Unexpected Outcomes

My apologies to all my readers: it's been quite some time since I sat down and wrote out a story, patient interaction, or lesson learned. Between recovering every other week from the next cold patients have given me and hanging out with Aaron, I've let time get away from me.

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Mr. COPD Strikes Back

Do you remember Mr. C (see last story on the blog entry, "plays well with others") ? He was the gentleman (I think I'm being very generous calling him a gentleman) who was hospitalized with respiratory failure and between gasping for breaths would ask me to marry him. We discharged him shortly after I posted the entry about him and he was back the very next day in even worse condition than before. He was unresponsive and couldn't breath without his BiPAP. If he tried to take it off, his oxygen saturation would drop almost instantly. Watching him struggle to breath was painful. He was having to use his accessory muscles, but even so, was very fatigued and would only take a voluntary breath about six times a minute. For days, he was not eating or drinking anything and wasn't even asking for his pain medications. He even asked one of the nurses what would happen if he kept his BiPAP off and how long it would be before he passed. I could tell he was terrified of dying, yet tired of the struggle and it seemed as if he was giving up.

We thought he was going to die and even went so far as to have the discussion with him that he wouldn't be with us much longer and asked if he understood, which he said he did. We stopped all the necessary medical interventions and put him on "comfort care". I began feeling very sorry for him again. His sons were called repeatedly and told they wouldn't have much time with their father and yet, they didn't come to visit. Here was a man in his early sixties lying half-naked in a hospital bed stripped of his dignity, hooked up to IVs and breathing machines, dying alone. I can't think of anything much worse. Part of me wanted to go in and sit with him just so he wouldn't be alone.

The day after we put him on comfort care, I went in to see him. Miraculously, he was better! His breathing was no longer labored, he had eaten breakfast, and was even talking to me and asking for his pain medications. Every day for the next week he made small steady improvements, but still required his BiPAP and didn't quite seem his feisty self until one morning when one of the nurses told me he called her an asshole and 15 minutes later he asked when we were going to get married. He was back.

We discharged him home two days ago in the best condition I've ever seen him in. As I was leaving his room that morning I asked him that the next time I see him, that it would not be in the hospital. He told me it was a deal and then asked, "So, you still haven't told me when we are getting married. What do you say?"

I gritted my teeth and replied, "You'll have to get through my dad first."

I didn't wait for a reply, but as I walked down the hall I heard him say, "Huh, you don't think I could run faster than him do you? Well, I guess you are probably right..."

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Making a Diagnosis

Mr. Sinusitis came in to clinic last week because he "just couldn't shake this sinus infection". He'd been seen the week previously for sinus congestion and had been given a Z-pak and told to follow up if things didn't get better.

Before I entered the exam room, I flipped through his chart and saw that he was a 71-year-old man with no significant medical problems. Sure, he's had his share of bone injuries and a couple of surgeries for those, but otherwise, he had no diagnoses and took no medications. I tried to think about what I'd tell him about his unresolving sinus symptoms and I was drawing a blank. I'd resolved to the typical medical student thing of asking a bunch of questions he'd already asked before and then ending the interview with something like, "huh, well I don't know what to tell you; we'll see what the doctor thinks, but I have a feeling you have a viral infection. There's a lot of this stuff going on right now and it might just take you a bit longer to get over it and antibiotics don't usually help."

I opened the door, introduced myself, took a seat and started in with the questioning: when did this start? has it gotten any better? worse? what have you done to treat it? As he started answering my questions, I got the feeling this wasn't a sinus infection and I broadened my differential. They teach us that you should always go back to the history and physical exam when trying to pin down a diagnosis and it seemed that his history was not that of a typical acute onset sinus infection.

With more thorough questioning I learned that his symptoms started over three months ago and consisted of no only upper airway congestion, but also daytime sleepiness, fatigue, shortness of breath, dyspnea with mild exertion, orthopnea, leg swelling, palpitations, and an irregular heart beat (which he apparently had been told he had last year). These symptoms set off red flashing lights in my mind: this man has congestive heart failure! As I finished up the history and started in on the physical exam, I began thinking about the things I might find if he did in fact have heart failure: crackles on his lung exam, possibly an irregular heart beat with or without a murmur, elevated neck veins, hepatojugular reflux, lower extremity edema. I started by listening to his heart: it was irregularly irregular (in medicine, that is pathognomonic for atrial fibrillation) with a 3/6 holosystolic murmur at the cardiac apex (pathognomonic for mitral regurgitation) which supported my diagnosis of CHF. His lungs were clear, neck veins flat, and there was no hepatojugular reflux, but he did have pitting edema in his legs and a negative HEENT exam (which speaks against a sinus infection as a cause of his symptoms).

