That's The Difference Between Us...

Rotating on cardiology, I've had the opportunity to see some of the, ahem, differences in how we approach patients. It was accentuated this morning when my staff said, 'your notes are so ER', which I took as a compliment--she said that because my entire written plan in the daily progress note was 'pt to CABG tomorrow'. I hadn't commented that we were replacing the potassium at the low end of normal, keeping the patient on a cardiac diet, monitoring the patient on telemetry, and so on. I just wanted to say what was happening and how they were leaving. Well, what more is really needed?

Although EM grew from medicine or surgery based on which hospital was covering the ED in the sixties and seventies, I would argue that we are now our own full-grown speciality. We're hyper and have the attention span of a caffeinated meerkat compared to the other services, we're the only ones to seriously consider things like toxicology, we think about disposition like no one else, but the real, real difference is one of mindset, and it all goes back to the teaching I got as a 4th year medical student.

My attending said, what do you think is happening, and, at the same time, what are you doing? You're in the ED, buddy, dispo is everything, and you can't sit there and scratch your head forever. 18 in the waiting room, let's go.

We 'diagnose' our patients, although that's a loose term and really an ED diagnosis is more like, are you going to die a) 5 minutes ago b) in the next 5 minutes c) maybe in the next few hours d) in the next 30 days or e) someday, but I don't know when and I bet you'll see another doctor before you do therefore relieving my liability.

If the answer is a or b, then we're at our best, and we DO diagnose to the extent of determining the pathophysiology of the shock present and the subtypes of life-threatening presentations we see, including poly-terrible situations like the 85 year old who either had a heart attack and hit a tree or hit a tree and had a heart attack.

If the answer is c or d, then our 'diagnosis' is not really a diagnosis but rather risk stratification for really bad things that might lead you to be in category a or b. Yes you have chest pain and it might be mantle-cell lymphoma (which if I weren't on a medicine service I wouldn't even know was a disease) but really what I care about is how likely are you to die soon? This is really, really tough and I'm still learning it. It's hard. And it always presents patients that don't fit the mold.

Medicine, god love them, and by that I mean internal medicine, is a vital adjunct to Emergency Medicine. They take all the patients in category c and d that we risk stratify to scary or at least a little bit scary and then they do something called rounding, which involves terribly long and inexorable walking conversations about patients to agonizing detail. They address changes of less than 5% in electrolyte levels over the course of days; they draw crazy tests like trans-thyretin antibodies, ceruloplasmin levels, anti-double stranded DNA antibody tests, dexamethasone supression tests, and so on and on. They get really excited by complicated patients with multi-system disease that affects multiple organ systems and they love the unifying diagnosis that ties all of this together.

This drives me bonkers. I can't concentrate. I pray for lines and codes and then feel bad because that means patients are sick. I go talk to the crazy withdrawing person because it reminds me of the ED.

A discussion the other day epitomized this divide. I wanted to start our sarcoid patient on steroids because we knew she had sarcoid and probably she had cardiac and GI sarcoid and she felt sick, so why not give her steroids and see if she feels better? What am I doing for this patient?

The med resident, who's very good, was all, we don't know for sure that it's cardiac sarcoid.

So?

Well, what are we treating then?

Um, sick person? Hope she feels better?

But that's undisciplined, she meant to say; that's untidy, that's not targeted therapy.

Sigh.

I love them because I admit to them. I'll stick to my version of diagnosis, though. Not sure what the point of this post was, other than to say, we all have a place, and the best way is to figure out how we complement each other.

Polypharmacy

I had to pronounce a patient the other night at 3 am. I could feel my own pulse in her arm which freaked me out until I felt my own carotid pulse at the same time. She was very, very dead. I didn't know the patient. There was no explanation for her death; apparently, she was getting more feisty, not less over the past few days. She was a nursing home resident on twenty or more medications.

Scheduled diazepam, as needed lorazepam, geodon (an atypical anti-psychotic), depakote sprinkles, effexor, propranolol, cipro, reglan.

