Last call for MICU. In fact, last call for my career (coverage for sick colleagues excluded). The rest of my medical training here will no longer involve in-house call.
I have a few more hours to go before I'm done and rid of the ICU. But I spent a great deal of time today reflecting.
One, on rounds, reflecting on the miracles (and curse) of modern medicine, of the amazing technology we have that allows us to help the very sick. Airlift helicopters that bring patients directly to our hospital. The most modern of ICU medications or protocols that as far as I know are not yet available in Malaysia (activated protein C for sepsis, hydrocortisone infusion for severe pneumonia). Out-of-this-world gadgets (HFO: high frequency oscillator which ventilates ARDS patients with ultrahigh respiratory rates. This one lady is being ventilated with 300 breaths a minutes, with baby breaths!!). The curse is, with our abilities we sometimes prolong death when there is no more life to sustain. Case in mind, when an elderly lady coded at 230am today with no electrical rhythm (asystole, notoriously difficult to bring back) we resuscitated her for 10 minutes until someone shouted back, "Pulses!". She was transferred to the ICU where I took over care. When she was being wheeled to my unit, all of us doctors were feeling pretty good about ourselves, almost to the extent of high-fiveing each other for bringing her back. Until I did a thorough exam on her in the ICU. Fixed dilated pupils, no gag, blink or doll's eye reflexes. In other words, she was probably brain dead, and our medical know-how allowed us to bring her back despite that. Just before I left the ICU for good, I had a talk with her family and suggested we withdraw support.
Also did a lot of reflecting on my residency. Tonight was our official senior graduation dinner; I was able to leave the ICU for 5 hours to attend that. One realizes that this place holds a lot of memories, good as well as bad. Many good friendships that were fostered. And, despite where we all go, how our paths diverge, friendships that will last a lifetime. And no matter what happens, nothing can change the fact that we were trained at Mayo. That was in our program director's speech. True.
Officially, residency has another 2 months. But, our graduation dinner has come and gone. Internal Medicine, Class of 2005.



Henry, Rachel and I. Enjoying a pre-banquet cocktail.



Group photo, some of my classmates and I.



Dinner at the banquet hall, Foundation House

MICU

This is my team. Or at least part of it, some people were missing from the picture. We were mostly in good spirits, mainly because the month is coming to an end (although I have been pulled to cover the ICU for a week in June for someone). 3 more days in the MICU, woo hoo! Hmm, then again, I am on terminal call Friday night (also the night of the senior graduation dinner) so I hope I didn't just jinx myself.

My ICU experience was just crazy; sick sick patients. Although I wouldn't want to repeat this again, overall it was an enjoyable and educational month.

Come Monday, it will be all outpatient work again, with no inhouse call. Phew!

Drained...

Was oncall again last night. Wasn't too bad a night, but my junior and I both felt really emotionally drained. So did the nurses. Mainly because of that one patient, young middle-aged male who tried to kill himself after losing his job (and other personal issues). Drank rat poison, weedkiller, paint stripper, hydrochloric acid and sleeping pills. Kept seizing, and was just drooling like crazy (effects from the weedkiller). He was intubated before he was flown to us.

The thing that did us in was his suicide note he left for his wife. I suppose he didn't expect to be found until after he was dead. And I felt like I was reading a personal letter to his spouse (which I was, but we had to document everything). And it just tore into our hearts and minds, reading about how torn and guilty he felt, how much he loved his family but felt like there was no way out but this.

He's young. In many ways I'm praying that we can save him. But somewhere deep inside, we were thinking too that it may be best that he died, because when someone decides to ingest corrosive chemicals like that, it just burns and scars the esophagus and gut so badly that even if they survive, everything else needs to be surgically taken out, and they live a life of misery (sometimes on IV nutrition lifelong). But, we do all we can. And pray for the best.

Have seen patients threaten suicide (usually to get attention) by taking some things. But some things people should never take just to seek attention (obviously, people should never attempt suicide just for attention. That's beyond stupid). Acetaminophen is one, coz if they come in too late for us to help them, it's a slow ugly death and it gives them plenty of time to regret and cry. Chemicals are another; they can cause irreparable GI damage. Burns a hole in the gut.