I left the room and look for Dr. Gunther who was in with another patient, so I grabbed Debbi, "can you please get an ECG on Mr. CHF (previously known as Mr. S)?"

When Dr. Gunther was done with the other patient, we went into the room and I presented my findings and offered my assessment and plan, "I think he has heart failure. I've already asked Debbi to get an ECG and I think we need to send him for a chest X-ray and an ECHO and get some labs today."

Dr. Gunther agreed with my findings, handed me the lab slip to order the tests I wanted, and made some calls to get him scheduled for the CXR and ECHO. Debbi came in with the ECG: sure enough, he was in A. fib. We explained to Mr. CHF and his wife what we thought was going on but said we couldn't be sure until we had some of the test back. We sent them to the hospital to get the CXR and ECHO and asked them to come back to clinic afterwards. They returned late that afternoon, tests in hand. The CXR showed an enlarged heart. The ECHO showed a markedly reduced LV ejection fraction, mitral and tricuspid regurgitation, but no structural wall or valve abnormalities. His BNP was elevated. In English, he had congestive heart failure.

Dr. Gunther broke the bad news and talked him through the diagnosis. He completely distanced himself, however: he stopped making eye contact and only replied with grunts, slight head nodding, and shoulder shrugging. Clearly he was upset and intentionally not listening. We shifted our attention to his wife who was fiercely taking notes.

Dr. Gunther asked me what I'd like to treat him with. "I guess we should start lasix for the edema and he'll probably need some KCl with that as well so he doesn't become hypokalemic...I'd like to give him digoxin for A. fib...Maybe a beta-blocker for rate control...I guess we should start and ACE-inhibitor as well...he should stop drinking as well (he drinks 4-5 gin and ginger ales a day), so he might need some ativan for 'his nerves' [this was code for alcohol withdrawal symptoms]."

"Very good, Emily." Dr. Gunther began writing out the prescriptions. Then I realized that I made my first bonafide diagnosis! I took the history. I performed the physical. I ordered the tests. I came up with a treatment plan. This was a new feeling for me and I surprised myself that I knew what to do. I was very sad for Mr. CHF and his new devastating diagnosis, don't misunderstand me, but I felt a sense of fulfilment and validation that I was actually doing something to help him.

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As scientific and exact as medicine is, there are always unexpected outcomes, whether it be Mr. COPD making a miraculous recovery or Mr. CHF being told that his sinus infection is in fact heart failure. I guess it's the uncertainty that keeps things interesting and provides the unending challenges that physicians must work through.

Last Days of Winter

Mom, I forgot to give you the bad news that I had a left leg amputation last month. The good news is it hasn't affected my ability to do a rippin' tele turn.




For more great photos visit www.middleforkbirddog.blogspot.com

A Girl and Her Dog

Again, thanks Aaron for a great day and fantasic photos.

Submarine Annie

For some reason Annie reminds me of a submarine on a not-so-stealth reconnaissance mission. She gets buried and then porpoises up and down all the while snorting and scoping things out as she goes. Sometimes she follows me, but most of the time she's on her own mission. Thanks for all the great pictures Aaron.
























This one's my favorite.

Life in Libby

Historically, Libby is a logging and mining town. Today if you asked me what people do in Libby, I'd answer, "I don't really know...I guess they work at the hospital...either that or get old and die in the hospital of lung disease," because that's all I can tell from being here the last few weeks. The mill has shut down. The mine, tainted with tremolite asbestos, has closed. Young families have moved out, looking for employment. Older generations remain. I see them at the grocery store walking around with their portable oxygen tanks: this is a dying community.

