Posts tagged medicine

Two Schedules on Shared Time

The challenge of my current schedule is that I must juggle my responsibilities between my core rotation and those of my clinic, to which I am obligated to spend time as well.

Sometimes it means missing out on some good learning opportunities due to conflicting schedules. Other times, the days off of one schedule coincide with the days on of another. I can be particularly hit hard if, like today, the day could have been spent sleeping post night shift.

Thankfully these scheduling anomalies are few and far between. However, when I think about how well established the challenges of balance are in residency, having an awareness of these issues can go a long way towards improving resident resilience.

The Paradox.

The Paradox.

How Do You Cope With Stress?

In my last community survey, I asked how you assess your stress level. The responses demonstrated just how diversely and how uniquely each person’s stress manifests.

This time, I would like to ask a follow up question and allow everyone to share how they deal with stress.

Beyond identifying and dealing with the source of the stress, I personally take more time to spend with my wife. I try to sleep earlier to catch up on rest. I take a step back from studying at home and instead take up sketching and drawing again while listening to music to help me relax. At work, I try to meditate during my breaks.

How do you cope with stress? Share your tips with everyone.

Posterior anatomy study of skeletal muscle articulations of the body, hands, and feet by Albinus, 1879.

Posterior anatomy study of skeletal muscle articulations of the body, hands, and feet by Albinus, 1879.

How Do You Gauge Your Stress?

Whenever I am stressed, there are some subjective markers I look at. I find myself more tired, I have a harder time concentrating, and I feel less motivated. 

Objectively however, I also have something to gauge my stress level. I have a tendency towards grinding my teeth at night, a condition known as bruxism. It is brought on by stress and goes away in its absence. The more stress I have, the more I grind my teeth. From inspecting my mouth guard every morning, I get a decent idea of how stressed I am.

So how do you gauge your stress level? Let me know in the comments and discussion below.

Hit him with everything!
When we get desperate with a patient - be it a cardiac arrest, a septic shock, or just outright aggressiveness - this is what the escalation of interventions feels like.

Hit him with everything!

When we get desperate with a patient - be it a cardiac arrest, a septic shock, or just outright aggressiveness - this is what the escalation of interventions feels like.

Our Deepest Condolences

One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner. 

By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief. 

I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis. 

"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.

By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.

Or so we thought.

It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”

Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward. 

We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.  

Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.

But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many. 

These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.

"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."

A yawn is a silent scream for coffee.

A yawn is a silent scream for coffee.

How the Sun Sees You by Thomas Leveritt.

This is a fantastic video illustrating the power and damage ultraviolet rays have on our skin. This is not to say however that we cannot enjoy time in the sun at all.

Instead, make sure that if you are going to spend any length of time outside, remember to put on some sunscreen, to cover yourself properly, and to be mindful of your skin.

From medresearch:
Newly discovered heart molecule could lead to effective treatment for heart failure
Researchers have discovered a previously unknown cardiac molecule that could provide a key to treating, and preventing, heart failure.
The newly discovered molecule provides the heart with a tool to block a protein that orchestrates genetic disruptions when the heart is subjected to stress, such as high blood pressure.
When the research team, led by Ching-Pin Chang, M.D., Ph.D., associate professor of medicine at the Indiana University School of Medicine, restored levels of the newly discovered molecule in mice experiencing heart failure, the progression to heart failure was stopped. The research was published in the online edition of the journal Nature.
The newly discovered molecule is known as a long non-coding RNA. RNA’s usual role is to carry instructions — the code — from the DNA in a cell’s nucleus to the machinery in the cell that produces proteins necessary for cell activities. In recent years, scientists have discovered several types of RNA that are not involved in protein coding but act on their own. The role in the heart of long non-coding RNA has been unknown.
Read more »
Funding: The research was supported by the American Heart Association; the National Institutes of Health; et. al

From medresearch:

Newly discovered heart molecule could lead to effective treatment for heart failure

Researchers have discovered a previously unknown cardiac molecule that could provide a key to treating, and preventing, heart failure.

The newly discovered molecule provides the heart with a tool to block a protein that orchestrates genetic disruptions when the heart is subjected to stress, such as high blood pressure.

When the research team, led by Ching-Pin Chang, M.D., Ph.D., associate professor of medicine at the Indiana University School of Medicine, restored levels of the newly discovered molecule in mice experiencing heart failure, the progression to heart failure was stopped. The research was published in the online edition of the journal Nature.

The newly discovered molecule is known as a long non-coding RNA. RNA’s usual role is to carry instructions — the code — from the DNA in a cell’s nucleus to the machinery in the cell that produces proteins necessary for cell activities. In recent years, scientists have discovered several types of RNA that are not involved in protein coding but act on their own. The role in the heart of long non-coding RNA has been unknown.

Read more »

Funding: The research was supported by the American Heart Association; the National Institutes of Health; et. al