one section of a Fifth Chance Media book, ISBN 978-1-944861-02-5.
From the editor: Health care is nearly 20 percent of our GDP. The surest way to be a full participant in this massive and growing sector of the economy is to get an MD. But it is a substantial commitment for a young person to prepare for, enter, and complete medical school. What is it like day-to-day? To help young people (and old people advising young people) answer this question, I placed a mole in one of America's medical schools. We pick up the story in the middle of 2019.
To preserve patient confidentiality, ages and other details are slightly altered. Students and teachers are also pseudonymous.
July 2019. I meet the SICU team at 6:00 am for handoff. The 35-year-old PGY3 "upper level" surgical resident is in charge of our team (he worked a Navy desk job before going to medical school), which includes a visiting fourth-year medical student (on an "AI"; see the end of Year 3) and two Critical Care fellows, one from internal medicine (Pulm/Crit) and one from emergency medicine. Both are already physicians, but are under our PGY3. We meet our attending, a cerebral 6'5" trauma surgeon balancing male-pattern baldness with a thick brown beard. He doesn't seem to have slept for years due to a combination of 24-hour calls, a 13-month-old child with a wife recently returned to her nursing job, and constantly refreshed waves of ignorant and incompetent students and staff, for which his patience is now limited: "Why would you give the patient 250mL for a fluid bolus? That's like 75 mL intravascular. The response is worthless information. If you think the patient is volume-depleted, give volume."
Patients include trauma (car accidents, shootings, etc.), high risk operations, operations gone awry (e.g., perforation, anastomotic leak, etc.), and neurosurgical patients (e.g., brain bleeds, aneurysm clipping, and tumor resections). The nurses say this is the only real ICU, compared to the cardiac care unit ("CCU") and the medical intensive care unit ("MICU").
Tuesday is a typical day in the SICU. I get in at 5:30 am to review my three patients' morning labs and any overnight events. I then head up for 6:00 am handoff from the night team in a conference room. We "run the list" going through each patient using the Epic handoff note that has free text bulleted information about each patient and a "To Do" list. The exhausted night team disbands, while our day team assigns each patient to a team member (students don't count). We pre-round on our patients until the attending gets in at 8:30 am to start rounds. There are 18 patients on our census in the two-floor SICU. We are part of the 24/7 ICU team that manages the patient independent of the surgeon who actually performed the operation. This structure is referred to as a "closed" ICU.
Rounds last from 8:30 am to 1:30 pm. We do system-based rounds. I summarize the patient. "19-year-old Jehovah's Witness presenting as MVC [motor vehicle collision]. He has bilateral leg injuries and a right proximal humeral fracture. Orthopedics is following and plan to take him to the OR for a left BKA [below-the-knee amputation] today. They splinted the right ankle for an unstable tibial fracture that will need surgical intervention at a later date. Overnight, the final read on the CT shows a submassive pulmonary embolism." Then I go through each system:
The resident or fellow would take over the presentation if I miss anything important, but hasn't needed to. Nonetheless, there are interruptions. Desperate to impress (he'll be applying here for a residency), the visiting medical student jumps in frequently and tries to get the last word.
We have some extra time in the afternoon, so one the Pulm/Critical Care fellow teaches me and the AI on different pressors and ventilator settings.
Wednesday at 3:00 pm, we get a 70-year-old admission. He was driving (without a seat belt) and was "T-boned" by a meth head. Both came to the ED around 2:00 pm, but the meth head was quickly discharged. The trauma team met the patient in the ED's trauma bay, and although he had a positive FAST (focused assessment with sonography) exam for a small amount of free fluid in abdomen, they elected to defer exploratory laparotomy. Like all trauma patients, he was "pan-scanned," (head-to-toe CT scan) which was similarly indeterminate for serious abdominal problems.
[Editor: the multi-thousand dollar imaging bill to Medicare will not be indeterminate.]
He was sent to the SICU for observation. Around 4:30 pm, he became hypotensive in the 50/30s and responded to 1L bolus and pressors. Throughout he was alert and conversant. Our attending explained we needed to explore his abdomen. The patient vehemently declined. We stepped out to allow his son and daughter-in-law to talk it over. We once again explained the need for the surgery. Around 10 minutes later, he called us back in and consented to the operation. I asked the trauma surgeon if I could scrub in. I ran ahead of the patient transport as I changed out of my dress clothes and into my scrubs. Lesson: no doctor gets anything done wearing dress clothes.
The trauma surgeon working the night shift is Dr. Cruella, the young universally-feared 39-year-old with whom I worked in Year 3, Week 4 (a spleen was thrown). The PGY3 is trembling: "She holds herself to extreme standards, and expects the same from others." I remember her as a great teacher so long as she doesn't think you will write her up for a non-PC joke. She allows me to make the first incision. The resident then takes over while the attending and I hold retraction to open up the fascia. Once open, the resident and attending explore the abdomen in an organized fashion while I hold retraction with the large "Rich" retractor. We suck about 1L of blood from the abdomen, which does not suggest a large artery bleed. "The liver looks good, no contusion." She then looks at the spleen. "It looks ischemic [not getting sufficient oxygenation from blood flow]." We open up the gastrocolic ligament to enter the lesser sac where we can see the deeper abdominal organs. Blood fills this area and takes several minutes to suction and absorb with "lap pads". We finally see a swirl of bright red blood amid the darker old blood. "Suction where we are exploring, not where you see fluid. Give it to [the resident]." The resident takes the suction and jabs it where the swirl is. "Guess we're doing a splenectomy," says our attending, and asks for a silk suture to close the artery. After they gain control of the artery by suturing it proximal and distal to the injury, we apply two Kelly clamps to each ligament connecting the spleen.
The resident cuts the ligament in between the Kelly clamps with Mayo scissors, and ties silk sutures on the ends of the ligaments. This time the spleen is not thrown, but rather gently passed from the attending to me to the surg tech. We then finish the exploration of the abdomen. There are several hematomas in the mesentery of the small bowel, but nothing bleeding. We then notice a "bucket handle injury" of the colon. In blunt trauma, the deceleration force causes the bowel to shear off its mesentery, a fatty sheet with blood vessels connecting the bowel to the aorta. I can put my entire hand through the bucket handle injury. We then notice blood pooling at the base of the mesentery. The entire middle colic vein was transected. The hole abruptly stops at the middle colic artery on the right hand border (i.e., a bit more force and the artery wouldn't have been strong enough to hold the colon). The pancreas is also injured, so we "paint" (cauterize) the pancreas that is bleeding, and place a drain, and pray. Dr. Cruella: "Never mess with the pancreas. We just have to pray it doesn't get mad." She asks, "What's the cardinal rule of surgery?" I answer: "Never mess with the pancreas."
We perform a transverse colon resection (removal of 8 inches of colon, out of a total of roughly 60) using a staple device. The attending and resident discuss if they should perform a "primary anastomosis" (connecting the two cut ends together). She asks the anesthesiologist, "How has the patient been doing?" The anesthesiologist explains he had come off pressors for 30 minutes after the four units prbc (packed red blood cell units) and 1 unit FFP (fresh frozen plasma), but recently went back on them. "Damn it. No anastomosis," says Dr. Cruella. Instead of closing the abdomen, we put a series of plastic liners and foam connected to a vacuum device ("wound vac") in the midline incision. We leave the bowel in "discontinuity" for a "take back" procedure tomorrow once he is resuscitated. I leave the hospital at 10:00 pm.
