Lesson #1 from Internal Medicine

Keep it simple, stupid.

During my 2 straight months of wards on internal medicine, i somehow wound up having the same patient on 3 separate occasions.  While I thought it was strange that he kept coming back (for legitimate reasons), apparently that is not an uncommon occurance at our hospital ... frequent fliers we call them.

Anyway, this particular gentleman had a host of problems, all centered around his prosthetic heart valve.  He had his aortic valve replaced with a mechanical one a few years back.  This surgery helped him live a more normal life, however it carried with it the consequence of needing to be on blood thinners the rest of his life.  No one really explained the importance of these blood thinners to him and he eventually stopped taking them ... leading to a him having a stroke on two separate occasions.  Then when he finally got back on the blood thinners he wound up having hematuria (doctor speak for peeing blood ... yikes).  Needless to say, he had a healthy distrust for the medical profession, being that he kept seeing doctors and it seemed to keep getting him in trouble.

Well, over the time he was hospitalized we developed a pretty good relationship.  It's funny ... patients in a teaching hospital usually have about 4 doctors on average it seems.  It gets pretty confusing with all of them coming in and out of the room.  The medical student is actually the only stable one ... the one that comes in 2 or 3 times a day and talks to the patient the most.  About halfway through his stay he was calling me his "favorite doctor" .  I must say I didnt mind the new title and only corrected him sometimes  =)

At one point we decided we needed to do an ultrasound of his heart (echocardiogram) to check and see if anything was wrong with his mechanical valve.  During that study, the tech saw a "shadow" on part of his valve.  It didn't really look like a clot, but since he had these two strokes we were concerned it may be something causing a problem.  To find an answer we needed to do another test called a trans-esophageal echocardiogram.

I went to the patient's room and told him we needed to do this test.  I told him the name of the test and that we would have to sedate him and put an ultrasound probe down his esophagus to let us confirm if he had a clot on his mechanical valve.

He looked confused.

Then he said, "So you're telling me that you wanna stick a big tube down my throat ... where my food goes down ... to look at my heart?  How is that connected?"

Me:  Yes sir.  I know it sounds strange but your esophagus is right next to your heart.

Him:  So you can look at my heart through my esophagus, and you want to put me through all this because someone saw ... a shadow?

Me:  Um, yes sir.

Him:  Well, ok.  You're the doc!

So the patient consented to the test and it turns out the shadow was just ... a shadow.  But better safe than sorry.

I learned two lessons:

1. Sometimes things that make sense to me don't make sense to my patients.  And it takes patience to take time to explain it to them in a way that they understand.

2. Einstein was right ... if you can't explain something in a way that your grandmother would understand, you really don't understand it at all.

The Perfect Weekend

To celebrate the end of my 3-month Internal Medicine clerkship, as well as the pseudo-end of my third year of medical school (still have to make up psychiatry ... gross), Stuart told me to plan "the perfect weekend" for us to spend together.

First though, I must preface all this by announcing we have a new (temporary) member of our family!  His name is Winston, and he is a stray half Schnauzer, half something else, and he is kind of adorable.  Some of our friends who live out in West Mobile saw him in the woods one day and he followed them home.  They couldn't keep him, so we are adopting him while trying to find his family.  We know he was owned at some point before because he's pretty well trained and neutered.  However, after 10 days of "due diligent" searching on our behalf, he is ours if no one claims him!  Until we find out for sure (Wednesday), we are enjoying him a great deal!

I love my dad!

Those ears!!!!!  Maybe he's part bunny.

So anyway, to begin the perfect weekend:

1. Farmers Market - There's not a whole lot I love more in the summer than fresh produce.  I had been wanting to go to a farmer's market for a while, but a lot of them around town are during the week.  But!  I discovered that Mobile has one downtown in Cathedral Square every Saturday in the summer!  So that was the first stop of our Saturday.  We took Winston with us and he was the star of the Market.  Everyone thought he was so cute and stopped to ask us what kind of dog he was ... to which we answered, "Um, a stray".  

All the tents lining the square.

YUMMMMM!