Vermiculite was mined out of the ground outside of Libby for many years. Mixed in this mineral are small particles of asbestos that are easily inhaled into the lungs, but not so easily cleared. Chronic or high volume exposure ultimately leads to asbestosis--a chronic, debilitating, even lethal lung disease. Symptoms of asbestosis do not manifest for some 30-40 years after exposure, however, which has resulted in high levels of long-term exposure to many people in this corner of the state. Miners were obviously exposed and affected. They would bring the dust home to their families, who were also exposed. What is more alarming is that the people of Libby who never set foot in the mine nor lived with someone who did, were also exposed to this toxic fiber and are now learning that they too have this terrible disease.

Dr. Gunther has told me about patients she takes care of who can remember playing as children in an old barn that was filled with asbestos. The kids would pile the stuff up and swing from a rope tied to the rafters into the fluffy bed of asbestos, all the while laughing as their bodies where immersed in the toxins. Another patient worked at the mine as a receptionist and questions about the safety arose, she started eating chunks of the mineral just to prove it was "safe" (needless to say, she tragically ended up with cancer of the palate of her mouth). The high school track and ice-skating rink were made from "generous donations" of excess minerals by the W.R. Grace Company. There would be mounds of the fibers neatly deposited in dirt fields and given away free as soil and plant fertilizer. In addition to overt fiber placement in Libby, winds would carry it for miles around, leaving it to settle in the valley. The people of Libby literally lived (some ate) and breathed asbestos dust for the better part of a century: it was simply a part of life in Libby.

The mine was shut down in 1990 and rumors of asbestos related disease started catching the media's attention in 1999. Today there is question about when W.R. Grace officials knew that this harmful substance was being mined and whether there was a cover-up to avoid substantial monetary losses to litigation, cleanup, and medical expenses for the people of Libby. In February, a criminal trial against W.R. Grace began in Missoula. It's interesting to be here while this trial is going on. When it started last month, I was curious to see what the talk around town would be like. I expected to hear about daily progress of the trial at the hospital and clinic, in the grocery store and athletic club, and in the newspapers (there are 3 local papers). Oddly enough, there hasn't seemed to be much talk around town. It is as though nothing is happening at all. Is it that it's just old news? Are people tired of talking about the too-familiar tragedy? Do people not care anymore? Is it because the trial is so far away in Missoula? It was only this week that I began hearing people talk about it. One of the nurse anesthetists brought up the subject in a surgery Thursday morning and later that afternoon the girls in my spinning class were talking about the trial they hoped would bring justice to their grandparents.

Please take the time to learn about this tragedy that has changed so many lives and left a community unemployed, diseased, and disheartened.

Libby, the mine, and W.R. Grace trial history

W.R. Grace Trial: Updates

Help me Choose a Career

Where do you think I fit best?

X-Country Skiing

Dr. Rice: "I moved here to cross-country ski. I ended up having to maintain the trails, so I do more biking than skiing." The Kootenai X-Country Ski Club got a new snow machine, groomer, and trail setter this winter. Dr. Rice is very excited about it and does a great job, too

Treasure Mountain.


Looking West toward Idaho.


Susie catching her breath on "roller coaster" two weeks s/p arthroscopic knee surgery!


I bet my mouth is pursed here.


I think I can.


Made it. Whew!


Wheee!

Just the Girls

Dr. Gunther, Debbi (the nurse who works with Dr. G.), Annie, and I went cross country skiing today. We headed south out of town about 10 minutes and drove out some forest service road until it was no longer plowed and strapped our skis on from there. It was so peaceful and with great views of the Cabinet Mountains.


Dr. Gunther and Debbi.




Debbi, Emily, Annie.


Dr. Gunther and Debbi.


Dr. Gunther, Emily, Annie...we did all the permutations for this photo!


Annie.
Dr. Gunther made a great observation about her energy level compared to ours: Humans use something like 80% of our glucose supply to power our brains, which leaves less for our muscles. Animals have more energy for muscles because they don't have a powerful brain to suck up all that energy and maybe that's why she can go and go and go...I couldn't agree more! I always said Annie wasn't very smart and when you knock on her head, it sounds pretty hollow. Maybe this is why everyone asks, "Is she a puppy?"
Less brain matter = less glucose to brain = more glucose to muscles = more energy = puppy-like traits.


Annie for the rest of the day. Outta glucose.


Notice the lack of tail movement.


Me after a shower and a nap (I'm doing a bit better than my companion). I miss you all.