Thursday, December 30, 2010

Excerpt from "Weaning the Vent"

As I slid into an exhausted sleep, memories of the last two and a half years floated past me; the gnawing nervousness I felt during my first ED shift and the amazing girth of my first patient (a woman with mysterious abdominal pain); walking home in bright East Sacramento morning sun after a 12-hour night shift and being ‘chauffeured” to work by Angela for early morning rounds; practicing intubations on surgical patients in the operating room and the horror of chipping a patient’s tooth in the process; a favorite attending teaching me the proper way to place a thumb spica splint and an hour of practicing on Angela at home; taking parents to the quiet room to tell them that their son was dead, a victim of random gun violence, and running after a psychiatric patient who was trying to abscond from the hospital, naked; a patient in the hallway of the ED whose primary complaint was coprophagia (eating shit) while a man with diarrhea raced by, trying, unsuccessfully, to reach the bathroom in time; a frustrated ED attending telling me as I attempted to place a central line catheter, “Ballard, you have bricks for hands,” and a disaffected attending saying “I’ll be napping in my office, call me if anyone is going to die;” cleaning maggots from an old man’s feet and removing scalpels from a young man’s urethra; harassing a crotchety nurse to do her job and being harassed, in turn, regarding my horrific, chicken-scratch handwriting; the glorious feeling of a night off from work and a drunken round of Cranium with friends, and the ache in my stomach before a week-long string of shifts; a wonderful delayed honeymoon to Maui and the simple joy of an overdue vacation with my wife; the feelings of self-doubt and loathing after failing to diagnose cardiac stent occlusion compared to the triumphant feeling of nailing a lumbar puncture on the first try; serving beers and relationship advice to Karl and listening to his panicked phone message the day he misplaced his cell phone; attempting to climb Mount Shasta the day after a night shift and the look of dread on Angela’s face as I slipped and tumbled down a glacier directly past her; the pain of working with a massive bruise and abrasions to my buttocks from my failed mountaineering expedition and the stupidity trying to play basketball the next day; a methamphetamine tweaker strapped to and humping a backboard and a meth cooker whose lab exploded in his face; sick patients of all shapes and sizes and circumstances…

Monday, December 13, 2010

"Donald" from Weaning the Vent

So, it was close to noon by the time we made it to Bed One, where we found a toddler named Donald Merrill. Donald Merrill was, for the moment, my only patient. It was my turn to lead the team. I was fortunate to have inherited a light load of patients, but that would soon change. I was on call that day and night and any kids admitted in the next eighteen hours would be primarily my responsibility. For now, however, Donald was it. I was preoccupied with the morning’s events, namely the disturbing visage of the girl in Bed Seven and Karl’s antics, and so when we arrived at Donald’s bedside I made a rookie mistake.

“Donald Merrill is a three-year-old male admitted from Sutter Delta,” I began “for pneumonia with hypoxia. The patient was brought in by Life Flight with an oxygen sat of seventy percent, but with otherwise stable vital signs. The patient initially presented to Sutter Delta Medical Center with two days of fever and congestion and was found to have a room air sat of ninety-two and an interstitial infiltrate on chest X-ray. He received one gram of Rocephin and was transferred to UC Davis. Overnight, Donald has been on non-invasive ventilatory support with Bi-level positive airway pressure, BIPAP.”

Dr. Connor interrupted me. “Wait, wait.” He gesticulated sideways, as if he might break into the electric slide. “Before you continue, please tell us what Donald’s underlying condition is.” I knew the answer and was about to respond, but someone else beat me to it.

“Ondine’s curse, also known as CCHS, Congenital Central Hypoventilatory Syndrome.” It was Karl. He just couldn’t help himself. “It comes from Greek mythology.”

Dr. Connor coughed loudly, but Karl continued. “The name comes from the tale of the Ondine, a beautiful water nymph. Ondine was wronged by a young lover and in revenge she cursed him. The curse…” Karl appeared ready to launch into a lengthy explanation. Dr. Connor appeared ready to burst a temporal vein.

“Doctor Krumholz,” Dr. Connor cut him off, “let’s allow Doctor Ballard to educate us about Congenital Central Hypoventilation Syndrome.” Karl nodded and flipped his hair again. Dr. Connor grunted, “Doctor Ballard?”

