ENT and psych

Got to shadow an ENT pediatric clinic today. It's amazing how psychiatry rears its head everywhere I go. Although I was shadowing the attending I also served as her translator for the many Spanish-speaking patients she saw her day. One particular Latino family stood out. There was a young man who came in with his mom to be evaluated for persistent throat pain and problems with swallowing.   The attending asked him some review of systems questions and it seems like everything she asked was positive.  "do you have any chest pain?" "Yes."  "do you get headaches?"  "Yes." And on and on.  After she had done a laryngoscopy and told him that everything was normal he finally piped up and says, "do you think it's okay to take a pill for stress?   I think I'm really stressed."  At the same time before the attending could answer mom says in Spanish do you think that trauma might have anything to do with this? With tears in her eyes she revealed that that prior April her husband this young man's father had died trying to cross the desert in Arizona back to United States.  When the police came initially to their home they handcuffed him and took him away to deport him back to Mexico and the young man never got a chance just talk to him or say anything to him.  The attending and I were speechless.  When we had first come out of the room the first time the attending said this guy is depressed.  We could never have guessed what trauma lyed below the surface of what this young man was able to communicate to us about how he felt.  It's unfortunate that this was revealed the ENT office where all she could do was reassure him that he was okay reiterate to him that potentially this stress and trauma was causing him harm by giving him stomachache and throat pain and headaches and possibly even chest pain.  The attending referred them to a counselor and make sure to send a letter to his primary care physician. I offered mom a Kleenex and we moved onto the next patient.

I am beginning to realize that primary care really is the intersection of psychiatry mental health and our physical well-being.  I'd like to think that for the most part most primary care physicians when they have a relationship with their patients are able to pick up on these cross sections intersections. But I also realize that as primary care physicians we have so little time with each patient and are not always able to pick up on these cues.   I worry that even with my dual training sometimes I won't be able to pick on up on these cues.  Because there's so little time.  

Back on psych

I thought I would be happy, less work, more calm. Not. I forgot what it is to deal with all of people's problems that are not a medically treatable condition with firm endpoints and structure. it sucks actually. I got used to asking people how they felt and expecting a response that should get better with time. Bleh. My tough psych skin wore off I guess. Now I've had to adjust to the patient who doesn't like you, who is hopelessly depressed, addicted and what not.

This is hard

Somedays I just feel like giving up. There is so much to know and it doesn't feel like it is sticking. Everyone seems smarter than you and like they get it more than you. It just feels overwhelming and unsurmountable. And then u also realize that you will never feel prepared it will always be learning and practicing and making mistakes no matter where you are in your career. That is freakin' scary as hell. Ur like damn I barely get it now I'm flying by the seat of my pants, and that probably not going to change!

Also difficult is that your patients seem to think that you know it all- and you don't! It's like it afraid to ask a question about symptoms for fear you'll unearth yet another problem to try to figure out and "solve.". And hello? Doctors cannot solve all of your problems. I don't know everything. Some problems don't need to be pursued they'll probably just go away on their own or maybe don't have any real logical explanation. I wish my patients would pick up some of the slack and try to take charge of their own health perhaps with Md. guidance but not as the grand oracle, cuz damn it is way hard sometimes to carry that burden, especially when we can't give the patient a very good answer for something.

The death rattle

In this last few weeks I have had more patients die then ever before. Not for lack of care but more because it was in their best interest. And what I mean by that is that a) their quality of life was poor 2) their prognosis was incredibly poor and 3) the treatments caused more suffering than anything else. Sad as it may be in two cases the family made tis tremendously difficult decision for their loved one and care was withdrawn. For the third the pt own mind/ body made the decision we as providers and family were postponing, and he died peacefully.
It is unsettling as a physician to see these things take place, in all cases I knew the families had mad the right choice but no matter it was still difficult. I found myself avoiding going to these pts rooms as a means of avoiding further discussions of impending death. The palliative care service was/is amazing. I don't know how they deal with death at every consult.
So this is what I learned about helping someone die comfortably. First help the family make the decision, answer all of their questions regarding death and the process once you begin, the duration, etc. prepare them and prepare the nursing staff help them feel comfortable with the process as well. Attend to their spiritual needs, get sw early to help them with funeral arrangements. And finally the patient needs benzos for sedation, and quiver of anxiety in their face, typically midazolam because of its short half life and quick onset. Morphine has a unique ability to take away the feeling that one is gasping for breath. In studies of people put to exertion morphine made them feel more comfortable and not as short of breath, making them feel more at ease despite being dyspnic. The same applies do a pr that is is being extubated and will likely be short of breath without intubation. Therefore morphine is given to quell the patients feeling of being starved for breath. And the last need is for glycopyrolate. As I have get to witness I have been told when a person dies secretions develop in their lungs and makes a sort of rattling in their chest, called the "death rattle.". Glycopyrollate helps with these secretions and eliminated the rattle, making the family more at ease. Also all lines unnecessary beeping machines are removed and stopped. And that is it.