Days like this, I wish family or loved ones were near. Then again, it's often hard to explain to someone outside of medicine what we feel. So sometimes it's better to just be alone until one gets out of the dumps.

Spent Saturday in Minneapolis with some friends. Did some shopping at Ikea... splurged on beddings and stuff, things I don't normally fuss on. But my comforter was starting to fall apart, and I decided to spoil myself for once with something else other than electronics.
It was a great day. Good time with good friends, and good music. Dim Sum lunch, and then a nice rib dinner with a good band. Got back past 10pm, but it was a good day.

I believe that imagination is stronger than knowledge;

That myth is more potent than history.

I believe that dreams are more powerful than facts;

That hope always triumphs over experience;

That laughter is the only cure for grief.

And I believe that love is stronger than death.

~Robert Fulghum

Something I read in one of the books of my favourite authors. For some reason, those words stuck in my head.

It was a busy call last night. Challenging, in terms of difficult patients, as well as the politics of medicine. The ER gave me a hard time yesterday. Dr. V, an ER consultant we all have come to fear because of his low threshold to admit people, was working the night shift. And so, I got vook-ed (word we use when we get screwed by Dr. V) several times by him with some really soft admissions that really were stable enough for the regular floor. The problem was, last night we simply ran out of beds. Yes, the Medical ICU ran out of beds, all 24 of them.

So, I had to shut the place down. Called triage and said we were no longer admitting and patients would overflow into the other ICUs.

At 630am this morning, they tried to admit a patient who was septic. And because of the overflow, the patient went to the cardiac ICU. And coded not long after she got there. The story I heard, was very septic patient, who went into v-tac after she perf-ed her bowel. And the cardiologists, though their efforts valiant, were just in way over their heads. After all, they were used to treating cardiogenic shock, myocardial infarcts, but not regular sepsis. The patient died.

It gets me mad though, because this patient clearly should have come to us. Not that we could have made a big difference in outcome, because if you decide to perforate your bowel and spew gut content into your belly, you better darn well have some strong antibiotics and a good surgeon nearby. But we probably would have had a higher chance of saving her.

But, because of the system, proper triaging was not enforced and our beds were taken by patients who didn't need to be there.

Like I said, challenging night. I get the rest of the weekend off. 2 more calls left! Looking forward to watching the Formula 1 race in San Marino this weekend. Haven't had the chance to watch any races yet this season.

Things You Don't Wanna Hear Your Doctor Say

• Oops!
• Oh Crap! (actually uttered those words when I was putting a line into the internal jugular last week. Luckily the patient didn't hear me)
• By the way, you weren't planning on having more kids were you?
• Are you insured?
• My name is Dr. Hannibal Lecter
• Nurse, we're gonna need the heavy-duty cement-dissolving enema
• You did say you were here for a vasectomy, didn't you?
• First, lemme give you the good news....
• Are we missing a pair of surgical forceps?
• You win some, you lose some
• Humming the tune of Money, Money, Money when he's checking you out
• I'll need the larger gauge needle

Congratulations, you are the winning bidder!

Got that email; had successfully bid on an item on Ebay. Had been trying to get an out-of-edition 26 year old Enid Blyton book for someone else (incidentally, my first favourite book was 'Chimney Corner Stories' by Enid Blyton. But shhh.... I pretend my favourite was something substantial like Eintein's Theory of Relativity).

Anyway, this would have been my 5th Ebay purchase. I kinda like the Ebay TV ads here. About believing that people are generally good. That would be necessary for something like an online auction to work. You need to take a leap of faith. And thankfully, it's been a largely good experience for me.

Let's see. I got an MP3 player (didn't work too well, but they fully refunded me), car GPS navigation system, digital camera (these were not on auction, the companies simply put their ads on Ebay with a fixed price), a Geo Prizm wheel hubcap (it was a birthday present for a dear friend who happens to be a lousy driver and lost her hubcap when she drove into a deep sinkhole. It was a cheap gift from me, but she said it was the most thoughtful gift she had received in a while).