The next day I ask to scrub in on the re-exploration operation with a fresh-out-of-fellowship trauma surgeon. We remove the wound vac and don't find any missed injuries. The pancreas appears quiet. Unfortunately, he is not stable and therefore we cannot reconnect his colon. We perform a colostomy with the proximal transverse colon and leave the distal colon as a large "rectal stump". The attending explains, "He could not handle an anastomotic leak. This is damage control." After his surgery, he is unhappy, but understands he is alive. He is exhausted and resigned to his new reality. It is conceivable that the colon can be reconnected six months from now, given sufficient health and nourishment.
Aside from the colostomy, this patient seems to have a good chance of recovering his life before the trauma. He has no neurological damage.
Unfortunately, however, when I come in on Thursday morning, the night team informs me that at 2:00 am he vomited a large volume of "coffee-ground emesis." We order an EGD (esophagogastroduodenoscopy) to evaluate for active bleeding. The test is negative for a bleeding ulcer, but he goes into respiratory distress at around 2:00 pm. He is reintubated and once again requires pressors. He likely aspirated gastric fluid into his lungs. We start him on broad-spectrum antibiotics. I discover he also has a superficial surgical site infection. The PGY3 jokes, "Seems like you are the common link to both procedures. I hope you didn’t cause it." Saturday, he is still intubated, requiring lower dose pressors. His bowels still have not woken up with no output from the colostomy. He hasn't eaten in 5 days. If this doesn't change, we'll have to start him on TPN [total parenteral nutrition, all nutritional needs are given through IV because the bowels are not working]. I leave Saturday night, a little dispirited for my Sunday day off.
The most unusual patient of the week was a drug-free 40-year-old who had recently moved in with his mother. His father died five months ago, but he had been behaving normally and his family also seems normal. Last week, he applied an animal castration band to his testicles. They must have been on for at least 48 hours because they were completely necrotic when EMS brought him to the hospital. After he applied the castration band, he amputated his left hand with a circular saw, got on an ATV and drove around the forest using the remaining hand. He threw the left hand into the forest. The police were able to get him off the ATV and into the hospital. The sister was able to find the severed hand and bring it to the hospital. Our hand surgeon completed a hand replantation. We had to keep him intubated to prevent him from moving his hand, anchored with just two short metal pins and any tension would have destroyed the delicately reattached veins. His family was devastated and had no idea that he was in distress. He had a second surgery for nerve grafts, but had not calmed down sufficiently to be extubated or taken off the propofol. The 25-year-old NP is skeptical regarding the $1 million in procedures that are paying her salary: "How do we know he won't saw it off again once we've patched him up and sent him home?"
(Some weeks later, I learned that he was experiencing guilt about having molested a 10-year-old niece.)
Unfortunately, our most common patients had brain bleeds, irreversible brain damage, and could not understand basic commands. Typically they have undergone a craniotomy (opening of the skull to relieve pressure) and an endovascular procedure that prevents further bleeding (estimated cost: $200,000+). They have some basic reflexes, but will never be able to come off the ventilator because of inability to control their airway. They are on the vent for five days and then the family will decide to let them go, with up to 10 family members crowding into the room for the extubation. Most of these patients are in their 80s, but many were fully independent before the bleed.
Classmates respond to Donald Trump's Salute to America:
Type-A Anita: Strange to celebrate a holiday for this country when there are people locked up in concentration camps.
Pinterest Penelope: Just want everyone to know that because Donald Trump wanted to have the Blue Angels do a flyover, all air traffic in DC has been grounded, and I am missing my connecting flight on the west coast this evening. Happy Fourth of July!
Comments: I just heard the flyover. What a pathetic little man he is.... Sorry you're missing your flight....
I’m so sorry. He’s an ass. I was wondering how many innocent travelers this would impact. I’m sorry you’re one of them. Trumpt [sic] should pay for the hotel cost.
Statistics for the week… Study: 12 hours. Sleep: 6 hours/night; Fun: 1 night. Grilled and played pool at Lanky Luke and Sarcastic Samantha's house on Saturday night. In bed by 9:00 pm to catch up on sleep.
Most of the patients are admitted for trauma or transferred after a brain injury. The patients on other services, e.g., colorectal, bariatrics, or surgical oncology, are here because something went seriously wrong. I'm on the "ICU Team," but enjoy listening in on the other surgical services during their rounds before their 7:00 am OR start. I run into Device Denise, doing her "acting internship" (fourth-year medical student taking over the role of a first-year resident for one month) on the acute care surgery (ACS) service. Has she seen anything crazy? "Mostly a lot of butt abscesses and scrotal nec fasc in fat people," she responds.
Every week we have a new ICU attending. This week it is the chief of trauma surgery. "The most important role of an attending is humor. If my residents don't laugh at least once per day, I have failed." He lets the PGY3 lead rounds: "If I cannot trust you to manage the basic stuff, we have a lot bigger problems." The PGY3, a holdover from the previous week, is a rockstar, so rounds go smoothly. We order a CT scan with IV contrast to look for any undrained fluid collection that could explain my patient's persistent pressor requirement. We place several arterial and central venous lines on patients. On Tuesday, the attending leaves midway to appear in court regarding a murder case in which the victim perished in our hospital.
A common ICU topic on rounds is optimizing ventilator sedation. "We don’t want the patient snowed [overly sedated]," the PGY3 explains regarding a brain bleed patient who has been in the ICU for 20 days. "Wean her sedation," he continues. "The nurses won't like us but we need the family to make a decision regarding goals of care." Are we withdrawing care; or are we progressing to "trach and peg"? (Tracheotomy, a more permanent airway through the neck and a percutaneous endoscopic gastrostomy tube for long-term feeding.)
We often struggle to communicate with a patient's family. A 50-year-old African-American male is suffering from lung cancer with metastasis to the lungs, liver, and brain. If he had never had any complications from surgery and if could be a candidate for palliative chemoradiation (e.g., recover enough strength to be able to walk), he would live for six more months. However, he has had two craniotomies due to brain swelling and is severely debilitated: unable to walk, unable to control his secretions, unable to speak or understand language. His aunt comes to see him every day, but his mother lives 500 miles away and is the one with medical power of attorney. Whenever we call her, she responds with "Just do everything," despite our cautions regarding quality of life. The aunt explained that the mother and son were never close, that she did not raise him, and that they have not seen each other in at least a decade. "She was not in his life at all," says the aunt. The nurses are distraught over this patient's condition, but the Ethics team tells us that there is no realistic way to overrule the absent mother, regardless of our notes that all care is futile.
[Editor: If Medicaid were not paying the $10,000+/day cost, the mother might be less enthusiastic about heroic measures.]
Our PGY3 explains his second Ethics consult of the week, regarding a 55-year-old male who had a log roll over him crushing his thorax and abdomen. "In addition to several rib fractures, he has a burst fracture of his 5th lumbar vertebrae. Unless he gets emergent fixation of the vertebral body, he will become permanently disabled. The patient has significant intellectual disability, operating at the mental capacity of a 7th grader. We learn that he is a vagrant, and was found living in a farm shed. The family adopted him, allowing him to live in the shed and help on the farm, but they can't approve the necessary surgery, which the patient refuses, saying that it is only a "bruise." He alludes to family living 200 miles away and the single trauma case manager spends a whole day unsuccessfully attempting to contact any relative. We therefore request a judicial authorization for surgery.
The morning after the paperwork went in, the judge, our institution's head attorney, and a public defender crowd into the ICU room. We are joined by the ICU attending, my PGY3, and a PGY4 neurosurgery resident. The attorney presents witnesses to the judge. They explain the medical context and likely outcomes. The neurosurgery resident explains, "If he does not receive this operation, he will become paralyzed from the waist down, develop urinary and fecal incontinence." The judge asks whether there are any less invasive procedures. "The alternative would be bed rest for six months in hopes that the fracture will heal on its own." The attorney asks the ICU attending regarding his experience and the implication for being bed-bound for six months. She then rests her case. The judge asks the patient if he understands the situation. The patient responds that he is not seriously ill, and can heal the bruise himself. The judge rules authorizes the operation over the patient's continued objections.
