It's All In Your Head

Somehow my neuro rotation is already over. In theory neurology is really cool...but in practice it's one of the last things I would want to do. I love neuroscience. I love the brain. While I'm not wild about dissecting mouse neurons (and killing mama rats), figuring out how the mind works is the next frontier. So cool. I would love to stick people in fMRI machines all day and see what happens (aside from them getting really claustrophobic) just like in Why We Love.

So what don't I love about neuro? For the interesting diseases such as ALS, Muscular Dystrophy, Alzheimer's and Parkinson's there's only so much (or nothing at all) we can do to treat patients right now. While the doctors can provide support and guidance, really they're just there to watch you slowly die. You can give people who have strokes TPA if they get to the hospital in time, but if they don't you just verify that they had a stroke and send them off to rehab. And don't get me started with all of the chronic pain/headache patients. I have total respect for doctors who manage that sort of amorphous complaint, because the pain certainly can be real, but not necessarily physiologic. Sure there are some great seizure medications out there, but then you have to differentiate the real from the "ma'am, that was not a seizure, that was a dance move". Oh how I love pseudoseizures, excuse me, "non-epileptic seizures". Every day of the past two weeks I kind of felt like I would have one myself if I didn't get out soon.

In other words, I hope to continue learning as much as I can about the brain for my own enlightenment. What's not to love about Oliver Sacks and "The Man Who Mistook His Wife for a Hat"? Plus Eric Kandel's amazing autobiography "In Search of Memory", apparently now also a documentary, was one of the most inspiring books about research I've ever read. And then we have the story of our very own Jill Bolte Taylor...check out her priceless "Brain Bank Song" she sang on Oprah's Soul Series (Part 4 Minute 25:15). I could sure use some inner peace right now, but I'd like to pass on the hemorrhage.

Salvage

Generally speaking it's never a good sign if the word salvage is associated with your medical treatment. Whether salvaging a limb, salvaging heart muscle, or using salvage chemotherapy, things can only be kind of desperate and the outlook can only go from bad to worse. In hematology, salvage chemo is usually not well established, there aren't many controlled trials and even fewer good outcomes. Not saying it never works...just that working is usually defined in terms of extra months or weeks of life, rarely anything close to a cure. And sometimes just stopping and making the most of what's left is the best move. Our patient with fungal sepsis decided to marry her boyfriend and spend the last weeks of her life at home. I find it hard to fathom that turning point, where you're ready to give up on life, but at the same time rationally I think it's a completely reasonable decision when all remotely useful treatments have been exhausted. Grey's Anatomy actually had a really moving scene in the most recent episode, Suicide is Painless. A patient with terminal lung cancer describes how hope can be extremely damaging when you are ready to die. She's living in pain and there's no chance of a good treatment or cure...she wants physician assisted suicide and is happy with that choice. However, the thought of what if (what if there was a new cure, what if something had been missed and she's not really terminal) keeps her from being completely at peace with her decision, even when there really, truly is no hope. Insightful. There was also some annoying talk about Whoville...which as much as I love the Grinch Who Stole Christmas seems like a desperate attempt to start a catch phrase. I mean, SERIOUSLY. I miss the glory days of Grey's.

Speaking of salvaging. I spent the past week trying to salvage what remained of my medicine rotation. I definitely suffered for serious burnout right around the time I would normally be having spring break instead of working 13 days in a row. Now it's on to neurology which has it's own depressing set of problems and even less effective treatments. But at least it's spring!