Well, this will be sent from England, so I'll probably get this in a few weeks. Supposed to be in pretty good shape other than a few scribbles inside the front cover.

The Definition of Irony

1. Medical staff watching an episode of ER in the ICU
2. A mechanically-ventilated patient with endstage alcoholic liver disease, whose first words when regained consciousness were 'Give me alcohol...'

It was a busy call again last night, partially too thanks to the incompetence of the ER. Received at least one bogus ICU admission, who really didn't even needed to be in the hospital. 'Pneumonia' in the context of a normal white cell count, no fever, unchanged chest X-ray and normal O2 saturation. Really. While I don't consider myself smart (conversely, I think my IQ is pretty low) at least I'm not in the habit of taking shortcuts and blocking admssions of every Jane or Joe who comes in. I was pretty miffed with the Pulmonary resident (a junior of mine) who declined to accept the patient and insisted on her coming into the ICU, just so he could get extra sleep and not work her up. Out of sheer laziness, and without even looking at the chest Xray he just said no, too 'unstable' for the floor.

But the others though, were sick. We usually worked as a team, my fellow, intern and I. But last night we had several patients arrive and crash at the same time, so we had to tag-team. Last night itself I had to intubate one patient and place 3 central lines in others.

I was able to finally lie down for a 45 minute quickie nap at 4am, 21 hours after starting call. By then, my brain had stopped working and I really just couldn't care less about anything else except getting sleep. Until I got the call that a patient's BP was 60/30.

'Comfort care only. Morphine 5 mg IV q 30 mins prn, titrate as necessary'

That was the last order I wrote in Mr. T's order book when I left the unit.

Elderly guy with his lung ravished by emphysema, who popped a couple of blebs a month ago and developed a huge pneumothorax. Still persistent despite the chest tube, probably has a broncho-pleural fistula.

Anyway, today he told me (and his family) that he's had enough. That he's fought a good flight, and he wants to stop. Probably the reasonable thing to do; the thoracic surgeons didn't think the pneumothorax would resolve.
He'll probably pass on tonight. Not in any pain or suffering, I hope. I told his nurse to give him as much morphine as he needs to be comfortable. Everyone understood what that meant. Even if it means that that stops his breathing.

In endstage cases such as this, comfort measures are not uncommon, and unlike euthanasia, is not illegal or unethical. Although the line can become very blurred at times. The aim is not to hasten death, but to minimize suffering.

If only I could show the next smart-ass I meet who tells me smoking isn't harmful to Mr. T. And show him his chest tubes that were trying to keep his lungs inflated. And how he laid there, gasping for something we take for granted: air.

Honda S2000.
My new car.
Heh heh, I wish.
Took Veronica to the mechanic's today (had the day off) for an oil change. Since it would take 45 minutes, the Honda people let me take their S2000 out for a spin. They know me, and I had brought them some friends who ultimately bought cars from them. So they were particularly nice to me.

Anyway, this was a sweeeet ride. 6 speed convertible, took her out for a test drive on the highway. Maybe a bit rusty on the clutch (Veronica's an auto) but still did ok. Took off like a rocket when I slammed on the gas. Redlines at 8000 rpm. The push-button start was a nice touch. I guess I can cross number 9 off my list of stuff to do before I die!

I had eyed this car when I was car shopping a year ago, but decided against this because of the cost, and the heavy snowfalls here.

I'll be back someday. When I'm a consultant and earning 5 digit salaries.

Sushi

My version of sushi. This is kinda backdated; did this last weekend. Was able to find a lot of sushi ingredients here (surprising, considering the size of this city). Anyway, it turned out quite well, and I was able to appease my lust for sushi (for now at least).

Clockwise from bottom: Salmon roe (masago) rolls, california rolls, and Inari.

No Problem!