(The patient was not on Medicaid, but the hospital is usually successful at getting patients signed up and obtaining payment for services performed within the preceding three months. Medicaid, however, won't pay for the case manager's time or the staff time spent with the judge. Rates for ICU care for privately insured patients need to be high enough to cover all of these losses.)
My 70-year-old trauma patient has not improved. I check in with him every hour or so and enjoy chatting with the hard-working son and daughter-in-law, a former respiratory therapist. I want this to be my first example of a trauma patient who completely recovers and regains a normal level of quality of life. We are trying to wean him off the ventilator, but he continues to breath at almost 15 L per minute (normal "minute ventilation" is 5 L). Although he has a colostomy, he has the potential to get this reversed if we can get source control and get his kidneys to recover. On the first day the 70yo patient after his operation, my PGY3 resident presciently warned the family and the patient hat we always worry about kidneys. He has developed renal failure, requiring continuous dialysis (CRRT). The full ICU team, consisting of the attending, two nurse practitioners, the PGY3, two critical care fellows, and myself, discuss with the family taking the patient off the ventilator. The attending jumps in, "You know a great way to see if a patient is ready to be extubated… Ask him." He asks him. The patient doesn't answer for a few seconds, then sadly responds that he needs it.
(I follow the patient for the next two weeks. After a three-week stay in the ICU, he is transferred to the step-down unit. He is off the ventilator (tracheostomy tube removed), but his kidneys never recovered. He is alive, neurologically and functionally intact, but will be on dialysis for the rest of his life. He has the potential to get the colostomy reversed after he has regained nutrition from this extended hospitalization.)
Thursday: interprofessional rounds at 10:30 am. The trauma and ICU team meet in a cramped conference room to run the list. The discussion is focused on getting patients discharged. Case managers and billers are in the room to go over questions and concerns. A common theme is a trauma patient, e.g., motor vehicle collision, now stable enough to advance to inpatient rehab ("IPR") and do three hours of PT a day. Administrators go back and forth regarding one patient fo ten minutes until our attending jumps in: "We know this routine. We are waiting for workman's comp to approve IPR and workman's comp is waiting for the patient to look too healthy for IPR."
Statistics for the week… Study: 5 hours. Sleep: 5 hours/night; Fun: 1 night. BBQ at Luke and Samantha's.
This two-week wound care elective starts at 8:00 am. Most hospitals have a wound care service that is run by certified wound care nurses who change dressings, order offloading devices, and apply negative pressure wound vacuums to complex wounds. Unusually, our hospital has a wound care physician who joins the nurses in their morning rounds.
Patients fall into three categories: (1) frail elderly with pressure wounds on their heels, sacrum, and buttocks (decubital ulcers), (2) obese patients with necrotizing soft tissue infections, and (3) IV drug users with abscesses. There are the occasional complex surgical patients with non healing incisions and fistulas (abnormal connects between two hollow organs, e.g., colocutaneous – colon to skin. The head nurse calls out: "We're going to need all hands on deck for the next one." A 450 lb. 38-year-old white male underwent debridement for a necrotizing soft tissue infection of the scrotum (perineal infections are common in the morbidly obese diabetic.) General surgery performed a debridement of the "dishwasher" fluid necrotic tissue and applied a wound vacuum to the 10" x 6" wound with three incisions merging in the middle. The ICU nurse, PA student on our team, the two wound nurses, and I hold up folds of skin, revealing his testicles, as we remove and reapply the wound vacuum. A first-year nursing student is observing. "Did you see her face?" asks the head nurse. "She was petrified, but I'll bet she enjoys telling this story to her friends." We finish rounds at 10:30 am.
[Editor: Let's hope that nobody quoted Dr. Evil in his group therapy session: "There really is nothing like a shorn scrotum... it's breathtaking- I suggest you try it."]
After lunch, Daniel Boone, the 45-year-old attending, takes me to the outpatient wound care clinic and I learn about the Christian mission trips that he runs to Third World countries. "If the patient needs a tooth pulled," he explained, "I pull it. Nobody else is going to." After completing a residency in family medicine, he worked as a hospitalist for ten years. He overcame a short bout of alcoholism by switching to a new specialty: wound care. "I loved procedures and I loved guts and blood. I would never want to be a sissy family medicine doc who refers everything out. I realized I had a knack for taking care of complex wounds and that there was a huge need for these providers." He exhibits old-school tendencies by making house calls and slaughtering pigs, sheep, and goats in his backyard.
The most severe complications of obesity and diabetes get a lot of press. People are warned about heart attacks, strokes, and blindness. After a day at the clinic, however, I appreciate that these patients spend years suffering from chronic issues, such as venous insufficiency and lymphedema that lead to leg ulcers that seldom heal. "People can say fear is not a motivating factor," said Daniel Boone, "but I can tell you that fear of losing a leg is usually an impetus for change." He's living proof, doing a "20:4" intermittent fast in which he is restricted to one meal per day. "This all started because I checked my blood sugar and was technically prediabetic," he said. "The nurses think I'm crazy, but I've lost 15 pounds and my sugars look great."
(Leg ulcers don't motivate everyone; many of the nurses on the service are more than 60 lbs. overweight. One of them is trying to bring her BMI down below 40 so that she can qualify for knee replacement.)
During a typical visit, the nurse will remove the patient's dressings. After a bit of instruction from the attending, the PA student or I take a scalpel and debride non-viable tissue. We might apply a stem cell product (e.g., foreskin or placental-derived tissue) or collagen matrix. If the wound is deep, we'll apply a wound vacuum. The nurse will then apply compression with a wrap or stocking. The patient will come back 1-2 weeks later and usually end up loving our attending, who has healed wounds that they've had for years.
Wednesday we meet at 6:45 am in the Starbucks parking lot. Against LCME regulations that forbid students and attendings from sharing a vehicle, we hop in his 15-year-old pickup for the one-hour drive to a rural hospital where he runs another wound clinic. Unlike in our academic hospital, everyone here is relaxed and informal. The docs and staff are integral parts of the community.
(Sometimes things can get a bit too relaxed. The attending mixed some ghost pepper red gummy bears into the office's bowl of regular Haribo bears. Loud Lucy, a refugee from Brooklyn who tells doctors and patients exactly what she thinks, ate one of the red gummies. "I was wrapping up one of the patients when it hit me and thought that I'd fall on her. I made it to my computer and Ginnie brought a wheelchair over. I was already on the ground under the sink in the fetal position." It turned out that Lucy was suffering from a gastric ulcer. Before Lucy could be rolled to the ER, the attending gave her Pepto-Bismol. "Fortunately, she recovered. I was imagining having to explain this to George [ER doc] and saw my medical license flash before my eyes.")
We see several diabetic foot ulcers, surprisingly in patients who are neither old nor severely overweight. "Diabetic ulcers" actually occur from neuropathy, or loss of feeling in the foot. Thus, repeated pressure from poorly fitting shoes or a sharp puncture wound goes unnoticed. A 34-year-old mother of two has been suffering from a heel ulcer. She stepped on a nail while setting up a soccer party. This went unnoticed until another soccer mom commented on the nail in her shoe. A person without neuropathy would start to limp from the pain, thus offloading the pressure on the wound.
[Editor: Trigger warning on the next two paragraphs!]
