Bum foot

So I spent halloween morning on the operating room table, having a walnut-sized cyst removed from my right ankle. I had whats called 'tarsal tunnel syndrome'; its like carpal tunnel syndrome, where your median nerve is compressed causing pain and numbness in your hand. Instead, my posterior tibial nerve was compressed from this cyst, and I had these symptoms in my foot. So for the first time in my adult life, I became the patient and underwent the series of clinic visits and tests that we often send patients to.

First, I visited UNC's orthopedics clinic, which wasn't bad at all. Got x-rays, then was seen by a resident then the attending surgeon. Told me I had tarsal tunnel syndrome, and suggested an MRI and an EMG-NCS (electromyography and nerve conduction study).

So I did the MRI - which is sitting in pretty dark and narrow tube, with lots of loud machinery sounds, for about 40 minutes, just to scan my ankle. I received gadolinium, which is contrast, and couldn't help but wonder about the 1:10,000 odds of an anaphylactic reaction or possible kidney toxicity. But I managed just fine.

Then I got the EMG-NCS. The nerve conduction part is easy. They place stimulators on your ankle to stimulate your nerve, and then place sensors around the other parts of your nerve, and see if the nerve can transmit the signals. Because my posterior nerve was compressed, it was not conducting any sensation at all.

The EMG portion is horrible. They stick a not-so-small needle in your muscle that they want to test, then they say "flex that muscle" even with a needle sticking in it, and it can read both the level of nerve and muscle activation. So there was a damn needle going in sideways into the arch of my foot, and they're telling me to move my foot around and spread my toes. Painful as hell!

So of course, the MRI revealed the walnut-sized ganglion cyst. Interestingly, they're also called "bible cysts" and most commonly show up around the wrist area. People use to put a bible on the cyst, and then slam the bible hard to pop the cyst! Wasn't an option in my case - it would just make my nerve impingement worse. And the NCS showed abnormal nerve conduction. The EMG showed that I wasn't able to activate the muscle. And I was scheduled for surgery.

Now I haven't undergone surgery since I was 6, when I was bit by a black lab on my face and had to get plastic surgery. All I remember then was that my jaw hurt and it was hard to eat the frosted flakes after surgery. But as an adult and a doctor, I was kinda fascinated by what I was about to go through.

Here are some observations:

- Wearing a hospital gown really does render you very vulnurable. I had the good fortune, however, of being given one-size-fits-all boxers so my bare ass wasn't hanging out.
- Versed (a benzodiazepine, like valium) is a sedating medication that's like IV alcohol. Instantly, I felt drunk, drowsy, and uninhibited. What a weird feeling.
- Apparently, I was belligerent when I was awakened after the procedure. According to Nicole, I was blabbering very loud, saying things like "I didn't get a Foley....that's awesome"; "You ligated my nerve?!"; "What was my drip rate for the propofol?".
- Percocet, a common narcotic prescribed for pain, makes me feel dizzy, out of balance, and nauseous. I don't know how people are hooked to it.
- You get many separate bills. For the MRI only, I got charged for the MRI itself, then the use of "hospital facilities", then a bill for the radiologist to read it. Its about a $2000 test!
- IF YOU HAVE A WEAK STOMACH DONT LOOK AT THE PICTURE BELOW.

I TOLD YOU!!

And now I have a large splint wrapped with foam and an ACE wrap on my leg, and I'm not allowed to walk for 4 weeks. All in all, the process has gone pretty well, and I'm lucky to have Nicole and my mom taking care of me. But it does suck to be a patient.

Saving a life

In medicine, I think its less common that we are honestly "saving lives". More commonly, we are treating flare-ups of common conditions, such as congestive heart failure exacerbations or COPD (ie chronic obstructive pulmonary disease, aka emphysema or bronchitis) exacerbations. However, there is a case that I treated recently, in which we saved a 21 year old's life.

I just finished the ICU (intensive care unit), a grueling and challenging month where you are treating the sickest of the sick. One of UNC's functions is as a "tertiary referral center", a place where other hospitals send their patients if they need more advanced care. This also applies to ICU patients. If other hospitals receive ICU patients who are too sick...they come to UNC, and we take care of them.