I told the team what I knew about CCHS, which wasn’t much. “CCHS is a rare condition, a genetic disorder,” I stammered, “one that affects automatic respiration.” Later, I would research the condition and its associated mythology. Karl was right, at least mostly right. Ondine was a water nymph, born in 18th-century German, rather than Greek, mythology. She was beautiful, enchanting, and extremely leery of men. Ondine, like other nymphs, could lose her everlasting life under only one circumstance: if she fell in love with a mortal man and bore his children. Despite her caution, Ondine fell in love with handsome young Palemon, who broke off his engagement to a noblewoman to marry her. On their wedding day, Palemon vowed, “My every waking breath shall be my pledge of love and faithfulness to you.” Years later, lovely Ondine bore Palemon a child, a son, and in doing so forfeited her immortality. Immediately, she aged and her transcendent beauty faded. Palemon’s eye wandered and on a fateful afternoon, Ondine heard the familiar sound of her lover’s snore in the stable on their estate. Entering, she found him entangled in a post-coital embrace with his former fiancĂ©e. Enraged, Ondine kicked Palemon and uttered a magic curse: “You pledged faithfulness to me with your every waking breath, and I accepted that pledge. So be it. For as long as you are awake, you shall breathe. But should you ever fall into sleep, that breath will desert you.” And so it was that Palemon’s next sleep, preceded by complete exhaustion, was his last. In the 1960s surgeons discovered a condition, following spine surgery, in which patients lost their spontaneous drive to breathe after falling asleep, and it was named after the mythical curse of Ondine. But at the moment, as I boiled with disappointment at Karl’s interruption, I didn’t know any of that.

Since its discovery, a genetic form of Ondine’s Curse had been found – linked in over 90% of cases to mutations to the PHOX2B gene and occurring in one out of 200,000 live births. Most victims died quickly, usually as infants. Donald Merrill was one of only 200 known living patients with CCHS.

Donald had survived to age three for a couple reasons. First, his mother also had CCHS so his family knew, even before he was born, that Donald was at risk. This allowed Donald’s physicians to make the diagnosis before it had fatal ramifications. Secondly, like his mom, Donald had a relatively mild form of the disease. He needed constant respiratory support when sleeping, otherwise his breathing became too shallow. But unlike some (approximately one out of every ten) with Ondine’s Curse, Donald did not need any when he was awake. None, that is, unless his lungs were compromised in some way, such as with an illness like pneumonia.

As we reviewed his situation, Donald was asleep in the room. I knew his family situation was complicated – the note from Sutter Delta mentioned that his mom was in treatment for heroin abuse, so I wasn’t surprised that he was alone. Pale and thin, with flat brown hair pressed onto his forehead, he looked sickly, although not critically ill. He wore an oval-shaped mask over his nose and mouth. When Donald exhaled, the mask clouded with mist. His breathing was even and peaceful. It looked normal, but I had to remind myself that if it were not for the mask, Donald might forget to breathe.

Donald’s care was pretty simple, and conscious of the length of our morning rounds, I summarized concisely. “We will continue antibiotics, await cultures and continue BIPAP at 12/4.”

“Wait, wait,” said Connor. “Doctor Ballard, it is important that you are precise. Imprecision is precisely the cause of most medical errors. What, precisely, are the antibiotics and what rate is the BIPAP set at?”
Yikes, more embarrassment. But he was right; the rate of the BIPAP respiratory support was critically important. Normal BIPAP merely assisted each inspiration and expiration with pressure that helped force air into and out of the lungs. But, this alone would not help Donald. He needed his breaths to be triggered on a regular basis. Thus, his BIPAP was set at a pressure of 12/4 (inspiration/expiration) and a rate of ten breaths a minute. I was about to correct my error, when we were interrupted.

“Bed Seven,” said a weathered nurse in pink scrubs, “she is hypotensive and de-sating. I’m worried about her. You need to look at her now.”

Monday, December 6, 2010

Treat them like family?

MY FATHER, a pediatrician, tells a cautionary tale.

