Constipated Teaching

Since I am practicing in a teaching hospital, besides treating patients, part of my duty is educating and training residents (doctors-in-training) and medical students. In fact the state university even gave me an academic title. My official title is: Adjunct Clinical Associate Professor. Adjunct, means extra or accessory. In other words, not that major. Maybe “A Junk” Professor is more appropriate. In my native language, saling-pusa.

Anyway, most of the time when I am seeing patients in the hospital, I am accompanied by medical residents or medical students. In the ICU though, my entourage could be quite large, composing of 2 to 3 residents, a medical student, a pharmacist, 1 to 2 pharmacy students, a respiratory therapist, and respiratory therapy students. Then when we round on a specific ICU patient, the nurse taking care of that patient will join our discussion too.

Having a group shadow me on my rounds has its perks, as many of the scut work the team could already accomplish in my behalf. Plus the bigger the entourage, the bigger the likelihood that people think you are important (not mere “a junk”), just don’t let that get into your head. But it has its disadvantages too. For one, I have to ask permission to break rounds, every time I needed to go to the restroom.

In our rounds, besides talking about the patients’ cases and our plan of treatment for each one of them, we also discuss about snippets of medical teachings, current trends of practice, new drugs and even latest research that support our plan of management. Thus I really needed to be updated on the most recent guidelines and studies.

Few weeks ago, as I was conducting my ICU rounds, we have been dealing with some very difficult cases as well as some unfortunate patients in our ICU whose chances of surviving were slim. As we went through consecutive depressing cases, I could sense the sadness and stress rubbing in into my team. I could feel the morale of the team was low, for taking care of these sad cases of patients.

As the captain of the team, besides making sure that the right management is given to each of our patient and assuring proper education and adequate training for my residents and students, I feel that it is my duty as well to keep a high spirit in my team.

One particular patient that we have was having a bad case of constipation that was made worse by his requirement for pain medications, on top of all his other life threatening conditions. We then discussed causes of constipation and its management in general. One complication of using opioid pain medication is constipation, as it can slow down the intestinal movement. So we decided to give our patient the relatively new injectable medicine for constipation that blocks the opioid receptors in the gastrointestinal tract without decreasing the pain relieving ability of the opioids.

Then I asked the team, “Have you heard of the long-awaited big study on constipation?”

They all looked at me shaking their heads as they have not heard of it, and anticipating more words of wisdom from me.

To this I said: “It has not come out yet.”

Realizing that I made a joke, and not to be outdone, our knowledgeable pharmacist chimed in, “But I heard of the recent study that said that diarrhea is hereditary.”

The team was smiling now, and seems to be in a better mood , waiting for the punchline.

The witty pharmacist concluded, “Because it runs in jeans (genes).” Eeeww!

With that we moved on into our next ICU patient.

*******

Pahabol na hugot: Constipation ka ba? Kasi I cannot get moving since you dumped me.

 

Intern Blues

The other day, I let our medical intern in the ICU place a dialysis catheter on one of our very sick patients. It is a minor surgical procedure of placing a thick catheter in the patient’s jugular vein using ultrasound for guidance. Of course she had lots of supervision, as one of our senior resident was assisting her, and I was around as well for support.

The intern was not able to place the catheter that quick being inexperienced, so it took a little longer doing the procedure. Though that is nothing out of the ordinary. This is normal for a teaching hospital, as interns and doctors-in-training has to start somewhere.

While we were doing the procedure, the patient became unstable, and then went into cardiac arrest. We called a Code Blue (a call for help on a patient having cardiac arrest). Moments later the whole room was teeming with hospital personnel responding to the code.

The patient survived and was stabilized after several minutes of furious cardiopulmonary resuscitation.

The intern was visibly shaken to what just happened. I saw her later in the workroom crying. One of the senior resident told me that the intern felt that it was her fault that led to the cardiac arrest.

However after extensive work-up, we found that patient has a weak heart to start with, and in fact was in congestive heart failure and kidney failure, and that was why he was in the ICU. Then he suffered a heart attack, that caused the cardiac arrest. It was just coincidental that it happened while we were placing the catheter. It was not a direct complication of the procedure.

I reassured the intern that it was not her fault, and gave her some words of encouragement, that this is all part of our work. Besides, this intern is good, intelligent, comes prepared on rounds, and has initiative to learn. I see a great potential in this young doctor. Her only fault is that she is new and inexperienced. But we all have been there.

I have been an attending physician in a teaching institution for a long time now. In fact five of my partners in our practice, who are now full pledged Pulmonary and Critical Care doctors are once my medical interns in the hospital. So at some point in time, I showed them the ropes. And now they are probably better than me, and once in a while I asked for their opinion in difficult cases.

I remember when I started my medical internship in a Columbia University-affiliated-hospital, I was not a “good” intern. At that time, I was a new arrival to the US from the Philippines, was new to the American system of medicine, and definitely not the sharpest among our batch. Compared to our star intern, a graduate of Johns Hopkins University, I was like a kindergarten. I was really lost and I struggled in the beginning. But I am thankful for my seniors and attending physicians who saw the rough potential in me. Though I would be lying if I tell you I was not lectured on at times, or even chewed and spewed.

At the graduation ceremony of my Internal Medicine Training, they gave me the “Tabula Rasa” award. It took me a while to figure out what it meant. But I guess I was really like a “blank slate” when I started, which what the Latin “Tabula Rasa” means. I must also had that blank stare like a deer in the headlights, that goes with my blank mind.

But as I said, we all have to start somewhere.

teaching-rounds

hospital teaching rounds, circa 1940’s

In some academic centers they have a very defined hierarchy. Even one year of seniority feel like a world of difference. The attending physicians act like demigods as they would climb up their high horses when they do their rounds. The attendings treat the medical residents as dirt. In turn, the senior residents treat the junior residents as dirt. The junior residents treat the interns as dirt. The interns treat the medical students as dirt.

It may be hard to admit, but I witnessed this hierarchical state of thinking when I was in my medical school in the Philippines. And being the medical student, I was at the bottom of the totem pole.

But I don’t buy into this old-school hierarchical philosophy and system that treats our inferiors like dirt. I adopted a philosophy of providing a more collegial environment which I believe is more conducive to learning even for the least of us. A resident, or an intern or even a medical student can approach me freely without fearing of being chewed on.

Back to my intern, I hope she’ll learn something from that difficult day. I know someday she will become a good, experienced and a well-rounded doctor too. And if someday she becomes the chief of the medical staff in this hospital, as she has a great potential, or becomes the head of a big-shot medical corporation, or even becomes the US Surgeon General, I hope she remembers me and the words of encouragement I gave her during one difficult day.

(*photo taken from reddit.com)