I had a 21 year old patient, who I'll call John Doe, referred to me from an outside hospital. He was found outside unconscious, and an ambulance was called. When he reached the outside hospital, he body temp was 88'F, and his toxicology screen showed opiates, benzodiazepines (like valium), and cocaine. He wasn't breathing well, so he was intubated and attached to a ventilator. Then, he was sent to us.

When he arrived, he was still cold, but in a matter of hours he began to have fevers, and he became exceedingly difficult to ventilate and keep his oxygen levels up. His lungs began to show a dense pneumonia (lung infection), and also began to show signs of diffuse injury, something we call ARDS (acute respiratory distress syndrome). ARDS can occur when there is any sort of severe insult to the body. He was at the tenuous balance, where we needed to give him as much ventilator support as we could, but not give him too much support which would injure his fragile lungs further. His kidneys had been injured. We placed invasive lines in many parts of his body - there was a tube in his lungs to help him breath, a tube in his stomach to feed him; a large central venous line in his neck to give him fluids and antibiotics; an arterial line in his wrist to closely monitor his blood pressure and take samples of arterial blood to make sure he had enough oxygen; a tube in his bladder to drain his urine; a tube in his rectum to drain his feces. We didn't know what kind of damage to his body the hypothermia caused - we hoped he didn't suffer any brain damage, or that the cold temperatures didn't hurt his organs. And just as dangerous, rewarming him can also cause "rewarming syndrome" which could hurt his organs.

And in addition, no one knew who this person was. We had no name, no ID, no family. He was found by strangers and an ambulance was called, and then was transferred to us.

I was his primary doctor. But we had an ICU team. Other residents and interns took care of him when I wasn't there. The ICU fellows and attendings provided guidance. The nurses carried out the orders, and looked after him very closely.

And then his family showed up, and we found out about this person's life. Had much of an antisocial life, misbehavior, frequently caught up in drugs, stole from his family. All too sad in a 21 year old kid, that he has been slowly ruining his life and killing himself, and now he's here attached to tubes in our ICU.

But he started turning around. Slowly made improvement. We were slowly able to wean the ventilator settings, and his ARDS and pneumonia were beginning to improve. He exhibited signs of drug and alcohol withdrawal, and required high doses of sedatives, but we began scaling back. And after 8 days, we were able to extubate (remove him from the ventilator) him, and he was breathing on his own. He was able to talk to us, and could move all his limbs. He was still intermittently delirious, but had survived the most horrible part of his illness, when he was in total respiratory failure. Now that he did not require a ventilator, and his vital signs remained stable, and no longer in withdrawal, we released him from the ICU to be taken care of by a floor team. I imagined he would be in the hospital another week, recovering and regaining strength and hopefully normal function. We consulted our psychiatry service, to address his underlying drug habits and probable mental illness, hoping they could share some insight with him.

2 days later, I got a phone call from one of my fellow residents. He told me that Mr. Doe was about to be discharged home, and that he would like to come up to the ICU to thank us. To walk to the ICU! And he did. This 21 year old guy walked up to us, and said "Thank you for saving my life." Gave me a handshake, then a hug. He wanted to see the room where he spent the past 8 days near the brink of death. He wanted to know how sick he was. And then he told us that he was going to change his ways. No more drugs, and turning his life around. Hugged me again, and then walked out of the ICU, and later that day walked out of the hospital and, hopefully, to a new life.

That was one of the best moments of my life as a doctor.

Okay okay trying to keep up

Hey everyone,

Well this is better than before, only a couple of weeks since my last post. But its been an eventful couple of weeks! Another step in adulthood. We just bought our first new car! It's a 2007 Honda Accord 4-door, EX-L, V6, in metallic graphite. Its an amazing car - sporty and luxurious, and fast. 240 horsepower! Only thing we didnt get was the Navigation, a bit expensive. I can't believe I'm saying this, but we did have to consider having a car that would work when we have kids. Yup, we thought about something smaller and sportier, but we worried about a carseat. So our top choices were the Prius (hybrid, cool and different), Camry SE (sporty, but still has stigma of a "camry"), and '08 Accord (but expensive as its brand new). But we got a great deal on the 2007 model, and we love it.