Healing Hands

Hematology has been a different world from life at the VA. The new cancer center is amazingly nice...big, well decorated rooms, floor to ceiling windows, fake hard wood floors, a meditation room, a courtyard with a giant sculpture, bamboo, a staff sanctuary...it really does create a good atmosphere. Never underestimate the importance of beautiful pictures when you feel like hell. The rotation itself has been a little awkward, even the resident doesn't really operate with anything like autonomy, which I guess is how it has to be in a super subspecialized acute care setting. In one week I've seen lots of AML and multiple myeloma...along with ALL, CLL, ITP and some lymphoma. It's been interesting to see how adult oncology differs from pediatric oncology...different diseases (I'm actually glad I'm doing hematology not oncology since most pediatric cancers are leukemias), slightly different chemo regimens, and those poor adults have to be awake during bone marrow biopsies (I don't think I truly appreciated how painful they are). The tranquil setting definitely helps.

Today was an interesting day. I was grilled by my attending, Dr. F, over pulmonary and cardiovascular physical exam findings. Scary but actually super helpful...when I can get over feeling like an idiot, I definitely learn the most when doctors ask questions and really teach. I could use more of it. Then I got to observe Dr. F in his bone marrow transplant clinic and see him grilled by a similarly type-A patient who wanted to know his prognosis...not just statistics but a specific number of years...an impossible question. Dr. F's response "Only God really knows, and he hasn't told me". I could do without the God part, but I think it captures the degree to which outcomes can be very patient specific and hard to pin down despite all the risk stratification. Control what you can control because so much is out of your hands. One of our patients, a woman in her 20s with refractory AML, has been growing fungus in her blood and now it's spread to her skin despite anti-fungal therapy. She has no white count and she can't fight the infection until she has a white count which probably won't happen for several weeks, if she even lasts that long. No one has told her yet.

Speaking of God, today the director of palliative care and a hospital chaplain performed a blessing of the hands ceremony for all the doctors and nurses caring for cancer patients. It was very symbolic and beautiful...they personally washed each of our hands and anointed them with oil (?!?). I love the idea of the ceremony, "blessed be these hands that have touched life, and felt pain, and embraced with compassion" but it was also way too non-secular/O Holy God, for me. I'll happily swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, but I'm not about to join STO.

Good Medicine

Every morning this past month on the way to the VA I walked past the remains of an old hospital being torn down. Quite impressive actually, watching a building get ripped apart (though who knows how many toxins I inhaled), but also kind of depressing. And that's how I felt with my month at the VA...one chronic health problem after another slowly destroying these patients until something like cancer or an MI comes along and really knocks them down. There's not really a good endpoint...sure you can try to fix the acute situation, but death is always there somewhere. Plus I felt like every single patient had diabetes, hypertension, chronic kidney disease, hyperlipidemia and BPH. Good grief! They could be my dad!

Don't get me wrong, I actually really enjoyed the month...I liked talking to the veterans, I liked having a little more autonomy (or at least the illusion that I could make some of my own treatment decisions), and the hours were quite nice. I'd gladly do my sub-internship there next year (hopefully this calendar year) since I know how to work the system now. But so many patients just waiting for placement in nursing homes? So many patients coming in for altered mental status due to alcohol or drugs? So many patients in for COPD exacerbations with 150 pack year histories of smoking? Give me peds any day. Though I have to say I'm now a little torn on whether I'd want to do a Med-Peds residency instead of just a straight up peds residency. When I think of the quintessential doctor, it really is an internist. There is a huge array of medical problems you'd just never see in a peds setting (though apparently diabetes, obesity etc. are becoming bigger peds issues...yay), and I feel like for my own knowledge I want to know how to properly manage those diseases. Especially if I end up doing anything global health related...I've got to be ready for anything.

Today was my first day on the Hematology service at University...back into the world of chemotherapy, ANCs, and lots of things that are totally over my head. So much to do this month...hopefully I'll keep it all together.

Pediatric Cancer Genome Project

How cool is this? St. Jude Children's Hospital and the University of Washington School of Medicine in St. Louis have teamed up for the Pediatric Cancer Genome Project, an attempt to map out the genomes of 600 pediatric cancer patients. The more I learn about chemotherapy protocols and all the toxicities that come with them, the more I can't wait for a future where specific tumor mutations or cancer genes can be targeted to treat the disease without causing infertility, cardiomyopathy, immunosupression, extreme nausea, hair loss, etc. Yay!

