In medicine, patients who have been admitted to the hospital have an option to leave despite being deemed too ill to be discharged. We refer to these patients as leaving “against medical advice”, or AMA.  Many times patients sign out AMA whenever they feel a desire to leave the hospital when work-up is still pending. I once had a patient who presented with symptoms suspicious for myocardial infarction, but had a flight to India several days later. He felt symptomatically better a day after presentation, and decided to leave to pack his bags even though we had not completed all of this cardiac tests.  I had another patient who was admitted for a gastrointestinal bleed from ruptured esophageal varices. No sooner had I finished transfusing him 6 units of red cells did he demand to leave. This guy was a cocaine addict who needed another fix. These are the cases which disobeying medical advice could result in death.

Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.

Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.

The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.

Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.

It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.

medicine medicine, work

I recently received a trial of Afrin’s PureSea saline rinse for review. As with my prior reviews of the Neti Pot and Saline Rinse, I’ve tested out the odds and ends of this new product. This product is a nasal lavage device to help clear out your sinuses during a sinus infection.

The main difference between the Pure Sea rinse and its precursors is that this is a self-contained apparatus with sterilized saline. No mixing of solution packets, no heating of water, and no hassle of maintenance.

A 4oz bottle retails for $14.99, which is considerably more expensive than its competitors. It appears that the saline was purified from the Bay of Saint-Malo off the coast of France, which explains the increased manufacturing cost. The bottle itself is constructed from standard soft plastic, which is sealed at the top by a metal stopcock. The rinse includes a detachable plastic spigot that you can rinse after each use.

PureSea uses an active pressure mechanism to rinse your sinuses, much like the Sinus Rinse, by Ketan Mehta. You squeeze the bottle, and the saline squirts out the spout. The difference is that PureSea uses a narrow spout, approximately 0.5mm on my estimate. In contrast, Sinus Rinse has a relatively wide spout of maybe 5mm. With a smaller area, you get a higher velocity but a much smaller volume of flow. The higher velocity may be useful to help dislodge any dessicated mucus from your sinus, but may also be more uncomfortable.

It is clear from assessing the volume of PureSea that it is designed to clear your sinuses through a high velocity jet rather than high volume. The 4oz PureSea bottle is designed for multiple uses at qid dosing while each refill of a Neti pot (8oz) serves as a single use. Whichever modality you prefer is subjective, but I’ve found that a larger volume at a slow flow tends to be more effective in clearing nasal passages. In order for you to remove the mucus from your sinuses effectively, the mucus needs to be hydrated adequately. Read more…

medicine saline rinse, stuffy nose

Several days ago, I attended a medical meeting in which Sandeep Jauhar was a guest speaker. I had recently finished reading his book, and was excited to have the opportunity to meet an author. A real book author! As fate had allowed, I ended up getting an autographed copy of Intern, and got to be in a picture with him! I felt like the kid in Slumdog Millionaire who dived through the bottom of a latrine in order to get a celebrity’s autograph.

The irony is that if I were a medical resident at LIJ, I’d see him every day in rounds at the cardiac unit. He would have been no different from any other teaching attending, prodding residents rationalize their medical decisions. Would this guy still hold celebrity status in my book? How is this guy any different from Gerald Appel, Richard Axel, or Eric Kandel?

He isn’t. Each one of these people has his own celebrity factor.  All of them are book authors. Axel and Kandel are Nobel Prize winners, and Appel cares for high profile people. Jauhar writes guest columns for NYT and NEJM. The bottom line is that I have his autograph and photo. Coolness.

medicine life, medicine

As a rotating intern, I spent time on the general surgical service. Traditionally, off-service interns are granted minimal responsibilities on the surgical service; they are akin to glorified medical students with M.D’s. Most of the rotators intend to become radiologists, dermatologists, or ophthalmologists. The administration is aware of the circumstances, and usually schedules accordingly. When I reflect back to my stint, however, this was certainly not the case. Somehow I was promoted to a level I was probably underqualified for, at least part of the time. Perhaps it was because I had mentioned to the team that Mehmet Oz once lectured to us about incorporating flaxseed into our daily meals.  Or maybe there was simply a shortage of bodies on service. Mind you, while some ophthalmologists spend a year in surgical internship, the only experience I had to draw from was one rotation as a third year medical student. Most of my time as a student was spent changing wound dressings. Here are a few notable instances that I was subjected to:

10. Consulted on 12 surgical cases while covering a service of 58 patients while on call. (A new pager battery died in a matter of 10hrs)

9. Incised, drained, and packed thigh abscesses on the floor. (I read a blog on how to perform the procedure beforehand)

8. Closed up subcuticulars in several inguinal hernias and lumpectomies.

7. Ate 10 chocolate chip cookies and drank 3 20-oz Powerades for dinner.

6. Served as first-assist in a laparoscopic J-tube placement on a woman with peritoneal mets–the case started at 8pm and ran 3hrs. I read a website how-to guide on the general progression of the operation. My responsibilities were minimal–just holding the camera at awkward positions, keeping the field clear, and working the 2nd alligator and dolphins.