In addition, our friends Amy and Nate just got engaged! Amy is one of Nicole's close friends, and they were in PA school at Emory together. Nate planned a big surprise, where he took Amy to the Bahamas and proposed to here there, without her ever knowing a single detail. He never even told her he got a ring until he proposed! Nate also surprised her by having us secretly going on the trip with them! We had a great time, and Amy was swept off her feet with the proposal.

Nate asked me to join him on this trip to the Bahamas, for the whole purpose of proposing to Amy, more than 8 months ago. I tried to keep it from Nicole as well, but she's too smart and figured out what we were doing. Nicole and I flew from Durham to a connecting flight in Atlanta, where we surprised Amy and Nate! Then we flew together to the Bahamas, and had an awesome time. The resort (Sheraton at Our Lucaya) was absolutely beautiful, and very quiet since it was the "slow" (aka Hurricane) season. Luckily, only a few showers, otherwise it was sunny and warm! We spent time poolside, on the beach, sailing Hobie Cats, and enjoying jerk chicken. Not to mention, the exciting engagement on the docks surrounded by a beautiful harbor and yachts!

Here are some more pics:

Well I just started a rotation in the MICU (medical intensive care unit). But this time, I'm a resident, not an intern. Overnight, its just me and my intern. I now have the responsibility of making decisions for these critically ill patients. I'll have to decide if they need to be intubated (have a tube inserted into their lungs and hooked up to a breathing machine), or if they have come to the point where we recommend withdrawing care. If a patient "codes" (or has a suddent serious event like a cardiac arrest, or can't breathe, or becomes unresponsive), they call the "code" over the entire hospital intercom, and we are the ones who have to respond immediately and decide what to do in the emergency setting. Whew, its quite anxiety-provoking to have to be this person to make the call! I guess I feel "slightly" prepared for these situations...whereas last year as an intern, I felt in no way prepared. Of course, we always have people above us where we can ask questions, but they are at home. We are the ones who are there, and we're the first call. Eek!

One more thing...HAPPY BIRTHDAY MOM! (Sep 29)

More later...and thanks those who are still reading!

Alan

"I'm growing up! Aren't I cute?" --Sofie Cheng

Well, I am guilty of procrastinating soooo much, that it seems I haven’t written in almost 6 months. If anyone is still reading this, I will be so shocked! I am sorry to have not written so long, especially since a lot of things have changed (and many things remain the same). I hope that some of you will pick this back up, as I am trying to renew my commitment to my blog as well.

So, here I am…back again.

So much has happened, that I guess I will just summarize.

I finished my last few months of my internship, and officially finished being an intern on June 24! It went by fast, but at the same time, I never thought it would end. What a long, tough, crazy, and educational year. In medicine, I think you grow more as an intern than any other year the rest of your career. I officially became an “upper level” or a “resident”. I now spend some time running the teams in the hospital, responsible for a set of interns and students, as well as a set of patients. I can look back and say it was a pretty good year, but often it didn’t feel that way. But, the last few months became much easier as I became more adept at being an intern.

Some of the boys - Mark, Bridger, me, Jason, Scott, and Andrew - chillin' at intern retreat 2007 in Wrightsville Beach, NC.

Our friends Jenny and Tem, at intern retreat.

More of our friends, Leslie, Mily, Karen, and Nicole at intern retreat.

We redid our lawn! It was filled with weeds and spotty grass, and we’ve always wanted a fenced, grassy lawn for Sofie to run around. We had a fence put up, then had the lawn killed and tilled, and had new sod put down. It’s looking much nicer now, but is still full of crabgrass that we will kill by next spring, and finally will have a nice lawn then.

Above, our lawn after it has been tilled bare.

1 day after the sod has been laid. Ahhhh....green.

After I finished my last days of internship, Nicole and I took a road trip down to Atlanta to see Keith Urban play at Phillips Arena. If you remember our first dance, our song was “Making Memories of Us” by Keith Urban (who sang this very song to Nicole Kidman on his wedding day…but we picked it first!). It was an awesome show! Michelle Branch opened for him…we caught one of her songs. Some of you remember that I had a crush on her too…

Above, the guitars for Keith Urban and the rest of his band, before they came on stage.