A 53-year-old hunter has had one of these foot ulcers for two months. He is the typical patient whose care was delayed by our overloaded multi-provider medical system. Primary care referred him to podiatry, but there was a two-week wait to get seen. The podiatrist was too busy to do surgery and therefore recommended a conservative treatment with antibiotics. The patient is without feeling in his foot so he couldn't tell that the wound was getting worse. The wife insisted that he return to the primary care doctor, who eventually referred him to the wound clinic. "No one wanted to operate on this patient for some reason," said Daniel Boone. "Even though he is not septic, he likely has chronic infection of the bone, which is why this wound does not heal even with offloading and appropriate care." I probe the wound with a Q-tip and then proceed to insert my pinky to feel the exposed calcaneus (heel bone) in the 3 cm deep wound at the base of his foot.
"We could send him back to podiatry to perform a bone biopsy in the OR, or I could do it today so we get the answer." Most physicians wouldn’t do a bedside bone biopsy with only local anesthetic, but he's not most doctors. "We would do these all the time on mission trips, but we practice in a different environment here. This is a great example of how perfection is the enemy of the good. If I did the bone biopsy under local, I won't get as great visualization but it will cost a hell of a lot less and we get results much quicker. If it's infected, we know he needs to get an amputation. Most people think osteomyelitis is a medical illness, but it's really a surgical problem. Get source control [remove the source of the infection]." The patient consents: "I trust you doc." Daniel Boone supervises as I use the rongeur to bite out a few chunks of the calcaneus and we send them to pathology.
(We see the patient next week. The pathologist found infected bone, which means our patient will lose his foot in a below-the-knee amputation. We explain the situation: "You have osteomyelitis. You're going to need an operation to try to remove the infected bone. You also have poor blood supply to the foot, which is further preventing healing. I'm going to see if a surgeon will manage this here or if we have to send you to the tertiary care center." It turns out that a vascular surgeon can do the procedure in this rural hospital.
"He could sue the hospital and every doctor he touches would go down," says Daniel Boone. "It doesn’t matter that I got him where he needs to go." What could have been different? "The podiatrist kicked him around instead of debriding. Everyone thinks that osteomyelitis is a medical illness, requiring 6 weeks of antibiotics. It's not. Osteo needs debridement to remove the source. I would do it myself, but we are in a large hospital setting where there is an expectation of utilizing specialty services. On my mission trips I would use lidocaine and debride the bone in our makeshift tent. In our health system, I send them to a surgeon who putzes around for several weeks until the patient is septic and needs an amputation.")
Daniel Boone summarizes his experience: "In my first year in wound care, I changed more people's behaviors than during my 10 years as a hospitalist and family physician."
Statistics for the week… Study: 5 hours. Sleep: 7 hours/night; Fun: 1 night. Burgers and beers with Mary and Luke. Mary just finished a one-month cardiothoracic surgery visiting elective at an outside institution. This was part of her interview process for their residency program. She is beaming when describing her first sternotomy (cut into the chest and open the sternum with a bone saw).
Monday is a typical day in wound care. I perform forearm squamous cell excisional biopsies. and suture the 3 cm incision. We chat about reimbursements. Wound care can be quite lucrative from debridement and graft procedures and marking up devices. "Our wound care clinic is not greedy," said Daniel Boone. "We frequently use devices that are not reimbursed. The patients love the SNaP vacs [Smart Negative Pressure, a disposable mechanically powered vacuum]. If their insurance won't reimburse for a stem cell-based graft that has a chance of working, we'll find leftovers from another patient. We make enough from the debridement and graft procedures to make it work. Administration at the rural hospital gives us a little more wiggle room compared to the [flagship hospital]."
Lunch is provided by a salesman from a home health agency. Most wound care patients require help at home with 2-3 times per week dressing and re-wrapping. The 45-year-old rep comes in with his company's head nurse and food that we'd selected earlier that morning. While eating my $24 ribeye, I learn that this agency provides coverage seven days/week in our rural area, that they have two certified wound care nurses, and that a nurse will answer a help line 24 hours/day.
Clinic ends at 4:00 pm. Daniel Boone and I drive 45 minutes in his pickup truck to a trailhead. We are joining a continuing medical education ("CME") course in which the wilderness medicine week attendees backpack for three days with evening lectures in the field. We hike for two hours to meet the class at their Day 2 campsite just as it is getting dark. I set up a tent while Daniel Boone strings his covered hammock cocoon between two trees.
At the campfire, we join 25 attendees from across the country. Half are emergency medicine physicians; the rest an assortment of general surgeons, orthopedic surgeons, and internists. The course is led by four EM physicians, two of whom regularly work at the Mount Everest base camp. We learn how to construct a rope carrier for an immobilized victim in the field. Around 8:30 pm, Daniel Boone gives a 30-minute lecture on tick-borne illness. I prepared some remarks on alpha-galactose hypersensitivity reaction ("alpha-gal"), an increasingly common allergy to red meat that leads to "midnight anaphylaxis" (delayed reaction).
Daniel Boone, a 35-year-old EM physician, a 55-year-old general surgeon who works in a rural hospital and I stay up late chatting around the fire. The EM physician got married last year at the Everest base camp. She explained that she works extra shifts when she's home so that she can spend one third of the year in the mountains while earning a full-time income. This is doable in EM because a full time schedule is only twelve 12-hour shifts per month. The general surgeon covers a 50-mile radius in rural Tennessee. "I love it. I get to do things I would never be able to be able to do in a larger hospital. It makes no sense. I've been doing C-sections, amputations, and complex hernia repairs for 15 years, but good luck getting credentialed by clueless MBA administrators of big health systems."
We wake up at 4:30 am to hike back in the dark, but we're still late to clinic. We skip our showers and change into scrubs.
Friday: Daniel Boone is a certified provider of hyperbaric oxygen therapy (HBOT; requires only a weekend course). "Almost everyone can benefit from HBOT," he says, "but patients are limited by insurance coverage." Insurance approves HBOT for refractory soft tissue injuries and radiation injury (e.g., proctitis after prostate radiation), but physicians are experimenting with a wide range of conditions. Daniel Boone is testing HBOT on a chronic Lyme disease patient, for example, and believes that stroke patients will also benefit from HBOT. "We don't have enough chambers for the demand."
Our institution has small individual hyperbaric chambers that hold just one person at a time. If the patient starts choking or simply panics due to claustrophobia, the staff has a 5-minute decompression protocol to get the patient out of the 3-atmosphere, 100-percent oxygen environment. (3 atm is the pressure experienced by SCUBA divers 100' below the surface.) "It's a massive bomb." I expected to see the chambers located in a specialized room; instead, the chambers are behind a curtain next to the nurses' station. Patients are patted down before going in to ensure no jewelry or flammable materials are worn.
One future candidate for HBOT is convinced that she was bitten by a brown recluse (Loxosceles reclusa) super spider that started her chronic, bilateral lymphedema ulcers (conventional medical wisdom would attribute these to her morbid obesity). This is her initial consultation at the wound care clinic. "DHS interviewed me. 14 people were bitten; I was the only one who survived. The superbug was engineered by a foreign government and is a test biological weapon." Daniel Boone, "This is the beauty of being a specialist. Her PCP can deal with her concerns about DHS and the spider."