"Size 7 1/2 gloves please. "
My critical care fellow stood beside me, providing back-up. My intern had declined to perform the procedure.
Looking at Mr. B now, I can't blame her. He's morbidly obese, over 300 lbs. I wonder how someone can allow themselve to get like this. Worse of all, he practically had no neck. So much for looking for the apex of the sternocleidomastoid.
We'll need the site-rite.
I guided the 'poor man's ultrasound' probe to his right neck. There! Didn't seem that difficult to find his internal jugular. Compressible? Check. That's not his carotid (good thing).
I scrubbed and gowned up. The patient, already intubated and on a vent, was unaware of my presence and what I was going to do to him (his next-of-kin, of course, had consented).
After infiltrating the skin with lidocaine (not necessary, really, since he was out. But habits die hard), I took the 3 1/2 inch gigantoid needle, and stuck it into his neck at a 45 degree angle. First go, no aspirate. Partial withdraw and aimed more laterally and went in again, while pulling on the plunger of the syringe. No blood. Repeated 3rd, 4th time (why oh why did I volunteer to insert a central line into the biggest patient we had in the ICU?). On my fifth try... about 2 inches in (I was starting to worry about popping his lung)... flashback! Nice aspirate of dark, venous blood. Removed the syringe and confirmed it wasn't the carotid (it wasn't squirting into my face). Quickly inserted the guidewire, then made a cut with the blade, and then the dilator. Finally, shoved in the dialysis Mahurkar line as far in as it would go. Put 2 stitches in, and I was done.
Good work, my fellow said.
No problem, I lied.

But when I removed my sterile gown and gloves, I notice I am covered in sweat, and my hands were trembling. No problem.

I realize too why I had been so nervous. I had inserted many lines before, but never in a guy this big. Also, this was the very room that had that patient who died of complications of a line placement just 2 years before; I saw my fellow then insert a line and caused a catastrophic tension pneumothorax. By the time the chest tube went in, it was all over.

10 Things I Want to do Before I Die

Mrs. B, the lady we admitted the other day with metastatic non-small cell lung cancer and septic shock, was extubated yesterday. She's talking now. Told us she wasn't ready to die; there were things she wanted to do still.
Well, what about me? What would be on my to-do list, before I kick the eternal bucket?

1. Skydive
2. To find my soulmate, and marry her (just once in this lifetime, mind you. Not the Britney marry-one-day, annul-the-next type)
3. Raise a family
4. See my grandkids
5. To see my sis take the Hippocratic Oath
6. Visit Australia
7. Get a tattoo on my right arm (Have been talking about this for 4 years, doubt I'd ever find the guts to do it. Mom's threatened to disown me!)
8. Go on a Caribbean cruise
9. Drive a convertible
10. Write a book (a real book, not a textbook)

Finally!

Finally. Months and months of hard work:

"This is just an update on progress of our book on Evidence-based Endocrinology. As you may know, thanks to your prompt submission, we were able to meet the publisher's deadline with 100% of the chapters. Just received word from the publisher, Humana Press, that the book is going onto production and that proofs will be available for review sometime in August.
I will keep you updated on any other information I get from them including target publication date and formal title of the book so that you can add your chapter to your CV.
Thanks again for your important contribution - I think you will be pleased with the company that each of your chapters will keep inside this volume. "

Finally heard from my research mentor that our work has been accepted. And, best of all, this wasn't a paper but rather, a textbook. My first co-authorship in a medical textbook. Although I don't get any royalties, I'm happy things went well. Will await the formal publication in a few months' time.

What a crazy night. Shortly after I last blogged, the code pager went off. As MICU senior, I still respond to codes, although thankfully my responsibility is mainly airway, and not code team leader as a few months ago.

Elderly male with a-fib on anticoagulation, as well as a right upper lung mass, who had a massive upper airway bleed. And it was massive: he spewed blood everywhere, and dropped his hemoglobin from 11.3 to 8.6 in minutes. He had to be intubated to protect his airway.

It was a rough night. Saw some friends at the end of my 30 hour shift. People could see I had a bad night; I just didn't want to talk to anyone, but leave.