There was a catwalk from the main stage to the middle of the floor. We were sitting about 15 feet from the catwalk stage! Sweet!

Keith Urban...great show!

Sofie continues to grow…the last pictures on my blog of her were as a puppy. Now she is about 65 pounds! She’s training us to be good parents. She’s become such a sweet dog, excellent with kids, doesn’t beg for food, and makes a so-so guard dog. She acts like she growls when someone new shows up, but I doubt she’d ever attack even a burglar!

Jenny and Jeff had their second child, a baby girl named Kaelyn. She is absolutely adorable, and her big brother Tyler is taking care of her! They were just up here visiting, and we had a blast swimming in the neighborhood pool, visiting the museum of natural science in Raleigh, and going to play video games at Frankie’s! Interestingly, Nicole’s cousins are also Katelyn and Tyler…I’m not sure why my sister is choosing almost identical names for their kids!

Tyler giving his baby sister, Kaelyn, some love.

Don't we look like a happy family! Good thing they're not ours...I couldn't handle it!

I have decided on a career path for myself – after much deliberation over whether I do primary care (clinic) medicine, being a hospitalist (a “hospital doctor”), or pursuing a subspecialty (such as gastroenterology, cardiology, nephrology, etc), I have decided to pursue a career as a gastroenterologist (GI doctor). It’s a great field that involves a lot of interesting disease, involves a lot of different parts of the body, and has really cool procedures (which are much like toys or video games). As a specialist, you do get to spend more time with your patients on each visit, and don’t have to rush to see 35-40 patients a day just to pay the bills. I’ll be applying this year to be a GI “fellow” after I finish residency. A “fellow” is a step above being a resident, when you are training for a subspecialty. Once you finish your fellowship, you are finally an “attending”, or full-fledged doctor.

Nicole has continued working for the UNC GI program, and is really enjoying her job. She sees patients in her and her attendings’ clinics about 3 days a week, and helps out with research and patient follow-ups and procedures the other 2 days. Her bosses are excellent – they really teach her well, and really appreciate her work…hard to get that combination from a lot of people. She works with world-class GI doctors who specialize in esophageal and stomach problems, and specifically cancer and precancerous lesions of the esophagus. They are among the leaders in the world in treating a condition called Barrett’s esophagus, a precancerous lesion of the esophagus coming from excessive and chronic acid reflux from the stomach. I am very proud of her! (Plus she makes all the money for us)

Well, I think that’s enough for now. Now that I’m starting this blog back up, I can start my random journal entries and free associations. I am really going to try and keep this up!

Also, I’m trying to start up a MySpace page, to also keep in touch with everyone that way too…

Miss everyone,

Alan

The last 4 months...

Events from the last few months...

Nicole graduated from Emory physician assistant school December 2006. She was one of the 5 people in her class with a perfect 4.0 GPA! What a smarty!


Andre, Colleen, Nicole, and Amy at the awards banquet before their graduation. Sorry, they're all taken...

Nicole's parents (aka the in-laws)

Us at the banquet...

Jenny, Nicole, Tyler, and Jeff at Nicole's graduation day.

Amy (far left) is single!

Our house lit up for Christmas 2006!

We got only 2 days of snow this year. Sure is pretty though...

Ben and Jen came to visit! Sofie loves him.

The wife in her place!
Dinner at our house, with Alex, Sarah, Ben, Jen, and her friend.

Useful web sites

Hey, if you have useful or fun web sites, let us know!

Here's some I discovered today for travel:

www.farecast.com - predicts airfare routes

www.airefarewatchdog.com - finds hidden airfare delas

www.site59.com - unsold flights for last minute sales

www.luxurylink.com - luxury vacation packages, we actually bought our honeymoon through this.

Ben told me about this one:

www.singsong.com - record yourself singing karaoke, and post it, and listen to others!

Others I use:

www.slickdeals.net - really great deals on bunches of stuff

Fishy peanut butter...