Daniel Boone is able to wind up clinic by 3:30 pm and fit in two house visits that had been planned for the weekend. The first patient is a 30-year-old overweight diabetic female struggling with a cesarean section incision from three months ago. "We were using Dakin's (dilute bleach) wet-to-dry dressings until I was able to get a fresh supply of SNaP vacuums. Once she got negative pressure, the wound started to make progress." He explained, "It's just easier for the family for me to go to the house and change the dressings and restock them with gauze and silver and silicone dressings for the husband to apply." Our second home visit is with a debilitated 30-year-old with severe mental retardation and skeletal malformations. He is unable to speak, cannot walk, and is dependent on a ventilator and feeding tube. "It's really a tragic situation," says Daniel Boone. "I keep calling him a child but he is a grown adult. The parents shouldn't have continued to care for the child, but those goals of care discussions happened years ago. We're here to deal with a stubborn sacral ulcer that is to bone [has eaten through skin and tissue and is now destroying the bone]." Although the parents have been turning the patient every hour, even in the middle of the night, and providing hospital-grade care, the ulcer continues to expand from too much pressure combined with malnutrition. "My plan is to debride some of the bone and put a wound vac on," says Daniel Boone. The father works overtime to fund what is essentially a mini hospital in the house, but the family was still struggling financially despite Daniel Boone's provision of complimentary wound care materials. The mother is on duty 24 hours/day, 7 days/week. She dismissed the home health nurses due to their not being as competent as she is. "They would have learned about these genetic defects in the second or third trimester of pregnancy," says Daniel Boone, "but the disorder does not have a name or a well-understood prognosis. By the time the mental prognosis was revealed, he was part of their lives."
Daniel Boone sends me off with a weekend Advanced Wilderness Life Support ("AWLS") certification course that he is helping to teach. Practicing physicians, medical students, Physician Assistants, Nurse Practitioners, and EMS personnel from all over the country gather in our medical school's auditorium. I thank him for signing me up and paying the $245 cost. He responds, "This is a great learning opportunity, I did not want you to miss it. Pay it forward when you're an attending."
Type-A Anita's Facebook opinion on the climate protests of 2019:
Greta is great, but if we’re only centering and uplifting white youth leaders on an international scale, we risk recreating the exact same dynamics of instilling a culture of white supremacy and silencing BIPOC [Black, Indigenous and People of Color] voices that is present in modern, adult organizing spaces. We must work to center the most marginalized voices, especially since Indigenous youth and young adults have been tirelessly leading the fight for climate justice for millennia. So here’s a list including other amazing young climate organizers and activists! …
@Isra.Hirsi  is the co-founder of the U.S. Youth Climate Strike and the daughter of Congresswoman @Ilhanmn. She says the climate crisis "is the fight of my generation, and it needs to be addressed urgently." [via @vice] …
@GretaThunberg  is a Swedish environmental activist attempting to hold politicians to account for their lack of action on the climate crisis. Greta is known for speaking about her school strike activism and having Asperger's. She is currently organizing #FridaysForFuture all over the world saying, "Everyone is welcome. Everyone is needed."
This was the same week that the Trump administration disagreed with "everyone is welcome" and "everyone is needed" by proposing to cut the number of refugees admitted as immigrants to the U.S. Anita responded: "fuck the patriarchy. fuck white supremacy. fuck trump and his supporters ...did I miss anything."
[Editor: all refugees are immediately entitled to Medicaid, so Anita's passion for refugees could simply be a desire to maximize her future income.]
Statistics for the week… Study: 4 hours. Sleep: 8 hours/night; Fun: 2 nights, both after the AWLS class. Instructors and attendees go to a local brewery with live music. A PA from Colorado: "I feel like whenever I go to these wilderness medicine gatherings, the presenters are longing for a disaster to hit so that we can apply these skills."
The cardiothoracic surgery service invites in some residents and medical students each year, but does not rely on them in the same way that other services do. For six months per year, PGY3 residents come in one month at a time. I am one of four medical students who will rotate in this year. Instead of the usual group of residents, an army of advanced care practitioners (ACPs, physician assistants and nurse practitioners) run the OR, ICU, and step-down units (separate wing of the hospital from general surgery's).
The clerkship director is a portly bald 60-year-old with a truly general cardiothoracic practice: 4 CABGs (coronary artery bypass graft) per week, 2-3 lung resections (removing lung cancer tumors), and 3 esophageal resections per month. "Most CT surgeons that graduate focus on either thoracic or cardiac. If I had to choose, I would focus on more thoracic now just because the lifestyle is better. As I get older, I'm less enthusiastic about being paged in the middle of the night." He also noted that demand for cardiac operations is weakening due to interventional cardiology with newer stents and endovascular heart valve replacements (e.g., transcatheter aortic valve replacement or "TAVR").
A typical day requires getting up at 4:30 am to look at the case board on Epic to select interesting operations, e.g., a CABG or an aortic arch replacement. I get in at 5:45 am to pre-round on patients on whose cases I previously scrubbed in. Each attending comes in at a different time to round on his or her patients with the ICU ACPs before cases begin at 7:00 am. I struggle to find them, roaming the OR, ICU, pre-op holding, and step-down units and pestering nurses every 10 minutes: "Have you seen Dr. Johnson yet?" I balance rounding on my patients with preparing for today's cases and try to find the attending with whom I want to scrub in. I usually find the patient first and introduce myself before getting formal approval from the attending.
The first case is a video-assisted thoracoscopy surgery (VATS) lung resection for a pulmonary nodule highly suspicious for lung cancer. The nodule was not amenable to biopsy. We are removing his right upper lobe (about 35 percent of one lung). The patient's lungs are terribly emphysematous from smoking. Large black spots and fluid-filled blebs line the lung surface. The attending points out all the relevant anatomy to me, for example, the pulmonary veins and aortic arch. I close the small incision after the PA closed the fascia and port sites. The case ends around 12:30 pm.
(I follow this patient for the next week. A known complication of this surgery, especially when the lung has been compromised by smoking, is an air leak into the pleural cavity from damaged lung tissue. Air seeping into subcutaneous tissue inflates his left chest wall, giving him the appearance of a weightlifter who works only his left pec. After 24 hours, the air has expanded his neck and face to chipmunk proportions and we take him back to the OR to pour water on the lung in hopes of finding the leak. The anesthesiologist will inflate the lung and we spray talc powder wherever we see bubbles. The resulting scar tissue sealed up the lung for this patient. Pathology results came back a week later on the tissue we'd removed. He had adenocarcinoma, stage 1. Translation: we found it in time and cured him, at least until the next smoking-related cancer reveals itself.)
Each attending handles one major case per day, four days per week, and has an additional weekly clinic day to talk to pre-op and post-op patients. I can generally leave at 1:00 pm, but there is usually an interesting patient in the ICU and a lot to be learned from the ACPs. For example, we have two patients on extracorporeal membrane oxygenation (ECMO) after septic shock. While the PA and perfusionist are explaining ECMO indications and options, there is a rapid response on my patient after a post-op day 2 coronary artery bypass graft (CABG)..
Our 86-year-old patient is in atrial fibrillation with rapid ventricular response ("AFib with RVR"; pulse in the 150s). She is conversant, but disoriented and feels lightheaded. "My heart feels like it's fluttering." All patients in the cardiac ICU have defibrillation pads on. If there is time, we sedate patients with fentanyl or Versed before energizing the pads, but in this case we just shook her and she yells from the pain before returning to her disoriented haze. Unfortunately, she returns to AFib with RVR quickly. This cycle happens again. Her condition worsens. She goes into ventricular tachycardia, but still has a pulse so we don't begin CPR (compressions). The ICU team pages the electrophysiology cardiology team for advice. They recommend something we'd already ordered: a bolus followed by a drip of amiodarone, an antiarrhythmic agent. This should have been on the code cart, but it hadn't been restocked so we waited roughly 6 minutes for our dedicated pharmacist to bring it up.
The attending, our clerkship director, eventually arrives and instructs us to stop the dobutamine drip (heart stimulator). Our patient goes into and out of sinus rhythm and AFib with RVR now. The attending asks whether we are pacing her atrium. The NP running the code grabs the pacer machine. During the surgery, atrial (blue) and ventricular (white) wires were placed in the patient's heart muscles. They're capped when not in use, however, and the rushing NP plugs them into the wrong ports of the pacer machine. Due to the switched leads, we can't program it to atrial pacing. "Who switched the leads?" the attending asks. "Our atrial lead is always blue. Who switched this? I want this written up." The NP: "I did. I will take the blame for that." The other nurses and ACPs shake their heads. The attending storms out.