And of course you can't go to the FM without getting a fresh-baked 800 calorie muffin!  Haha

After browsing a while we finally decided on some ingredients for our dinner that night: A ratatouille based-pizza.  First of all I must say that you can't beat buying produce from the farmer that planted it.  And second of all - it's cheaper than at a grocery store (no worries Publix, I'll be back soon!)

2. Shrimp - after bringing all our produce finds back to the house, we headed out to Orange Beach, accidentally by way of Florida.  One of our favorite things to do is drive the back roads of Baldwin County.  We love this place!  The land is gorgeous and we like to dream about building a house with lots of land and having a huge garden and our own chickens (Stu isn't so sure about that one).  Anyway we got so into the drive that we neglected to turn onto the connecting road to the beach and wound up having to drive to Florida.  Once we eventually got on the right road it was about lunch time.  We stopped at a beachy restaurant called Bubba's for some chow.  I don't think you can get the full beach experience unless you eat a big fried seafood platter, and eat we did!  It was great!

3. Beach - After our bellies were full we parked at the Gulf State Park and walked across the street to the public beach.  Somehow, whenever we go to the beach for a day, we find ourselves right next door to some pretty interesting people.  This weekend didn't fail us as we found our towels laid out next to a homosexual male couple and their 3 year old son, Hunter.  Needless to say, that was quite an eavesdropping experience.

We spent a few hours just chillaxing on the shore.  I attempted to read a Steinbeck, but wound up napping in the sun a majority of the time.  While we were on the beach we noticed a huge cloud of smoke behind us at the tree line.  As we sat there the cloud got bigger and bigger.  Eventually, a lifeguard truck came by and told everyone staying at the Gulf State Park to evacuate because there was an uncontrolled fire.

Crazy!

Nothing like a day at the beach!

We were feeling a bit sunburned so decided moving our car and going home would be a good idea.  Later we found out, thanks to someone dumping out non-cooled charcoal, about 500 acres of the park have been lost to fire.  Sad!

4. Cooking together - Now if there's anything I love as much as produce, it's cooking with my husband.  I had recently been inspired for this recipe for Ratatouille Pizza I found online.  I decided to make a homemade pizza sauce from some of the market tomatoes, garlic, basil, tomato paste and other spices, and Stuart chopped all the veggies.  Our pizza turned out not quite as beautiful as the online picture, but it was soooooo good!  And healthy too!  Of course, anything topped with goat cheese can never be bad, right?

Stuart hard at work

Finished product ... eggplant, zucchini and tomatoes with goat and mozzarella cheese!

5. Church - while Internal Medicine was a blast, I have worked every weekend for the past two months.... meaning of course that most of the time I haven't been able to be at church with Stu.  We made up for it this weekend by being there with bells on bright and early and being greeters!

6. Grand Hotel - going to the Grand Hotel for Sunday brunch is our occasional fancy treat.  It's where we go when we have a reason to celebrate and want to eat a whole lot of delicious food.  And when I say eat, I mean eat!  I may or may not have had 3 plates of food, including, but not limited to, mahi mahi, cornbread stuffed sausage, cheese blintz, southwest corn, and cheesecake.  It was amazing.  Of course after we came home we had to take Winston for a walk to work part of it off!

Ahhhh what a great weekend!  We did a lot of fun stuff, but we were just glad to finally have a whole weekend to spend together!

I started my psych rotation today and hopefully can remember some good internal medicine stories to share with you later!

An Open Letter to Kim Kardashian

Dear Kim,

My Internal Medicine team admitted a patient the other night who is one of your biggest fans.  Unfortunately she was having chest pains and couldn't immediately share why she liked you so much. 

I mean no offense by saying this, but I didn't really know too much about you until a few months ago.  Apparently you became famous by being the daughter of a rich lawyer in LA.  Just being known for that wasn't enough, so you decided to explore the world of acting with a couple appearances on semi-popular TV shows.  But your big break came when you posed for Playboy a few years back.  After that, you were offered your own reality show documenting your stressful and chaotic family and dating life.

