Thursday, July 26, 2007

HIV meets diabetes meets HIV

In the early 1990s, I never believed it would happen. But in mid-February 2007, I heard a cardiologist talking about the cardiovascular effects of HIV, who then put his talk in context by casually saying, “Even so, I’d choose to have HIV over having diabetes.” The doctors-in-training listening nodded in agreement. They probably didn’t remember that people used to talk about comparing HIV to diabetes like it was an impossible dream.

In 1992, Bob Rafsky, a person with AIDS and a member of the activist group ACT UP, wrote in the New York Times, “It's always possible we'll win. The drug, or drugs, that will turn AIDS into a chronic illness like diabetes will finally be discovered.” But, he wrote, “it's not likely, at least not in time for me.” Rafsky died the next year, in 1993.

Just three years later, starting in 1996, the kinds of drugs Rafsky had hoped for arrived in wealthy countries like the United States, used in combinations of medicines that together became more than the sum of their parts. Along with other improvements in HIV care, that allowed people to live with HIV for much longer periods of time than before.

Even back in 1996 and 1997, people were starting to say that living with HIV could finally be like living with diabetes, a difficult but manageable chronic disease. This didn't mean that it would be easy.

With modern medical strategies, the most common and serious effects of diabetes aren’t short term crises of sugar levels, but the effects of long-term damage to blood vessels: problems like stroke, heart attacks, kidney failure, blindness, nerve problems, and foot and leg infections that can sometimes require amputation.

Avoiding these problems over the long-term requires constant vigilance. In fact, as HIV medications become easier and simpler to take, sticking to them is often less complicated than sticking to diabetes regimens.

Especially early on, most Americans with HIV got the virus either from unprotected gay sex or sharing needles, which is part of how HIV got the stigma that it still has today. By contrast, Type I diabetes often comes in childhood, as a result of an autoimmune problem; no one blames people with Type I diabetes for their disease.

But stigma does influence how society responds to the much more common kind of diabetes, called Type II diabetes. Whether people get Type II diabetes has a lot to do with genetics. But higher amounts of body fat are associated with higher risk for Type II diabetes. That’s political poison for mobilizing a response to Type II diabetes, because Americans tend to misunderstand why people gain weight, think of fat as a kind of moral shame, and vastly underestimate the difficulty of losing weight and keeping it off. And so society can distance itself from Type II diabetes, by blaming the disease on the people who have it.

When AIDS was a more lethal disease in the US than it is now, it inspired intense fear and stigma and discrimination. In the late 1980s and early 1990s, people with AIDS and their allies, including activists like Bob Rafsky, began speaking against that fear and demanding the solidarity of others. They won the support of many; red ribbons became de rigeur for celebrities for a while. That kind of activism (both the angry kind and the syrupy Oscar ceremony kind) helped bring the day that HIV infection became more like diabetes.

Now, as Type II diabetes becomes more common, and also stigmatized for its increasingly well-publicized association with fat, the new challenge might be for Type II diabetes to become more like HIV—in which people with the disease and their allies stand up to demand that the society get over its prejudices, and start paying more attention.

Saturday, July 21, 2007

Night float: "MD aware"

Last night I was on night float--this time, a one-time thing, to give other night float interns a night off. Today, I'm spaced out and headache-y. Some of the other interns are getting together for dinner and drinks tonight, and I should go, but I feel as if I can't bear to talk to anyone or go anywhere. Instead, I'm sitting in my apartment while Ms. Dr. Hemodynamics is on call. I'm listening to KCRW on the internet, writing this after cooking myself some dinner.

I'm not sure when the concept of night float was invented, but it's become a lot more common with work-hour restrictions for residents. In overnight call systems, when residents literally lived at the hospital (hence the word "resident"), "call" meant not only admitting patients to the hospital but also cross-covering other residents' patients.

Now, the interns and residents on call stop admitting after a certain point in the evening, and a nighttime team takes over both admitting and cross-coverage. In our hospital, the night float interns respond to the problems of patients already in the hospital. The night float residents admit new patients who are coming in overnight.

That means that as an intern, I was answering pages from nurses for some large number of patients--I didn't want to know exactly how many. Something in the range of 50 or 60 or 70, I think, but I never counted; I just answered pages.

Some of these pages seemed simple; this patient wanted medicine for back pain, while that one wanted something to help him sleep. But for me last night, anything but the simplest and heavily chart-documented chronic back pain warranted a visit (was it new? where was it? was it a kidney infection or a spine infection? or just from sitting in a hospital bed for days?). Help with sleeping required at least a chart review (how was the patient's kidney function? liver function? what had they taken in the past? any psychiatric issues?) to try to figure out whether the easiest choices might make them crazy or dangerously sedated.

Then there were the pages that went something like "[Patient name] down to 90/56". A drop in blood pressure can be truly ominous: it can be a sign that someone has a new serious infection, or an acutely failing heart, or new internal bleeding. But the majority of overnight pressure drops last night were probably mostly caused by something simple: sleep.

One of my more alarming pages about low blood pressure last night was solved by turning on the lights and talking to the patient and listening to her heart and lungs with my stethoscope. When that was done, she was at an average blood pressure, and I was convinced by her quick wake-up and easy return to coherence and consciousness that she'd been doing fine all along. The unfortunate effect of this kind of evaluation: when the number on the screen means a nightmare for me, that's the end of sweet dreams for you. On the other hand, it's better than getting a bag of unnecessary IV fluids.

