Sanjay Gupta

A 39 y/o super-specialized television doc with no public health experience as our next surgeon general?  Not only no public health experience but hasn't ever worked as a full time clinician since residency.  Not the person I would place as the advisor to the president in a time of health care crisis.  Come to think of it, if he just wanted a young, good-looking, no-experience doctor with hypnotic charisma, he could have chosen me.  I'd have considered it.

The flu

I just finished reading an excellent article summarizing diagnosis and treatment of influenza.  It is a shame that people, including physicians, don't respect this bug more.  Everyone is afraid of "pandemic flu," which they should be, but very few understand the seriousness of regular old influenza.  Doctors in the hospital often don't test for it when they should because they think incorrectly "there is nothing I can do about a virus" and also because it is a pain for nurses and docs to have to use isolation precautions (masks, gowns, etc.) while waiting for the test to return.

There was a patient during my intern year that cemented the seriousness of this disease in my mind.  I was on night float, meaning that I was working nights to admit new patients and it was my responsibility to take care of issues that arise.  I was asked by the day docs to check on some lab results for a patient.  He was an eighty year-old guy admitted for influenza.  He had some mild heart disease but was feeling great and doing well prior to this.  He had gone to get a flu shot at the store a few weeks prior but they had run out.  Anyway, I was notified by his nurse around midnight that his lab work showed some heart damage.  I went and woke the guy up and he said he felt fine, just tired.  I ordered some meds for him and went back to seeing new patients.  

About 5am I was called again by the nurse who said the guy looked rough.  I went back to see him and the change was startling.  He was having trouble breathing and when we checked his vitals we found that his heart rate was about 160 and in an abnormal rhythm.  This is not good in an eighty year old heart.  His blood pressure was dropping as was his oxygen level.  I called a code and started to tell the patient that we needed to shock his heart to slow it down and I couldn't give him a lot of sedative medications or it might drop his blood pressure even lower and kill him.  He said to do what we had to.  We gave him a touch of sedative and shocked him.  It didn't work so we wheeled him down the hall to the ICU.  He had stopped responding by now.  The ICU doc showed up and we started meds to keep his blood pressure up and try to slow his heart.  I distinctly remember one of the nurses saying "look, his heart rate is finally slowing down" and then watching the monitor as his heart rate went from 160 to 120 to 80 to 20 to flatline in about thirty seconds.  The nurses started CPR at just the same time the chaplain tapped me on the shoulder and said that the patients three daughters were here and waiting for an update.  

I left the patient with the ICU team and went out to the daughters.  I introduced myself and then got right to the point that their father wasn't doing well and his heart had stopped and we were trying to resuscitate him right now.  One of them looked at me and said "he just had the flu!" with enough disgust and anger to actually make me feel guilty and mumble something inadequate.  All three women then pushed past me like I was a flasher on the street and went up to their father's room.  One kept yelling "you're gonna make it Dad!" while the others just cried.  He was finally declared dead about 8am.  

It felt terrible.  I remember this guy very well as I think all docs remember their first deaths in residency.  This guy was pushed into heart failure by plain old influenza.  He was just fragile enough as lots of old folks and young kids are.  So get your flu shot!  If not for you, get it so you don't give it to someone weaker than you.

Sydney just fell asleep on my chest after spending about thirty minutes looking out our dark hotel room window, watching the waves roll in on the Oregon coast.  If only every day ended that way.

I've been reading Harlan Coben thrillers lately.  He has an amazing way of tapping into and expressing human hopes and fears, especially about parenthood and family.  If you enjoy thrillers, try him out.  I even have Sherrie addicted now.  There is a recent French film version of his book "Tell No One" that I am eager to see.  Anyhow, he often discusses the intense protectiveness parents feel and how if we are really honest with ourselves, we will admit that we would sacrifice a thousand strangers for our children.  It has nothing to do with justice or deservedness, it is just how things are.  