Well this last month has been fabolous. I had a "regular" job for once - showing up at work from 8 to 5, and having my nights and weekends off! I was in the Same Day Clinic, kind of like an urgent care clinic but only for our established patients that we see at UNC Internal Medicine. You see the range of things, but most common being colds, sinus problems, musculoskeletal problems, and diarrhea. I got to perform "outpatient" procedures, such as injecting joints, incise and drain some abscesses (collections of pus), and did a spinal tap on a really fat guy.

It's funny what the news and media can really brew up in the community. You have maybe heard of the outbreak of salmonella in Peter Pan peanut butter. It's been all over the news, and the CDC (Centers for Disease Control) has confirmed it. Apparently a batch of Peter Pan had been contaminated with a bacteria called salmonella. This is usually found in raw chicken or poultry, sometimes in raw eggs, and can give you a pretty bad gastroenteritis - an infection/inflammation of the GI tract, often causing fever, abdominal pain, and bloody diarrhea.

Anything outbreak in the news inevitably makes it to the doctor's office...and they come in droves. I had a number of patients who stated that they ate Peter Pan, and then had an upset stomach and come to the doctor to ask if they got infected by the Peter Pan. Of course, no one I saw actually had the infection. But some of them even wanted to sue Peter Pan. I told them they were fine.

One person even brought their peanut butter in. Sure enough, it was from the batch that got contaminated. If the 1st 4 numbers on the top of the can start with "2111" then the CDC recommends you throw it away and if you're sick, see your doctor. She brings it in, sure enough its "2111". So, being the curious doc, I open the peanut butter and smell it. Smells like peanut butter to me. I even ask my attending if I can culture it and see if it grows salmonella. But we didn't, and it got thrown away. I advise the patient to throw away the rest of her Peter Pan at home. She'll be fine. She had no bloody diarrhea or fever. I reassure her. She says okay, but if she gets sick, she's gonna sue!

I have to say, being a doctor, I complain about being busy all the time. But, its never boring!

The enemy

As medical students, we are often idealistic, thinking of how many ways we can help a patient, and wanting to help or save every patient we ever see. I remember being somewhat appalled at how some of the fellow interns of residents treat patients. They were rushed, and didn't spend time with patients, always having one foot out the door, or cutting patients off while they spoke. I remember thinking, "I will never do that to a patient. I'll always give the patient my time and respect they deserve, because they are the one with the illness and need the sympathy, empathy, and healing..."

But as an intern or resident, we are often tired and overworked, and our patience can run thin. Yep, we are all guilty of it. Every one of us has come to the point where we view the patient as "the enemy." If you spend 20 minutes talking with the patient, you realize your to-do list expanded from 5 to 15 items. You were just paged something like 8 times and need to return these calls. And you always have too many patients...patients are the source of work, the ones who complain, the ones who bring you more paperwork and requests for laxatives at 3 am. And your patience is simply lost when a patient is narcotic-seeking and giving you attitude for not giving them their oxycodone.

You enter residency bright eyed and bushy tailed, ready to learn and save the world. Ready to be there for your patients 24-7. But we get tired and jaded, and we forget that naivete, that idealism and desire to do good and mean well. And the patient becomes the enemy.

I admit, I got that way myself. I think there were classmates of mine who were worse, and then some who always cared for the patient no matter how crappy their day went. I fell in the middle. I felt that overall, I wanted to care about and care for everyone, but some days it was a damn challenge. Some days I just wanted to forget that certain patients didn't exist and walk pass their room, so they couldn't pester me for more narcotics.

It is standard procedure to ask patients when they are admitted about their "code status" or "advance directives." This means, we ask patients that, if in the case that their heart stops or their lungs fail, would they wants us to perform CPR or place the patient on a breathing machine? Some, but a minority, of patients have already thought about this ahead of time. Most patients, however, have never thought about it. And at my most jaded or most frustrating of days, I remember asking this to patients bluntly, as if I'd be better off if they said "no, don't bring me back," and then I woulnd't have to worry about bringing them back. If they died, they died, and that was one less patient for me to "care for."