Anyway, back to my patient.  She's a nice lady who weighs about 300 pounds and was admitted to the hospital for chest pain..  For the past few months she had wanted to lose some weight and start exercising so she could be healthier.  Unfortunately, eating healthy wasn't working fast enough for her, so she opted for a quick fix, appropriately named Quick Trim.  I believe you'll recognize this as a diet pill that you endorse.

After we ran a bunch of tests on this lady and luckily found she did not have a heart attack, we were suspicious for another cause of the pain and decided to look into these pills of yours a little more.  Oddly enough the ingredients aren't listed on the back of the pill bottle, but with much searching online I found them. 

1. Caffeine.  Specifically, the same amount of caffeine that is in 4 cups of coffee.  Imagine not realizing that was an ingredient and taking it with your breakfast which in most Americans' case includes a big cup of coffee!

2. "Herbs" - while herbs aren't necessarily bad for you and can add great flavor to your dinner, there are some out there that aren't worth consuming ... like willow tree bark extract.  Turns out this herb actually enhances the action of caffeine.  So we'll up that to the equivalent of 6 cups.  Wow, that's making my chest hurt already!

3. Diuretic - this is basically something that makes you pee.  We give diuretics to patients who have too much fluid in their body - like people in heart failure. If you give a diuretic to a normal person, they wind up peeing out too much water (dehydration) and also losing a lot of their electrolytes. 

4. Laxatives - um, self explanatory.

You market these pills as "natural fat burners that rid your body of excess water and waste".  What does that mean exactly?  Well based on the ingredients it means that a person desperate to lose weight will take these and be super jacked up on caffeine, and always be near a bathroom secondary to ingredients #3 and #4.  If they're unlucky, they may have some supra-ventricular tachycardia from all the caffeine and a little chest pain due to their heart beating so fast.  If they're extra lucky they will have peed out all their potassium and have muscle breakdown and some changes on their EKG.  Kim, were you aware that you encourage people to do this to themselves?

Well, fortunately, our patient turned out okay.  She had a little chest pain from the caffeine but it turned out to be relatively harmless.  I just feel bad that she went through all that worry and built up a pricey hospital bill and didn't even have any weight loss to show from it.  While counseling her at discharge, we couldn't decide which of your lifestyle promotions we would rather her take up: your Quick Trim, endorsement of Carl Jr cheeseburgers, or Sugar Factory Lollipops.  

Maybe I'll just suggest she go about being healthy the recommended way: healthy responsible eating and regular exercise.

Thanks for putting your product out there and keeping hospitals in business; unfortunately its from side effects and not because they are "consulting their doctor before beginning any weight loss regimen".

Sincerely, Kacie

Vegetarian Shepherd's Pie

Sometimes you just need to cook.

Sometimes when your work days are too long, and the questions you get asked are too hard, and the patients you are seeing are too sick, sometimes you just need to chop, slice and saute. There's a quote from the movie Julie and Julia that I can't quite remember, but it goes something like: when everything goes wrong in life and nothing makes sense, I know that I can mix flour, sugar and eggs and it always makes a cake.

And sometimes you just need comfort food.  For me growing up, comfort food always involved mashed potatoes.  Mom often cooked "veggie plates" for dinner.  I would consistently  request mashed potatoes (I still can hear her hand mixer hit the stainless steel pan she mashed up the potatoes in) and she would always add in some sort of peas or beans for protein like any good mom would.  And one of my favorite things was to mix the two together.  Gross?  Maybe, but I think it's delish!

A while back I made shepherd's pie for our small group and used lamb.  However, I recently stumbled on a recipe for a veggie shepherd's pie, using lentils as the meat.  I was a little skeptical, and needless to say Stuart was a little skeptical, but I attempted it tonight anyway.  I learned some things:

1. Parsnips are delicious.  You can mix them half and half with potatoes and when you mash them, the parsnips give such flavor that you don't really even need to season it!

2. Lentils take a really long time to cook.  But they are tasty!  And oh so healthy.  A few days ago I had considered sprouting some because sprouting them increases their nutritional value.  But then I found out the recent E coli outbreak in Europe came from sprouts.