In Mountains Beyond Mountains, there is a discussion between the author and Paul Farmer about Farmer's views of humanity and his views of his own daughter.  I haven't read the book in a while, but if I remember correctly, Farmer is ashamed to admit, that yes, he does care more about his daughter's life, health, safety than the children he cares for in Haiti.  He views it as a moral failing.  

Of course, as a father, all of this resonates with me.  I think it is a moral failing, but it is one that defines us as human.  All of us, even the Paul Farmers of the world, are unable to escape it.  Thinking about this has given me new appreciation for the gospel and the language God uses.  Not a new thought, it just hit me in a different way.   

Perspective

A couple of months ago, I admitted a guy to the hospital with a severe infection.  He was a very unfortunate soul who had a stroke to his spinal cord in his neck, leaving him a quadriplegic.  He was fairly young, maybe early 70s, and very healthy prior to this.  After his stroke, he was put in a nursing home and he was admitted to the hospital every few months for some complication due to his spinal cord injury.  As everyone in medicine knows, this often means a urinary tract infection because of the presence of a chronic catheter in his bladder. 

I got called by the ER about ten minutes before he would have been the night doctor's responsibility and it had been a long and busy day.  My friend Seth is an ER doc and he asks me why I don't just ignore the page for ten minutes when this happens.  I hadn't thought of this brilliant trick at the time so I went down to the ER quickly to get him admitted for presumed sepsis due to urinary tract infection.  When I went in the room, he was alone and looked quite ill.  He was delirious, which is very common in older folks with infections, and unable to give me much history so I pretty quickly got to examining him.  When I pushed on the back of his head, his neck didn't flex at all and he yelped in pain.  Uh oh.  Fever, confusion, and neck stiffness= meningitis until proven otherwise.  I finished my exam and called his wife and his nursing home RN thinking that maybe his neck is always stiff now because he is bedridden or due to his stroke.  Both said nope.  Shoot.  I knew that this was probably just a urinary tract infection, but you can't afford to miss meningitis so I knew he needed a spinal tap.  This was going to add another couple hours to my day so I sighed and sent him up to the ICU and began trying to find the correct equipment.

I'm almost to the point of the story so bear with me.  It is now about 8:30 and I'm gloved up and poking a four inch needle into this guys back.  I use lots of numbing medicine but it still can't feel good when I'm trying to find a little gap in his not-so-flexible spine.  By now, he has received a bunch of IV fluids and is talking and making sense and not acting confused at all.  In fact, he is moving his neck just fine whenever the needle pokes the bone and he feels some pain.  Before I even get any fluid back, I'm realizing that this is definitely going to be just a bad UTI.  

I eventually get the fluid and I start to clean up all the equipment when the patient starts a very pleasant conversation, asking me about my family, etc.  He is now completely lucid.  He starts to shiver so I go to get him a blanket from our warmer.  I'm laying out the blanket over his body when he looks up at me and says "I feel like the luckiest man in the whole world."  I must have stood there for twenty seconds just staring at him.  Are you kidding me?  This guy is a quadriplegic, living away from his family in a nursing home, sick in the hospital, and I've just finished torturing him with a needle in his spine.  My life is embarrassingly comfortable by almost anyone's standards and I still whine more than this guy.  I vowed to be thankful and gracious and not to whine for at least one day.  Instead, I told the gentleman goodnight and then went to find the night hospitalist and complain about all my admits.

Here goes...

I just finished a long work-week and I caught a cold.  I should have gone to bed at eight when I felt tired, but I didn't, and now it is midnight and I can't sleep.  So I might as well start a blog. 

I've thought about it for a while now.  I don't have anything great to say and I have no writing aspirations, but I do have thoughts that tend to bounce around in my head for too long.  Maybe writing about them will get them out and lead to some interesting conversations with friends.  

Most of the ideas that have inspired thoughts of blogging have come from my work in medicine.  At the same time, I don't really want to write about medicine.  A med school classmate writes a blog about science, medicine, and society that is very good.  I, however, tend to get stuck on the more personal stories I encounter and how they change my view of the big picture.  I don't even really know what that means so maybe I should just get started.