Did attend noon conference before I left. It was an ethics lecture, focus mainly on the recent passing of Terri Schiavo and the ethical, moral and legal dilemmas the family had to face. Without sounding like I'm taking sides (but really, I am), I wonder if the family knew what they were going to put her through, wanting to leave the feeding tube in.

Terri was a young, married woman who went into cardiac arrest at home. By the time EMS got to her, she had been pulseless for a significant amount of time, and as a result, although they were able to revive her, she had irreversible anoxic brain injury, which led to her being in a persistent vegetative state. She had a feeding tube placed through the abdominal wall directy into the stomach. Her husband cared for her for many years before deciding, as her legal guardian, to stop the feeding and let her go. This led to a huge falling out between him and her family and many many court sessions. People were demonstrating in front of her husband's house. Even received death threats. In the end, after 15 years of being alive but not living, she passed on.
Morally, perhaps this may be wrong, letting someone go. But, I wonder if all these 'pro-life' people know what it means to be in a persistent vegetative state? Yes, it sounds nice, keeping someone alive. But have they seen the massive pressure ulcers people get just lying in bed, the ones that are so deep that you see pelvic/hip bone? The complications of being bedbound? Of tube feeding?

I think all in the audience today are 'pro-life'... after all we're all doctors. But having seen things this side of the fence, I think all of us would agree with her husband's action.

For the record, if ever I'm in a situation like that, please let me go. Extreme measures only if expected quality of life is decent, but otherwise, no long-term mechanical ventilation, no tube feedings.

This case is making a lot of Americans aware that they should have advanced directives to dictate their care should they become unable to decide for themselves.

Mr. A passed away on Sunday. I heard from a colleague.

And now, half-way oncall in the MICU. Sick sick sick. A lady just passed away 5 minutes ago. Family finally withdrew care. 60 year old lady with cholangiocarcinoma, duodenal-vena caval fistula (holy crap, how is that possible??), with an enteric gram-negative bacteremia. Can you get any sicker than that?

And just now, I just had another patient, right upper lung non-small cell carcinoma with liver mets, admitted for spontaneous bacterial peritonitis and multiorgan failure.

April is gonna be a looooonng month.

Medical ICU

Today was the real start of MICU for me. I was postcall on change-of-service on Saturday, and hence the team let me go home at 11am, after I had spoken to them about the patients. And I had Sunday off. So that left me with today.

Walking to the entrance of the medical ICUs, I had a sense of dread. Intensive care unit. Sickest of the sick, many of them on mechanical ventilators, vasopressors keeping their blood pressure up. One and one half feet in the grave.

This place reputedly has the 2nd largest ICU in the country. 8 intensive care units in this hospital alone (medical, surgical, cardiac, neuro, pediatric, neonatal etc). The MICU has 24 beds. Filled to the brim for most of the month. My internship MICU rotation was easily the toughest month in my career, with me questioning my faith, strength and abilities for most of the month. For most of the month, I was depressed. I kept waking up at 4am in a cold sweat even when I wasn't on call.

Strangely enough, this morning, on my first day back in the MICU, this time as senior, I woke up again at 4am. Except the difference was I woke up to pee, and was able to go back to sleep. I told myself I wasn't nervous. But I have to admit, walking into the unit today, rounding on the sickies got me anxious again. I tell myself this time things will be better. And that I've learnt a lot more since that difficult month 2 years ago. And I thank God that my upcoming endocrinology fellowship will have NO in-house call, especially in the ICU. Pity those poor saps who wanted to do a critical care fellowship!

My first MICU call tomorrow. Only time will tell. Wish me luck, and pray I won't wake up at 4am in a cold sweat again.

Sun!

Finally! After waiting for months, was able to take my bike out out of garage for biking. 21-speed front & rear suspension Mongoose. Had neglected him for a while now. But Sunday was just so sunny that I couldb't resist. A high of 18C! Gawd, how I miss biking. Hopefully, it'll be warm enough in the next month for us to go canoeing.
I think we've seen the last of snow, at least till next winter. In fact, the days were so nice that I went out and bought a Black & Decker high pressure washer for my car, and gave her a nice 2 hour wash and wax. I think I need to get a life!