3. It's amazing how much better I feel after spending some time in the kitchen.

Mom used to peel her potatoes with a knife, but I cut myself when I do that.  So I have a cutesy bird peeler.

Lentil action.  With a little tomato, onion, garlic and cayenne.

Mashed taters and parsnips

Ta-da!  Veggie Shepherd's Pie.  I threw a little corn in there for fun.  You could almost mistake those lentils for meat.  And it was delicious!

Finally!

No more food pyramid!  Last week the FDA decided to switch their illustration of healthy eating from the food pyramid to the "My Plate" method.  I'm probably one of the only people in the country who is very pumped about this.  What's the difference, you say?  Well first of all, the food pyramid was not exactly correct.  If you remember the old school pyramid, it had grains and starches down at the bottom level indicating that should be your largest % intake.

Then we realized that refined grains (non-whole wheat) was bad for your waistline and bad for your health (hellooooo diabetes).  In comes the new pyramid.

This was bad because ... well ... what the heck does it mean?  Theres a man climbing up the side of a pyramid of food.  I think it tells me I need equal amounts of grains and dairy?  And there's really just food all over the place.  Not helpful.  But now!  I think they've finally got it right:  The Plate Method.

This is a method I have used many times to teach my patients how to eat healthfully.  It just makes sense!  Half of your plate should be filled with fruits and veggies.  1/4 is for your protein (no steaks filling half the plate, please), and the other 1/4 is for your grains, which are preferably whole grains.  And the white spaces in between mean that you should always be able to see empty plate between your food items (perhaps this rule was put in specifically for my family potlucks!)

Anyway, this is super easy to teach patients, and I think that it actually works.  If you make an effort just to fill half your plate with veggies (and they aren't fried veggies), I guarantee you'll be healthier than the average bear!

Out with the old; In with the new!

Dearest Mustang,

You and I spent a great 10 years together.  I remember feeling like the luckiest gal on the block when my dad brought you home from the dealership on that crisp February morning in 2000.  Back then you were shiny and almost-new with a mere 6,000 miles.  I felt like the hottest thing in town. We turned a few heads, you and I!  I admit I may have broken a few speeding laws with you, but you always got me safely to where I needed to go, and for that I'll be forever grateful.  You were kind to me even after that fateful morning of the ACT when I hit a pickup truck and put a trailer hitch ball in your front bumper.  Sorry about that...

We've had a great relationship through college.  You've taken me to the beach for many spring breaks, but according to mom and dad brought me home from Auburn too few times.  We've been through 101,000 miles, a wreck, a few jumped curbs and 5 moves together.  We've been pulled over quite a few times, but still with NO speeding tickets (yes I'm proud).

And now, I hate to break the bad news, but I'm moving on to someone else.  Someone who gets 50 miles/gallon.  Someone whose paint isnt chipping off, whose radio display tells me what station I'm listening to, whose seatbelt retracts back in the holster, whose power steering doesn't leak.  Someone who's a little less "crazy teenager" and a little more "earth-friendly responsible adult".  Someone who has 4 doors and the ability to transport friends and groceries.  Someone named Prius.

Please, Mustang, don't be hurt or jealous.  We had good times together.  But sometimes, you just have to move on.

Love, Kacie

 

Lesson of the Day: Always Listen to Your Patients

Even if they are crazy ...

This Tuesday I was on call.  That means that I, along with my team, hung out in the Emergency Department and admitted all the patients in serious enough condition to stay in the hospital.  My assignment for the night was to admit a lady who we'll call Ms A.

Ms A came in at 6am that morning for a chief complaint of sudden blindness.  Her estranged husband (who just so happens to live in her back yard) brought her in.  When I strolled in the room he flashed me a toothless grin and told me his ex-wife wouldn't wake up yet.  I glanced over to the patient and realized she appeared quite sedated.  I'll later tell you why, but for now let's move on with the story ...