[Editor: Why wouldn't these leads and ports have connectors such that it was mechanically impossible to hook them up in reverse? How tough is it to crimp a 15-cent connector on the end of the lead instead of relying on bare copper and a color convention?]
As the staff return to the nursing station, my attending continues to unload on the NP: "I also need to talk to you about removing the Swan-Ganz catheter on my patient. When we are using that information to increase pressors, don't remove it until we have stopped the pressors. How else will we know if we can stop that intervention? How do we know she still needs the pressors?" (He has a legitimate point, the NP should not have green-lighted the removal of the Swan-Ganz catheter while the patient was on an increasing pressor requirement, despite the pressure to remove it under the established standardized protocols.)
Cardiac surgeons have a reputation for being unfriendly to students, but I found them quite welcoming in the OR, if not prone to small talk. Nobody asked about my background or what I hoped to do after graduating.
Statistics for the week… Study: 5 hours. Sleep: 6 hours/night; Fun: 0 nights. Coffee with Ambitious Al at the hospital twice. To boost his resume for plastics residency, he is doing three away rotations, also known as "acting internships" or "visiting electives".
I've now done enough coronary artery bypass graft (CABG) surgeries to learn the typical sequence:
Medical students are required to skip cases on Thursday to attend a Dean's session highlighting a "medical topic of critical importance," one of three each year. The topic this week is "LGBTQ myths and medical miracles" and the speaker ("Dr. Castro") is an internist from San Francisco. "How many of you have heard of Stonewall Inn? This is recognized as kicking off the Gay Pride and fighting for gay rights. I went to medical school in the 1980s. We had a psych lecture titled, 'Homosexuals, pedophiles, and beastiality.' I give this timeline to highlight the challenges people have overcome, and the amazing change in perspective in such a short amount of time. I want to remind everyone that this fight is still ongoing. Look at Pulse Nightclub, an evil that should shake every American. Look at Trump trying to say sex is not gender identity, and that anti-discrimination laws do not apply to us."
[Editor: Why would LGBTQIA+ community members want anti-discrimination laws to apply to them? Generally these laws cover classes of workers whom employers regard as inferior, e.g., older or disabled workers, racial groups with low academic achievement, etc. Would it help gay physicians, for example, if the government officially says "Because of their evening sexual activities, these doctors will not be able to treat patients as well and therefore you shouldn't hire them unless you're forced to"?]
He pauses. "How many of you are in a target group?" Half of the hands go up. Dr. Castro: "Every single one of you should raise your arm. Every woman should raise your hand, you don't get equal pay for equal work. If you have any degree of pigmentation in your skin, raise your hand; you are a victim."
The first slide contains only the text, "If we can get to sensitive." Dr. Castro asks the class, "Let's say a close friend came out as gay. How would you feel?" The first answer, "I would not care," turns out to be wrong. "Embarrassed he did not tell me sooner," and "Proud they trusted me" were received with approval.
Nobody was willing to go on record with an anti-gay sentiment, so the speaker had to step in and play the role of the prejudiced. His stereotypical anti-gay sentiments included "They walk around in Speedos at Pride festivals," and "Are children raised by gay couples at a disadvantage?"
[Editor: "Growing up with gay parents: What is the big deal?" (Linacre Quarterly 2015, a bioethics journals) reviews the research on the last topic. Sample:
A 2013 Canadian study (Allen 2013), which analyzed data from a very large population-based sample, revealed that the children of gay and lesbian couples are only about 65 percent as likely to have graduated from high school as are the children of married, opposite-sex couples. The girls are more apt to struggle academically than the boys. Daughters of lesbian “parents” displayed dramatically lower graduation rates. Three key findings stood out in this study: children of married, opposite-sex parents have a high graduation rate compared to the others; children of lesbian families have a very low graduation rate compared to the others; and children in the other four types of living arrangements (common law marriage, gay couple, single mother, and single father) are similar to each other and fall between the extremes of married heterosexual parents and lesbian couples.
Dr. Castro explains, "One of the critiques from last year's session was that there wasn't enough medicine in this talk. So let's talk about some of the medical treatments available for gender dysphoria." Slide with two columns:
Gigolo Georgio asks, "Does insurance cover these treatments?" Dr. Castro: "Right now typically not, but we can get around this sometimes by using a different diagnosis. For example, a patient may have a fibroid that wouldn't typically be an indication for a hysterectomy, but under this situation it can be. Or if the patient has a questionable breast mass, we decide that it should be removed." The big event recently is we now have a DSM code for gender dysphoria. If we as advocates continue to persist, insurance companies will eventually pay for treatments with this DSM code."
[Editor: "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden" (2011): "Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group."]
Dr. Castro talks about the challenges faced by his transgender patients: "My patients usually shy away from the spotlight. They work night jobs, or at a call center. Several are truck drivers. All transgenders are marginalized early which leads to distrust in systems, including the medical system. Many were kicked out by their family, had trouble finding a job, many drop out of school due to bullying. One in four attempt suicide by 25. One in five who come out are kicked out by their PCP. There is no way to reverse this overnight." Type-A Anita is the first to respond. "How do we fix this?" Dr. Castro: "It will take concerted effort. For example, educating medical staff on proper pronouns, and redesigning medical forms and EMRs into gender neutral forms."
Statistics for the week… Study: 6 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun. Jane, Luke, Samantha, and I grab beers and burgers. Samantha gets $5,000 per year for CME at her HCA hospital job. She and a colleague (also a PA) just returned from a hospitalist conference in Oregon.
Over dinner, we discuss media coverage of hospitals taking poor patients to court and garnishing wages. A large academic center (University of Virginia) was featured for pursuing patients whereas the for-profit HCA hospital was more charitable. Samantha: "HCA doesn’t divert. We will accept any patient even if our hospital is full. It is so bad right now that each hospitalist has 27-30 patients." Jane, "I can't even keep my 2-3 patients straight." Jane continues, "The ED is full, we have patients being admitted, treated, and discharged all in an ED bed. It got so bad once that we converted the cath lab into beds. I have 17 patients. The hospitalists who are in charge and technically sign orders and notes for billing don't ever see my patients."
Year 4, Week 7 (Interview Prep)
Interview season has commenced, which means we get days, weeks, or even a month off to travel to residency programs. With the exception of a few specialities such as urology and ophthalmology, the Match starts when the Electronic Residency Application Service (ERAS) opens at the beginning of September and interview offers start shortly after the end-of-September application deadline. The application includes volunteer and professional experiences, research publications, and letters of recommendation from attendings. A letter from one's medical school dean is required, but we are told that this is ignored by programs. We also have to submit a personal statement. Popular topics include challenges overcome [Editor: a victimhood narrative!] and motivation for becoming a doctor ("earn money" will not appear here). The less competitive programs will send their interview invitations first.
Students apply to as many as 90 programs and even more if they are applying to multiple specialities. Our Dean of Student Affairs sent an email out overviewing the process, highlighting that we are nearly guaranteed to match into a chosen speciality if we interview at 12 or more programs. "If by December 1st you do not have that many interviews, contact me."
Most programs email four interview dates that fill up within hours. The Dean of Student Affairs recommends giving login information to a trusted family member to accept interviews as they come in case you are in the operating room and don't open the email soon enough. One program sends more interview offers than slots. Lanky Luke responded within 30 minutes, but "I was waitlisted because they already filled." Sarcastic Sally empathizes: "This happened to me too! I just don't understand why a program would leave it to chance to decide who they interview. Select the better candidate. I don't buy it that someone who responds within 30 minutes shows more interest in coming than someone who doesn't respond for an hour."