5. Diagnosed an acute appy in the ED (cool!), but had to assist in the case at 4am. (I watched a video from some website in India beforehand to figure out where to put the trocars)

4. Replaced a G-tube that had fallen out of a floor patient (with guidance from a nurse and the instruction manual).

3. Placed a G-tube via endoscopy (with supervision from attending)

2. Hand wrote 16 progress notes in one morning.

1. Performed 50% of a lumpectomy including sentinel node biopsy and tagging. (Attending thought I was a surgical resident and did not listen when I explained that I was a non-surgical intern; I did however prepare for the case extensively beforehand)

The experience, while harrowing at the time, was actually extremely gratifying afterwards. Now that it’s over, I suppose that I’ve added to my adventures of residency.

* Note: In no way should the aforementioned anecdotes be construed as a reflection of those parties involved. Ophthosurgery and its authors hold no responsibilities to any parties mentioned on this website. Ophthosurgery is not liable for the use or interpretation of any content found on this website. See disclaimer for more details.

medicine work

There are two brothers who are well-known in academic ophthalmology in the U.S. Those of you in the field will know who I am referring to, but I will not mention names. Both of them are incredibly intelligent clinician-scientists. One of them is actually a genius. No, not your everyday “super smart” guy, but a real genius. He apparently is the youngest medical school graduate in the World Record books, and has wunderkind abilities akin to that of Mozart. No joke.

In any case, I had the fortune of meeting both of them during the residency interview season. They are known to be difficult interviewers; some have mentioned that they pose challenging dexterity tasks to their interviewees. One applicant was asked to pour water into a narrow-spout without spillage. Another was asked to throw some knots using 12-0 sutures (without loupes). One of them interviewed me for a spot at his program.

Going into my interview, I wasn’t too nervous about these menial skills. I had poured gallons of anti-freeze into the tiny tanks of cars in my lifetime working the blue collar jobs. Those long hours of video gaming sessions certainly honed my dexterity. What else could he ask me to do? Well, my interview took an interesting turn.

He did not greet me as I entered his office. He did not ask me to sit down, nor did he even look at me directly during my entire interview. His desk had stacks of papers scattered about, along with remnants of silk sutures, styrofoam cups filled with blue water, and 0.3oz bottles. I remember that he asked me whether the U.S. should invade Iran, and that I muttered that I didn’t think there would be any economic or political benefit to the U.S. if that were to happen. He subseqently made several arguments that suggested that I knew little about politics at all (which is probably true).

He followed up by asking me if I really was well-versed in college basketball. Yes! On my application, I had listed that I loved watching college basketball. Indeed, as a Blue Devil fan, I went to my share of basketball games. At the time, I knew who the best free throw shooters in the league were, and which teams had a decent shot at winning. I watched a lot of basketball. Try me! I told to fire away. And then he dropped the bomb on me:

“So, in a single-elimination basketball tournament with 128 teams, how many games will be played?”

Math eh? I didn’t see that coming. It sounded like one of those M$ or Cisco interviews rather than a medical residency one. Well, I gave it some thought:

In a tournament, there can only be one winner. Everyone else is a loser. Every match will produce one loser. So in a group of N teams, there must be (N – 1) losers. There will likely be (N – 1) matches. At the time, I was nervous. I wasn’t confident that my logic was correct. So I quickly ran through some arithmetic in my head: With 2 teams, there will be 1 match, with 3 teams…2. (Team 1 and 2 play, and then the winner plays Team 3, for a total of 2 matches). That logic seemed to work out.

I told him “127″. He asked me why, and I explained my logic. His only response was, “Not good enough.” He then stood up and motioned me out of the office.

Wtf?

I was miffed. During the rest of the interview day, I was thinking about the problem. I scribbled more computations on the lunch napkins, and I was convinced that I was right.

Now that it has been more than a year or so since that encounter, I am still not sure what he meant by his response. Did he want a formal proof? Based on induction alone, I could have shown with brute force the number of games needed for a small number of teams and induced the result for N teams. Or did he want something with a binary tree? Doing so would probably involve some base 2 logarithms which would eventually simplify to (N – 1). To this day, I am still baffled by the genius. “Not good enough?”  I guess I simply wasn’t good enough.

If any of you have any thoughts, please contact me. I’d like to learn something. This sort of stuff keeps me up at night.

medicine ophthalmology