The picture is of ecstacy pills and they would probably give you a less durable high than that cocktail. I would be OUT like a trashbag full of poopy diapers on that cocktail. What did she die of? Hmmmm.

One of our teaching attendings summed it up thus: 'you've had a nice life, grandma, now please go and die'.

So what did she die of? Polypharmacy. Epocrates multi-check lists QT-prolongation and arrhythmias with both cipro and effexor combined with geodon; depakote impairs excretion of lorazepam leading to higher levels; and all of them have additive effects that lead to CNS depression. Pick one.

The crazy thing is that three days later I discharged a woman back to the nursing home on a similar list. What's wrong with grandma? She's agitated, we're giving her more medications. Why is she agitated? Never mind hypoxia, it's probably her baseline dementia. She's talking to people that aren't there, she must be nuts and sundowning. Besides, she's DNR/DNI. More drugs, more drugs, more drugs.

When I talked to my sweet LOL (little old lady) and asked her who else was in the room, she listed off about ten names; Oh yes, there's Mr. McSo-and-So, and Mrs. Whozit, and Mr. Horton, and Mrs. Who, and the baby...

But who's to say that's not normal? It's psychosis, certainly, even though she knew who she was, where she was, and what year it was (thus, she was 'oriented'), but does it need treatment with multiple sedating medications?

You Know You're on Internal Medicine When...

...the attending hospitalist keeps everyone up for a FULL HOUR discussing the differential diagnosis of hyponatremia at 3:30 AM. 30 hour shifts are the whole reason I stayed away from IM, at least one of them. I just had to laugh, in order to avoid gouging my own eyes out with my pen which was running out of ink anyway since we have to handwrite our dictations.

My other favorite:

Me: the patient in ED bed 9 with the acute asthma exacerbation looks like she'll avoid intubation thanks to continuous nebs and 5 over 10 biPAP plus mag and epi times three from EMS, but she's still tachypnic in the high thirties and speaking in 1-2 word sentences, just FYI.

Admitting doc: Did you get a complete review of systems and family history?

Me: Well, I kinda was worried about treating her and she's, again, only speaking in 1-2 word sentences.

Admitting: just go back and do a complete 12-point review when you're done. Make sure to dictate the ROS by system.

These med folks do some good work and I sure like to admit to them, but jeez...

Beer Belly

There actually is a prosthesis--like a CamelBack only not quite--to carry beer outside your gut instead of in, as seen here. A patient I saw this last week had been working for twenty-five years in order to avoid this problem by just drinking until he had a beautiful beer gut to call his own. Or so we thought.

He came in with just some fractured ribs. Three days later he had gone into kidney failure and had a potassium of 6.9 at the highest, normal being 4.8. He had EKG changes and depressed mental status, shortness of breath. He got dialysis and an endotracheal tube. He felt better.

In the midst of all that running around and worrying that this large man on a small bed was going to crash and die, I never thought twice about his body habitus; facial and central obesity is nothing new in Wisconsin.

It was only when his parents arrived a few days later and said, 'we're still trying to figure out why he gained 90 pounds last year'. Last year? He grew that much in a year?

Ah, the medicine differential. So long, so complicated, so fundamentally useless. I did a longer interview, and eventually came up with a variant of Cushing's disease, or pseudocushing's disease; atypical rheumatoid arthritis, atypical sarcoidosis, perhaps histoplasmosis, even intestinal angioedema from his ACEI--all this in the setting of a CT scan of his abdomen with no free fluid and a normal cardiac echo, as the most common reasons for weight gain are fluid related (ascites, heart failure). I even talked the team into a serum cortisol and some enzymes. Nothing found.

He had a history of boxing, was actually 49-4; perhaps a late lesion of the medial hypothalamus? He had been suffering from night sweats for thirty years--autoimmune disease? Cancer?

On a surgery service, he was treated for his ribs and went home.

Reality 1, Ockham's Razor, 0.