Every specialty and program has different interview date ranges. Our dean explains that around 2010 there was a movement to cluster interview dates by region to allow for decreased travel costs. For example, southwestern surgery programs would have their interviews clustered around one week but coordinated to avoid overlap. "They no longer do this," said the dean. "Expect to spend $7,000 to $10,000 during interview season on hotels, cars, and airfare. This has been budgeted into the MS-4 cost of attendance so you can borrow more money if needed."
I'm applying to general surgery, which requires 4 recommendations. Mine are from three surgeons, a research mentor, and, unconventionally, an internist with whom I worked frequently.
Statistics for the week… Study: 5 hours. Sleep: 7 hours/night; Fun: 2 nights. Dinner party with Lanky Luke and Sarcastic Samantha.
I meet my attending, Coach K, in the four-urologist private practice at 8:30 am. The radio is tuned to the sports channel as he signs paperwork before the first patients are ready. "If I can get you to not consult urology when you cannot pass a Foley, you have had a successful rotation." (A Foley catheter drains urine directly from the bladder.) His new nurse is a friendly 63-year-old. Nancy retired after working 25 years in a family practice office, but returned to work because "my husband was driving me crazy with us both sitting at home with our kids out of the house."
Nurse Nancy explains that Coach K likes to stay busy. He usually double- or triple-books each 15-minute appointment slot. This is plenty of time if Nancy is able to get a urine sample and the post-void residual bladder scan in a timely manner because most visits take less than five minutes. For example, if following a patient for elevated prostate specific antigen (PSA), Coach K will ask if there are any changes since the last visit, and then recount the options of biopsy versus active surveillance (PSA every three to six months). He says farewell, while Nancy draws blood for a lab company rep to pick up at the end of the day.
Urologists see a wide spectrum of ages. Most patients are between 50 and 75 years old referred for either elevated prostate-specific antigen (PSA) or difficult-to-manage benign prostate hypertrophy (BPH). We see patients of all ages for kidney stone management. Young couples come in for vasectomy referrals. A vasectomy is a 10-minute office procedure done under local anesthetic. Coach K offers a valium to take beforehand in which the patient has to have someone to drive him home. I see a 29-year-old male accompanied by his wife and the mother of their five children. Coach K asks if they are sure they do not want any more children. When they learn that he could come in alone, the wife responds, "Oh no, I'll be here. I have to make sure he goes through with it!" Coach K explains, "You will need to use protection for three months. After that he will drop a semen sample off here so we can test it to ensure there are no sperm present."
[Editor: See also "Hamptons bachelors are getting vasectomies so gold diggers can’t trap them" (New York Post, May 27, 2017). "'There’s a spike in single guys' who get the procedure in spring and early summer, said Dr. David Shusterman, a urologist in Midtown. 'This extortion happens all the time. Women come after them. [They get pregnant and] want a ransom payment,' said Shusterman. 'Some guys do an analysis of the cost — for three days of discomfort [after a vasectomy], it’s worth millions of dollars to them.'"]
We see roughly eight benign prostate hypertrophy (BPH) patients per day. Coach K: "10 percent of men at 50 will have obstructive symptoms, 100 percent by 80." When asked about symptoms of obstruction, patients lights up as if saying with their face, "Finally, someone understands what I am feeling!" Obstructive urinary symptoms include: sensation of incomplete emptying, double voiding, dribbling, and decreased force of stream. A lot of men report having to get up in the evening. I learn that this is more related to irritative symptoms or excess urine production from mobilizing fluid while laying flat. Coach K explains, "Put your feet up 30 minutes before bed so you can pee off this fluid before getting into bed." Most men's BPH can be managed with medicine, either an alpha-1 blocker and, if needed, finasteride. Finasteride takes 3-6 months to have an effect as it lowers DHT levels that drive the growth of the prostate. Coach K explains, "The main side effect of finasteride is decreased libido, but most people are fine."
[Editor: Reduced male libido may not be a problem: "Only 48% of married women want regular sex after four years." (Good Housekeeping)]
My attending continues, "One controversial topic is whether finasteride increases the incidence of aggressive prostate cancer. The jury is still out." If these medicines do not control the symptoms, Coach K discusses surgical options including transurethral resection of the prostate (TURP, pronounced "terp") or a green light ablation. In theory, a primary care provider should be able to manage BPH, but several patients report it is easier to schedule an appointment with a specialist. "The earliest appointment was in four months for my PCP," states a 62-year-old.
Patients are cheerful during their one-week post-op visits after TURP. "Doc, I feel like a teenager again!" exclaims an 80-year-old man. "Doc, one more question. Do our balls sag when we get old? Every time I sit on the toilet they touch the bowl!" His wife slams her hand on her face. Coach K responds: "Everything sags when we get older." Another post-TURP patient exclaims, "Finally, I can go on my dream trip to the Canadian Rockies."
A common complaint during office visits is the cost of erectile dysfunction medications. Although generics have been available since 2017, our older patients can't figure out how to avoid being charged $300. Coach K: "I tell patients to always ask for the cash price and use GoodRx. In a study of the five most commonly-prescribed urologic medications, CVS was by far the most expensive. Walmart and Kroger were in the middle of the pack. Mom and pop pharmacies were the cheapest." What about the Aetna-CVS merger? "It's been terrible. Our office gets called by Aetna all the damn time telling us to switch a patient's medication [to a cheaper generic-available drug]. The patient could be on the med for the past 15 years." He is adamant. "No, I am not switching them, there is no medical reason."
We see a 62-year-old patient whom I cared for six months earlier in the surgical ICU. A tractor rolled over him and fractured his pelvis. It was nice to get to know him as a person since he'd been delirious for his week-long ICU stay. Since discharge, he has been working with physical therapy, and is now able to use a walker. His wife asks if there is anything to help with control of his bladder. When he does any activity, e.g., rises from sitting, coughs, or laughs, he leaks urine. For two months he also had fecal incontinence, but this has slowly resolved. Coach K instructs me to perform a digital rectal exam (DRE). He has no rectal tone, and no bulbocavernosus reflex (squeezing head of the penis should lead to squeezing anus). He has damage to his pelvic floor muscles. "This might get better, time will tell and there is really nothing for us to do to make it go quicker." We prescribe him Sudafed, a stimulant that can improve urethral sphincter tone. "It'll make you feel jittery, but take it 30 minutes before you work with PT. It should help with leakage." We also see several bed-bound patients that need a Foley exchange.
Twice a day we see a child for bedwetting. Coach K explains that secondary nocturnal enuresis, in which the patient at one point did not wet the bed, is almost always a result of trauma, e.g., sexual abuse or parental divorce. "There is nothing we can do for them except try to reduce their stress level," he says. Most of the time this is for primary nocturnal enuresis (bedwetting since birth), for which Coach K explains that we are also without medical interventions.
[Editor: But not without an ICD-10 code and an insurance reimbursement!]
A 7-year-old female who has been potty-trained since 2.5 is brought in for bedwetting. "You'll hear the same spiel as last time," says Coach K. He explains to the family that this is a common issue due to immaturity of the connections between the brain and the bladder. The condition is strongly heritable and usually at least one parent recalls having been a bedwetter. Deep sleepers are more vulnerable to this condition. Do you have trouble waking her up in the morning? "Oh yes, she is such a deep sleeper. She won't wake up from anything." Coach K explains, "Bedwetting gets better with time. Only one percent of 18-year-olds are still wetting the bed, but the improvement will be gradual, coming down from 4-5 times per week to 2, to once per week to once per month." Behavioral modifications, such as decreasing fluid intake between dinner and bedtime and restricting caffeine, will decrease the amount of urine produced at night, but won't reduce the number of events per week. He hands the family a small pamphlet for a bed alarm. The bed alarm senses fluid and wakes the patient up. "It won't stop the bedwetting," Coach K explains, "but will make it more manageable for motivated children."