A family physician, the story goes, agrees to work at a lakeside summer camp for boys. Several days and many bandaged bumps, bruises and bee stings into this service, the campers catch and fry up some perch. As it turns out, the fish is rather bony, and four kids come to the doctor complaining of bones stuck in their throats. One by one, the doctor examines the boys and removes the small slivers of calcium until he gets to the fourth boy. Here, he loses his nerve. He can't get the child to properly open his mouth, and he can't find the bone. Finally, he gives up. This child, he declares, must see a doctor in town. The problem is that the boy is his own son.

I recount this story in order to scrutinize the oft-encountered circumstance in which physicians and other health-care professionals provide medical assistance to friends or family. Today, I'm not talking about lighthearted, curiosity-inducing discussions, but rather situations in which good health may be at stake.

Situations like this are stressful for everyone involved, and for health-care professionals there can be the added stress of a unique inner conflict. On the one hand, we have knowledge -- not only medical knowledge, but also insight into how the system works. On the other hand, we often take on an added responsibility when we attempt to treat loved ones.

Medical evaluation and treatment requires a tremendous amount of weighing risks and benefits. Unfortunately, for many physicians, the simple fact that they are now giving advice to a family member may change their usual risk/benefit calculation.

In particular, physicians in this situation may have a diminished tolerance for making an error of omission -- that is, failing to take action. For instance, we may be reluctant to reassure a family member that everything is going to be fine if there's a chance that we'll find out later that it's not.

And while the term "taking action" has a positive connotation for many, in medicine there are real risks associated with doing so.

According to a 2007 report from the Institute of Medicine, more than half of medical treatments in this country are unproven. Meanwhile, most physicians, patients and malpractice juries tend to overvalue treatment over potential harm from side effects (for example, in most situations the potential benefit of taking antibiotics for a sore throat is much less significant than the potential harm caused by an adverse reaction to those antibiotics). Mix in concern about committing an error of omission, and you may have doctors making unnecessary and risky recommendations to their family members when in fact the clinical situation calls for a doctor with the courage to do nothing.

Medical science is just starting to explore the implications of certain personality qualities, such as risk tolerance, on clinical decisions. A recent study by Dr. Jesse M. Pines, director of the Center for Health Care Quality at George Washington University Medical Center, found that emergency physicians' scores on a standardized risk-taking scale (sample question: "I try to avoid situations that have uncertain outcomes") were associated with significant differences in the clinical management of patients with chest pain. Interestingly, scores on both fear-of-malpractice and stress-from-uncertainty scales were not associated with differences in decision-making.

While this study also did not attempt to judge whether risk-adverse physicians provided better care than risk-tolerant ones, the clear implication is that how physicians perceive risk can affect their decisions. Thus, it stands to reason that physicians giving advice to family members will have an altered risk-taking score -- they are, after all, taking on a new complex level of risk.

Doubt this conclusion? Then ask yourself these questions: "I try to avoid situations that have an uncertain outcome for my patient" and "I try to avoid situations that have an uncertain outcome for my mother."

During my medical training, I was told to treat patients as if they were family. This "grandmother test" was often invoked when considering a treatment or procedure. "Young Dr. Ballard, would you recommend the procedure to your own grandmother?" The assumption was that such an association would lead to better, more-compassionate decisions. Now, I wonder if that's always true.

Do physicians provide better advice to family and friends than to their patients? On the contrary, I believe that in many circumstances the closeness of the situation may cloud our judgment. A number of physicians I asked about this shared my concern.

For example, one said: "I find myself giving so many 'if/then'-type statements and covering every eventuality it really leads to a breakdown in the decisiveness I have when dealing with a patient. Throw in the often odd family dynamics, and you have some pretty crappy advice."

When I contacted Pines, he agreed that medical advice given to family members is often different but asserted that the quality of this counsel depends on the situation.

"The advice might be better in situations where they are very familiar with the family member's medical history," he says. "But the advice could be worse in cases where the doctor may not feel comfortable asking particular questions (like history of sexual partners) and in certain instances feel less comfortable doing a physical exam."

Valid qualifying points, but nonetheless, I wonder if we should reconsider the maxim, "Treat patients as if they were family"? How about we change it to, "When they are sick, treat your family as if they were patients"? Or, better yet, like the camp doctor of yore, leave the treatment to someone with less emotional investment.