and if there are any long-term side effects. Still, it’s something to consider if you’re worried about suffering from shingles.

If you don’t know what “shingles” is, consider yourself lucky. It’s a reactivation of the Varicella Zoster Virus – the same virus that causes chickenpox. But when it reactivates (usually in older people with weakened immune systems) instead of breaking out in those characteristic red blisters all over, shingles usually results in a more localized blister. It’s localized because after suffering from chickenpox, the virus retreats to a nerve, and upon reactivation will generally effect only that nerve. The area of skin supplied by these nerves is called a “dermatome”, and if you look at the picture below you can see how these are distributed across the body (borrowed from the website http://www.thecompounder.com, which I’m pretty sure was borrowed from Frank Netter’s Atlas of Human Anatomy):
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So the virus hangs out in a nerve root near the spine, and upon reactivation affects a strip of skin that correlates to the strips in that picture. If it presents classically like this, it’s probably pretty easy to identify by a doctor or nurse, although the NY Times article describes a woman who had to make a few trips to the ER and Urgent Care clinic before getting diagnosed and treated.

I can say from personal experience that you do not want to suffer from shingles. I had an outbreak at 23, which I’m assuming is pretty rare. It’s associated with old and immunocompromised patients, but it can also erupt because of extreme stress, which is what I believe happened in my case. I had just moved across the country, started medical school, and ‘came out’ to my very Christian parents about my atheism – there was definitely a significant amount of stress in my life at the time, though I was trying to manage it by exercising and eating relatively healthy (obviously it wasn’t enough!).

I had what I assumed to be multiple bug bites or poison ivy (I’m an outdoorsy person), and decided to go to the doctor after the ‘bites’ wouldn’t heal and appeared to get worse. Fortunately my primary care doctor identified it immediately as shingles (literally, she took less than one second) and put me on retroviral therapy for a week to put the virus in check, but I’m not sure whether other doctors would be so quick to catch it in a younger patient, which I believe was part of the problem with the woman in the article who was repeatedly misdiagnosed (plus it was on her scalp which probably made it more difficult to see). The next few weeks were miserable, to put it mildly, as the blisters crusted over and went from causing a minor tingling sensation to spontaneous severe, sharp pain. Even after the spots healed and disappeared, I would still get random tingling or brief pain for months. Fortunately this disappeared, but in some individuals (the article says about 20%) this pain never goes away and is referred to as ‘postherpetic neuralgia’ (PHN). I feel very sorry for anyone who suffers from PHN – I think I would go crazy if I had to live with those sensations for the rest of my life.

So would I get a shingles vaccine? I think it’s sort of a moot point for me – having suffered from shingles already the odds of a second incident are small. Still, if I were older and in a risk group for an attack, I would probably get the vaccine. It’s worth the $200-300 not to experience the weeks of weird sensations and pain, and definitely worth it to avoid experiencing PHN.

Miles Levin, 18, has passed away

I wrote about Miles a few weeks ago under the title “Brevity of Life,”after following his personal CarePage for the past few months. Miles had a rare form of pediatric cancer that he had been fighting, and after exhausting all treatment options, gracefully accepted what was to come. So it was with sadness that I read upon the blog today a note from his family, indicating that he passed away. They write:

This is the update you’ve been dreading: Miles’ earthly body has left us….early this morning. This is the day we’ve been dreading since June of ’05, and fearing it would come and now it has. We did everything humanly possible to arrest this disease. Our efforts were not enough. There are no interventions currently available that could have produced a different outcome. Hardly a comfort….Talk about destiny, G-d’s plan, purpose, anything you want, but the fact is that our boy, our beloved son and brother, was snatched from us, and it hurts. We knew it was coming, yet we’re shocked. We knew it was coming, yet we’re unprepared. We knew it was coming, yet it feels unreal. We knew it was coming, but we hate it.