The community n inpt

Back in the grind after a two week vacation. I am working at a community hospital in a largely Latino community. So amazing. First shocker was pictures of the virgen de guadalupe on the wall, followed by the perfect Spanish spoken by various specialist who are also Latino. It was empowering to see Latino specialists. I feel like I rarely meet Latino physicians. And it is so incredibly refreshing to have pts who look my grandparents, nmother, brother, sister. My Spanish was in major hibernation and now it is flowing smoother each day. I can just feel the connection between my patients and I. after an encounter today my patient asked what clinic I worked at and were disappointed that I was all the way at the university.
Beyond the amazing environment this has been a chance to see how far I have come. Last time I was on wards in the inpt I felt much less confident and more frazzled by pages from nursing or just note writing daily. I find that I am much more efficient than I was as an intern. Next challenge is learning to think quickly and admit prs. Today I learned the chest pain work up.

Cp: EKG x 2, cardiac markers x three, ua, cxr, morphine, Asa, oxygen, nitrites, and beta blocker. Tsh, lipid panel. Start high dose statin. Heparin gtt. TTE. And then consider stress test vs adenosine movies vs cath.

I also learned to build my problem bloat based on lab abnormalities. Also learned that for anyone who is anemic do iron studies as well as fobt.

I have a lot to learn still. Looking forward to it.

Clinic

Funny how fast clinic can be when u know ur patients. Still seems like there is so much to know and learn, even on things that seem simple. Need to read more. It was cool that a lady isaw in my intern year who I referred to psych remembered me after all this time.

There is no crying in medicine...

Yes, yet again I have shed public tears. I was an intern on my first call on medicine wards. In hour 27 of a 30 hr call I had to call a cardiology consult on a patient. The patient was in his mid 50's with metastatic cancer essentially everywhere, he was aware, and after this admission In which he was found to have dic he was ready for hospice. To this day I am not sure what our question was for cardiology, but given his medical hx we were unclear if the ekg changes we saw were merely from demand ischemia. Or if they were something we should act on. I was just one phone call away from getting to go home and sleep. I was tired, uncertain of myself, and vulnerable. So I paged and awaited the call back. Little did I know that I was not paging a fellow resident but rather the attending. Right away before I could even present my case he ripped on me, telling me that I was paging the attending and that I needed to know that and god know wat else. I finally was able to proceed and tell him about the case. He again was upset and questioned my consult, repeatedly asking me why I was asking for the consult. I replied that my attending had requested it. To which he responded. - your the physician caring for the patient you should know why you are calling this consult. I attempted to explain again. And again he kept asking why? At this point I was at a loss, I could feel my throat closing and my chest tightening, I couldn't speak, I just kept quiet. " are you still there? Answe me I am the attending!" he said. "I don't know," I choked out. "are you crying?l. "no," I lied. He moderately softened and disgruntled accepted the consult not before again lecturing me on the importance of knowing the consult question and taking responsibility for my patient. By this point I couldn't speak and was choking back large sobs. And of course all parties in the work room could hear and could see and hear me sobbing. And once I start it's hard for me to stop, my whole body convulsing in an effort to choke back tears, to appear strong, but ultimately look sad and hopelessly weak. My senior tried to console me and told me that that attending was notoriously mean and that I should talk to the medicine coordinator to report my mistreatment. One of the other seniors who now is actually a chief later told me he spoke to that attending whom told him that he felt very bad for what had happened and apologized. Too little to late Ofcourse as by that time I was embarrassed for one crying in the work room, crying to an attending, and for being made to feel like a complete and total idiot. A feeling that as an intern I was already trying so hard to suppress and deny. And make my self believe in myself and my knowledge. I was mortified and terrified of ever calling or running into that man in the hospital. I came home and cried and cried. My bf consoling me, and yes angry at that man but also angry with me for not standing up for myself and letting that man make me feel so bad, his belief that no one can make you feel some way and that how you feel is up to you. In theory a nice idea but oh so difficult, especially when it feeds iinto a feeling that you already have about yourself. I never did seek recourse and go to the medicine director.
There is no excuse for that attending behavior. And it also serves as a reminder to us when we are on either end of a consult, whether we aree the consultant or the consultee, to be patient and respectful, take the opportunity to educate and remember we are all on the same team- with the common goal of helping people. And that we don't know everything. Regardless of how tired we are or overworked that is no excuse to take it out on our colleagues.