Why not offer them medications? Coach K later explains to me that the success rate of DDAVP (desmopressin) is so low that parents get more discouraged when it fails.
Later, I see a one-percenter: a fit 19-year-old freshman sporting a well-groomed large beard followed for primary nocturnal enuresis for over a decade. Coach K asks how college is going. "I'm studying construction engineering. Math was always easy for me in high school, but I am struggling to stay afloat for some of these classes." He's in a "Live and Learn" community that should be supportive. In high school he tried imipramine, an antidepressant (TCA) that has side effects of bladder retention, which did the trick. He went from 5 events per week to 1 per week. He gave up the drug due to its side effects and now wets the bed 3 times per week. "I am sure this is a killer to your social life," says Coach K. The patient asks to go back on the medicine and Coach K prescribes him a half-dose, emphasizing, "Keep in mind alcohol will make this worse. It puts you into a much deeper sleep."
We see five bladder cancer surveillance patients per day, all of whom are former or current smokers (a big risk factor due to irritation of the mucosa). Bladder tumors are mostly diagnosed after gross hematuria (visible blood in urine) or persistent microscopic hematuria on urine dipstick testing. As long as the tumor is superficial, and does not invade the smooth muscle, treatment is removing it in the OR through cystoscopy (fiber optic scope with a cutter at the end). After the initial diagnosis, the patient is screened for recurrence every three months for one year, followed by six months for four more years, and then yearly. "I have patients that I find a recurrence every six months, and I have patients that are clear for a decade, and one pops up." The first cystoscopy is alarming for both men and females. The patient is prepped in the procedure room with a drape over their exposed genitalia. Coach K inserts numbing gel into the urethra, followed by a flexible scope. When he sees an interesting finding, he signals me over to look into the scope.
[Editor: Bladder cancer patients seem to generate annuities for urologists. In 2012, Forbes noted that "These specialists earn an average of $461,000, not including production bonuses or benefits."]
Statistics for the week… Study: 3 hours. Sleep: 9 hours/night; Fun: 2 nights. Taco and tequila bar with Straight-Shooter Sally and her boyfriend, an engineer for a green energy design firm.
I am in the OR with Coach K on Monday and his partner Comedian Tom on Tuesday. I see three TURPs (transurethral resection of the prostate) on each OR day. After the patient is under general anesthesia (anesthesiologist chooses between endotracheal tube versus LMA) and draped, Coach K inserts the rigid cystoscope into the urethra. He points out several anatomical landmarks in the urethra and bladder on the screen. He points on the screen to the verumontanum, a subtle elevation of tissue identifying where the ejaculatory ducts enter. "As long as we remove tissue distal to the verumontanum, the patient should recover full control of the bladder. The external urethral sphincter and levator ani (pelvic floor) are just proximal to this landmark."
He inspects the bladder, there are trabeculations and several indentations into the bladder surface. I ask why they're there. "The bladder, like any muscle, hypertrophies from the increased pressure trying to push urine through the prostate obstruction." The diverticula look exactly the same as a patient with diverticula of the colon. He withdraws the scope to the prostatic urethra, inserts an electrocautery device, and uses its 5mm-diameter semicircular wire to cut through the urethra and prostate to open the channel. As he shaves the prostate, a few bleeders are seen piercing through the clear water. He cauterizes the bleeding vessels. "The prostate is a poorly perfused organ so there isn't that much bleeding when you cut into it; these bleeders are perforators."
The nurse periodically hangs another bag of 7.5 percent glycine on a post near the OR table. A tube flows down to the scope to keep the bladder distended so we can see the entire prostate. Coach K explains that we use glycine because the electrocautery device would not work in saline. "The current would not be discharged to the local targeted tissue, but instead be conducted through the salt water. Glycine does not conduct so the path of least resistance is to whatever tissue is touching the wire. If we are just scoping the patient we use saline. Pure water would work, but it would kill cells from the osmotic pressure gradient. There is a small risk of hyponatremia [low blood sodium] after these procedures which is why we try to keep the irrigation time under 1 hour."
There was a noticeable contrast between Coach K's technical skills in the TURP versus Comedian Tom. Coach K carved out the prostate creating an elegant circular channel that was all cauterized with no bleeders. I felt Tom struggled to get good visualization during the procedure because he couldn't completely coagulate off the bleeders distorting the picture. He didn't "butcher" the patient, but it wasn't as technically satisfying. I couldn't tell if the channel was circular or how much he removed at the end. His patients still get benefits but I wonder if they have different 10-year outcomes. Coach K: "90 percent of patients at 10 years after TURP do not have any obstructive symptoms. 10 percent get regrowth that requires either medical management or re-operation."
Although these doctors operate at our hospital, they are partners in their own practice. "Private practice is hard. There is a reason it's a dying breed," Coach K explains. "We are clinging to paper charts for as long as we can. EMRs are so expensive for a small practice such as ours, but we also get penalized by Medicare for not having meaningful use." He picks up a patient's folder. "This patient was admitted for an obstructing stone. I was called in and removed the stone. Here is the fax from the stay. Is this meaningful?" He hands me a 25-page print out from our hospital's Epic EMR for the two day admission. The first five pages are demographic information, mostly blank (e.g., address 1 filled in, addresses 2 and 3 unfilled). There are numerous nursing notes, a CT report with paragraphs describing how radiation exposure was minimized, and his operative note. "This is all checking boxes. You cannot find actionable information." When patients come to his private office for a follow-up after hospitalization he ends up throwing nearly their entire hospital record into the protected health information (PHI) shredder bin.
Another assault on his income is that our hospital has gradually bought up clinics and practices to form a regional health system in which providers are encouraged to refer to specialists within the system. The private practice doctors end up with the worst parts of working for the hospital, e.g., taking call, and none of the benefits. The private partners are also at a disadvantage when purchasing supplies, sometimes resorting to Amazon for scarce items.
[Editor: this was before the "supply chain" catastrophes that started in 2020]
Our last patient is a 73-year-old self-deprecating truck driver who walks in with a USA 45 hat. He has classic symptoms for BPH and an elevated PSA. He introduces himself, "I'm all healthy doc, except for my pee-pee." The nurse measures a post void residual of 490 mL (this is pretty close to what would be considered full in a healthy individual; less than 50 mL is considered normal). He explains to me that he drinks 2 jugs of coffee to stay awake on his daily 8-hour drive. He sleeps with one of the cups due to fear of urgency and leakage. We start him on tamsulosin, and schedule a one-month follow up appointment.
One of our classmates just matched into urology. Coach K helped mentor him so is quite proud. My classmates meet at Buff Bri's house for a penis celebration. Sarcastic Sally gets decorations from a bachelorette party store, including penis hats and straws. Mischievous Mary brings assorted nuts for snacking. We reflect on senioritis. Pinterest Penelope summarizes: "I have instagram and snap chat to deal with. I can't be at the hospital." Mary shares her latest experience: "I was doing an APR (abdominal peritoneal resection, removal of the rectum and anus) with a jewish colorectal surgeon and a resident. The Poop Doc was across from me, while the resident was in between the legs struggling to remove the rectum through the anus with all his might. Poop Doc: 'You can help the resident by pushing on the abdomen from above.' As I do this, the rectum shoots out with liquid poop, which seeps down the resident's gown. The resident exclaims, 'It's in my socks!' Poop Doc, 'Oy vey.'"
Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 1 night. Penis party.