It'd be great if the cute little 16 month old boy I did a bone marrow aspiration on last week had a better than 25% chance of survival with his Stage 4 Hepatoblastoma. It'd be great if our 19 year old girl just recovering from sepsis and trying to survive her third relapse of ALL could go have fun in college with her boyfriend. It'd be great if our 6 year old boy with Hodgkin's Lymphoma didn't need radiation and could still have kids when he grows up. The future can't get here soon enough!

Haiti

As things continue to fall apart in Haiti post-earthquake, the stark inequalities in health care (and building practices) are painfully obvious. I think I'm particularly sensitive to this right now since I'm in the world of Peds Hem/Onc and the NICU where it is not at all abnormal to spend upwards of a million dollars trying to save one child. I'm not implying that shouldn't be done, how on earth can you deny available treatment to a kid when it might save their life? But just think what that money could do in Haiti...save 10,000 kids or 100,000 kids by giving them vaccines, anti-virals, food. In third world environments, actual health care is only part of the problem...sure you can give people antibiotics, but if they don't have clean water to take them with, you're doomed. The resident on hem/onc is from Pakistan and he was telling us about the one Peds Hem/Onc clinic at their main teaching hospital. They have most of the necessary drugs and can follow the recommended treating protocols, but when the kids are immunosuppressed at all they must keep them in the hospital or the infection rate is just astronomical due to general unsanitary conditions. Health care inequalities are really just one manifestation of overall inequality.

Today was rough...one of the patients I saw on my first day who had a lytic lesion in her leg which we hoped was just a brodie's abscess got her pathology back today and it turns out the lesion is a high grade osteoblastic osteosarcoma. Not good. Then we were consulted on a 5 month old in the NICU with end stage liver failure. She has major coagulopathies since her liver is pretty much nonfunctional and because she's not a candidate for a liver transplant there's really nothing that can be done. Maybe someday soon we'll be able to create new livers in a lab, no problem, but that might just widen the health care gap. At least in the U.S. most kids won't be denied treatment from inability to pay...but sadly for this little girl science just isn't there yet. Then we have our patient who might be a vampire...

I wish I had the training to go and help in Haiti. At least Partners in Health is still relatively intact since it was based in rural areas. I've been rereading Paul Farmer's "Aids and Accusation"...health disasters in Haiti are hardly new, how much can one country take?

What Now?

How do you decide what you want to do for the rest of your life? I know you can change your mind about residency programs (even after you start them, if you must) and certainly any fellowship decisions are still a few years away, but I'm really starting to feel the pressure to make up my mind. This month I'm on my pediatric hematology/oncology ambulatory elective, and it definitely is something I can see myself doing in the future. Not that the elective is everything I hoped it would be...there are three students instead of just one (though they're both friends so it's fun) and there's not all that much for us to do most days. A lot of patients are in the process of being treated so it's hard for students to just jump in and, of course, the chemo protocols are ridiculously complex.

Nevertheless, while I may feel out of place as a student, when I think about what the doctors do all day, their ongoing interactions with patients, their procedures, their research, etc., it certainly seems like something I'd like to be doing long term once I actually know what I'm doing. Fortunately I can still keep my options open...but every day I'm a little more confident in the decision to do a pediatrics residency.

I've certainly seen a range of patients in the last week...from the four month old with the atypical teratoid rhabdoid tumor with an abysmal prognosis (brain tumor + brain surgery + no proven chemo or radiation treatment + young age = bad news) to the 19 year old 3 years out from completion of treatment for Hodgkin's Lymphoma who's doing great. The doctors and nurses are a great support system for patients and families facing a scary treatment and rocky road for the next few years...they offer hope and reassurance. I want to do that. Now if only I could figure out my next few years...