I now look back, and I can't believe that I thought these thoughts. These are human beings, and I can't believe I even had the thought run across my mind that if a patient died, I'd be better off. Have I forgotten what it means to be a physician? Or to be a person who cares? Or to put myself in the place of a patient and understand what it is to be in a thin, half-gown laying in a hospital, always being awoken, poked, sent off to tests and scans often without even advance notice, having catheters put in my urethra, and all the while sick with whatever disease they've got?

The funny part is, every one of us interns has likely had those thoughts. Thats how grueling this process is, and how low one can get. The good news is, once we become better at our job - better at being an intern - we are able to step back and start looking at our intern year with some perspective. And we realize we're in a dark place, where no one outside our profession could possibly understand. And when things start getting easier for us, we stop being jaded, and we start caring again. We remember that these patients are human beings, they have loved ones, and we need to do everything we can to care for and protect them. The meaning behind being a doctor in training returns. The thirst to learn returns. And the work is still there, but flows easier, and you realize that the nightmares of residency really are true; you've lost the naivete, but gained the perspective of the dark side and climbed out of it.

UNC 79, Duke 73

Since I now live in a college town with a real, major college sporting team, I can't help get caught up in the fever. The UNC-Duke basketball rivalry is by far the most talked-about sporting event in this area each year. Actually we play each other twice this year. Tonight, UNC beat Duke at Duke, 79-73! And on the news, people on Franklin Street, the main street through UNC's campus with all the bars and restaurants, were gathering in the streets. Apparently there is this tradition of creating bonfires in the streets, and then (perhaps foolishly) students jumping over the fire. I can see how that might be slightly unsafe...meanwhile I'm at home, bout to get ready for bed. Exciting.

Anyways, go Heels!!

Vacation time...

Ahh, I finally made it to my next vacation. I get a week off starting today, and its been a rough 4 months having had 2 of 4 be ICU months. But, all is good as Nicole, Sofie and I are heading through Atlanta and to Tampa! We wanted to do a vacation, but Sofie is too young for a kennel and not even spayed, so we decided to go home to Tampa so she could come with us. We definitely plan on relaxing, and spending time with the family, and seeing some of our friends while in the area (hi Danielle and Kristen!)

As a med student you are idealistic, thinking of all the ways you can help a patient overcome whatever problem it is. You have the opportunity to spend long amounts of time with a patient, really listen to them and get to know their story. Unfortunately, as an intern, you don't. On cardiology we worry about chest pain, and if the chest pain is caused by a cardiac problem, or not. If we find out its not the heart, or anything else serious, we discharge them. Thats great, except that they still have chest pain, and we don't know what its from. If they have other complaints that aren't serious, but are bothering them, doesn't matter...their regular doctor can see them. It's a bit unsatisfying for me, and for the patient, and for some folks they keep coming back to the hospital with the same pain...it hurts too much that they don't want to wait for their appointment with their doctor, but we never find a major cause for it. Half the time these people get admitted with the diagnosis of "rule out MI" (which means make sure its not a heart attack), rather than an actual condition. I'd love to be the med student again, sitting down with the patient and exploring other reasons that could be causing this patient their pain...how is their personal life at home? Their work? Stressors? What activities have they done lately that might have caused this? Rather, I have to work quick, and move on as 10 other patients will be needing my attention too. I sure hope its not like this when I "graduate" and become my own doctor.

Which is another sad part, that any "general doctor" often sees too many patients in one day in their clinic...often its 20-25 patients a day, but I've heard of even 35-40 patients! 40 patients divided by 8 hours, or 5 patients an hour, 12 minutes a patient, not including your lunch break, paperwork, phone calls, arguing with insurance to get them to pay for their patient's procedure. Maybe its down to 7-8 minutes a patient. Cann I really help that patient who is depressed and needs to talk about whats going on in their life in 8 minutes? Or just give them the script for an antidepresant...

Specialists, on the other hand, are the cardiologists, or GI docs, or the kidney docs. Their experts in their field, and they usually see patients when their general doc refers them. Their load may be 10-15 patients a day, and they can spend more time with their patients, work less hours, and often are paid more than generalists. Seems like a great gig. But a really good generalist is invaluable...they know the patient the best, and have a sense of perspective. Not sure which I want to do...