I had to get the story from the grinning ex who lived in the back yard since my patient was obtunded.  He told me that last Thursday she came to the hospital for outpatient excision of "skin cancers".  As I look over to her I notice she has multiple sutured lesions on her face.  After the surgery all was well and they sent her home.  Well a few hours later she started getting sick at her stomach and came back to the hospital.  Lo and behold, they did some blood work and she had pancreatitis!  So obviously she got admitted and underwent the standard treatment for pancreatitis.  While in the hospital, records indicated she had been a bit "hesitant" about going home, and at the time of discharge kept telling everyone she had a bad headache.  As some in our patient population seem to enjoy their stay and free meals in the hospital, I think this statement was ignored and she was sent home.  

A few hours later that night, around midnight, she suddenly gets very nauseated and begins vomiting.  She calls the ex from the backyard and out of the blue, she suddenly goes blind in both eyes!  Everything was completely black!  Now let me tell you friends, if you havent figured this out for yourself, sudden blindness is not a thing that usually happens.  And especially not in both eyes at once.  The story continued on per toothless ex, "well she just kept throwing up and saying she had this headache and couldnt see nothin!  Then about 30 minutes later all the sudden she could see again!  But she said it was real shadowy.  Then about another 30 minutes later she went blind again!  So a few hours later I decided to bring her in because I kept giving her Lortabs and they wouldnt work."

At this point, I had already been told by the ED staff that this lady was crazy.  Her ex had also reportedly told a nurse she was crazy.  And this story was crazy!  Blindness that got better and then came back again in a few hours and not deciding to go to the hospital for 5 hours afterward just wasn't coming all together for me.

But then the story gets more interesting ...

At this point, the ED staff decided to get a CT (cat scan) of her noggin.  Sometimes a special type of "mini-stroke" can present with blindness, though not necessarily in the way that this patient did.  Of course to no one's surprise, the CT came back normal.  They then called neurology because they didn't know what to do with this woman.  They suggested an MRI, because that usually gives you better pictures of the brain.

So off to the MRI Ms A goes.  She keeps mentioning she's nauseated (and oh by the way her sight is fully back now) and the nurse goes down to MRI to take her some nausea medicine.  As he hands it to her, Ms A stiffens her whole body, and then has a grand mal seizure.  The nurse witnessed the seizure, but others who saw it thought it was a pseudoseizure.  Pseudoseizures are non-epileptic psychological seizures (aka, the patient is faking it).  She was treated for a seizure regardless (hence the sedation I mentioned earlier) and was administered a test to see if she had a seizure or not.  And that test was normal.  Suspicions again grew.

While Ms A was knocked out from her medicines, we decided to sneak her into the MRI to actually see if anything was going on in her noggin.  MRI's take a while to get back, and so our team went upstairs for dinner.  It was interrupted by a call from the radiologist saying we better take a look at this MRI.  It looked like this:

See those white splotches at the bottom?  That's not normal.  And this is the area that controls your vision.

And then on top of that, add this picture to the same one

See that white spot in the middle popping out at you?  That's not normal either.  This is a picture from the internet, but her white spot was even bigger.

Uh oh.  We've got trouble. Now we all felt pretty terrible that we thought this lady was "malingering", or exaggerating/creating symptoms for personal gain/attention/sympathy.

After seeing the images and debating over what they meant/how they got there.  The top ideas were malignancy (especially that middle white spot), a stroke (either spot, but neither of them really screamed a stroke to the radiologists), or an interesting syndrome called Posterior Reversible Encephalopathy Syndrome, which she had all the symptoms for.  We wound up treating her for the latter, and then during her hospital course we wound up ruling out everything that we thought of.  She went home today stable, but still without answers as to what is going on in her brain.

Ill probably never know how things turn out for Ms A, but I did learn a valuable lesson from her.  Sometimes in the healthcare field it's pretty easy to become jaded and maybe even a touch cynical.  A lot of patients seek drugs, and a surprising number of them may exaggerate their symptoms, or even fake their symptoms for various reasons.  But just because a patient may be odd, or you are suspicious of their motives doesn't mean that they can't be very sick too.  If someone tells you they are sick or in pain, you can never ignore that and write it off as insignificant.  Not only did I learn what Posterior Reversible Encephalopahy Syndrome meant during the past few days, I also learned to truly listen to your patients, to not make judgments, and to not jump to conclusions.  A good lesson learned.