I’ve never met Miles, but he still managed to have an impact on me. It is sad when someone dies of ‘old age’, but to die before that feels much more than sad…it’s tragic – like they were pulled from this earth before their time. My thoughts and condolences go out to the family of Miles, the many friends he made in his short but meaningful life, and the many strangers who, like me, found inspiration in his story that he so graciously shared. The family has requested that any who wish to honor Miles do so by making a contribution to the “UJF Miles Levin Fund,” described as a “newly established tax exempt fund designed to support existing efforts to combat pediatric cancer as well as providing our family a vehicle to create new directions in patient care”:

UJF – Miles Alpern Levin Fund
P.O. Box 2030
Bloomfield Hills, MI 48303
Attn: Susie Feldman

Miles Levin, whose blog inspired thousands, dies” – Detroit News, 8/19/07

Whatever life we get is bonus” – Anderson Cooper 360 blog with Miles Levin as guest columnist, 5/9/07

Brevity of Life

Ever since I stumbled across his guest column on Anderson Cooper’s 360 blog a few months ago, I’ve subscribed to Miles Levin’s personal blog on carepages.com and have been following his journey.

Miles is a recent high school graduate who is facing a very deadly form of pediatric cancer, and it seems that, as of last week, he has run out of treatment options. He apparently only has 2-5 weeks left (unless some new treatment option appears, which seems unlikely), yet he faces it with a kind of calm that is both impressive and inspirational. From his July 26 post:

If I am nearing the end, I am trying to relax into it, to accept what is to be. I know that things are happening as they are supposed to happen, if not by divine destiny then by the overpowering forces of nature. I know this because I know that we have given this fight our all. We have left no stone unturned. I have fought my very hardest.

Now its up to the greater powers, whatever they may be. It seems a certainty that my path was not meant to be ordinary, but while everyone wants to feel special, I find myself alternating between feelings of gratitude for all that my life has been, with the feeling that it’s not asking too much to wish for more–to trade it all for a normal, obscure teenage existence in which I craved greater impact.

I’m getting quite a lesson in not getting what I want. Turns out it is one of the hardest we’ll ever have to learn. I’m not a child anymore; I can’t get away with throwing a tantrum. This is hard, and there’s no easy way around that.

It’s very humbling to read his words – every day many of us strive to get rewarded, to feel special, and he would trade it all just to buy back his life. I imagine many of us would share his feelings if we were in his position; and while we are fortunate to have our life and hopefully our health, we will likely continue to take it for granted until faced with a debilitating condition such as cancer. I don’t think there’s anything inherently wrong with this approach, but perhaps every now and then we should stop, breathe, and remind ourselves to enjoy our life, even if only for a brief moment.

Death by softball

A 12 year old girl died after being hit in the head by a softball. Certainly this is a rare occurrence, otherwise parents would never let their kids participate in the sport, but it does highlight the level of danger that is possible when large balls are flying through the air – a danger I have a new appreciation for after recently (Monday) getting hit in the head during a game of softball.

I was hit directly under my left eye on the orbital bone, probably much less dangerous than where this 12 year old was hit (I’m not sure where the ball specifically hit her, but the article implies the skull immediately surrounding the brain). Still, the area around my eye began to swell within 1 second, and after a minute it had swollen so much that I could barely see out of my left eye. I went to the ER and had a CT scan to check for broken bones, and to make sure that none of the fluid now pressing my eye shut was pushing on my optic nerve. Fortunately for me (and a bit to the surprise of the docs) nothing was broken and I was sent home with pain meds and instructions should my head take a turn for the worse (risk of concussion).

Just as I went to my softball game on Monday expecting only nice weather and good fun, the family of Maggie Hilbrands never imagined how that day could have turned so suddenly for the worst. My thoughts and condolences are with her family and teammates in this time of mourning.

Potter-mania

Apparently the latest Harry Potter book has broken records, selling over 8 million copies in the first 24 hours.

I was at WalMart on Saturday and saw that they had a bunch of copies sitting out, so I bought one, not even realizing that it was the first day the books had been released.  Does that make me a Potter fanatic?  At least I didn’t wait in line to purchase one at 12:01 AM, considering how many copies the store had left over 12 hours later (although that could have been 12 more hours I would have to read it this weekend).  So I’m about 1/3 of the way through, and it has yet to disappoint.  I’m not sure how much time I’ll have to read it during the week, but you can bet I will try and find the time.  🙂

Welcome to my blog!

Though I have very diverse interests, this site will probably be dedicated to those for which I feel most strongly: science, medicine, politics, and the occassional rant on religious crazies. Still, I can be a bit free spirited from time to time so don’t be surprised if other random topics pop up.