Some reasonable proportion of us, if we had telemetry monitors hooked up to us at home every night, would be setting off alarms all the time. But even when nurses are reasonably sure that this kind of normal situation is why the pressure is low, they need to page the doctor anyway. In the nursing note, they have to make note of abnormal vital signs, and they write something like "BP down to 89/56 during night while pt sleeping. MD aware."

As with my first night on the MICU, I was once again grateful for my hospital's well-educated and experienced nurses. In one case, a renal fellow talked to me about the patient in some detail in the late evening, and then checked back in with me in the morning about how the plan had gone. I explained that we'd stopped the fluids, and why; the fellow was pleased because this is what she'd called to recommend.

"Actually," I said, "the nurse called when the labs came back, and said we should stop the fluids, and I said that sounded like an excellent idea." The fellow laughed, and praised me for listening to the nurse.

I said, "I try to do what the nurses tell me, probably... mmm... 85% of the time." She laughed again: "Sounds about right," she said.

The rest of the 15% is complicated, and it's rarely due to some error on the nurse's part. More often, it has to do with differing priorities. For instance, since the nurse is hearing the patient complain all night, and is sick of answering the call button again and again, the nurse might be more ready to want the patient to get a sedative medication for sleep. Often, this is informed by knowing that a particular medication is given all the time, and knowing that a particular patient is medically stable, and knowing that it's really hard to get good sleep in a hospital.

On the other hand, for people with complex medical problems, a lot of these medications can be frightening for the doctor to prescribe, and if I can avoid prescribing them, I will. The most satisfying visit last night was with one of these patients, who had many medical issues. The patient and the nurse wanted a sedative to help him sleep. The idea was worrying to me, since all I knew about the patient was a list of medical problems, and the drugs I knew best each had some possible bad interaction with at least one of those problems. I was doing some other things, and took a while to come up to evaluate the patient, probably to the annoyance of the nurse and the patient. But by the time I got there, the patient was asleep without my help. (The ideal solution for this situation is for the doctor who is taking care of the patient by day to anticipate this problem and suggest a possible sleep medication for the night float intern to prescribe if necessary--but it's July, and that kind of hand-off is a ways off.)

The most frustrating thing about night float was one of the things that makes night float systems worrying to most people who think about their risks and benefits: hand-offs. I got some less-than-totally-informative descriptions of what was going on with some of the patients I got called about overnight. And on my end, hopefully just because it was my first night, the system I was using to keep track of overnight events turned out to be much-less-than-excellent, and I fear that I may not have handed off all the information I should have.

But looking at the hospital computer system from home, it looks like everyone is OK for now. The people I worried about didn't get the kind of labs drawn that would suggest problems (like arterial blood gasses, which are drawn for people in respiratory distress). A tentative sigh of relief: night float is over, and the day has come.

Sunday, July 15, 2007


A little while ago, another blogger tagged me with a meme that I was then supposed to pass on. I didn't have it in me to send on the meme but then I realized that I therefore also hadn't linked to any other bloggers--and therefore had done nothing to support the nebulous but important community of bloggers.

To redeem myself, here are some links, not quite all blogs, and in no particular order, except the first:

1. Amanda of Ballastexistenz takes on the 8 random things in a literal way, much more lovely than my version--8 random things, photographed and explained.

2. In a parallel to my previous post, fellow internal medicine primary care intern/ MICU warrior/ blogger Dr Jess seems to be liking being a doctor too.

3. Just in case Dr Jess and I are warming your heart too much about doctors, though, the ever-scrappy Barbard Ehrenreich recently posted about the consequences of a healthcare system based on the drive for profit--including the tale of a truly terrible doctor.

4. At Acid Reflux, the always witty-and-pretty Miss Retro Virus is on her world tour. The sponsorships on her tour poster are a nice touch, but if that means that Miss Thing is really injecting T-20 (aka Fuzeon) 2x/day in Kigali, I truly salute her. Brian has lots to report in recent dispatches, including moving accounts of a meeting with people living with HIV in Rwanda.

5. If you're hoping that Miss Retro Virus will have a more fabu entry inhibitor soon, or you just want to get your own hands on one, keep tabs via the Treament Action Group's handy guide to antiretrovirals in the testing pipeline.

6. Chris at Methed Up continues to wrestle with how to make sense of his life as an addict, and is now looking back on the days before crystal meth came along. Crystal meth has been beating the fabulousness out of a lot of gay men (and, of course, others); and as a worried spectator when it was just a local West Coast curiosity, it's made me really sad to watch it spread coast to coast. But reading this entry reminds us that waves of new drugs don't hit randomly; they're most likely to hurt the people who had already been struggling--or would have been struggling--with the old ones. Like vodka, for example.

7. In theory, this link to Tundra Medicine Dreams should have something to do with health. In reality, it's for the really great sled dog puppy pictures and story of the retiring sled dog mom, by the rural Alaska physician's assistant who writes this blog.

8. And my longtime buddy from back on the West Coast, Big Sister, who writes about knitting but also has various other things to say (including some great recent travel pics that will make you want to go to Belize and the Alameda County Fair, in that order). In this post she showcases some items from I then went to Etsy and found a slightly overwhelming amount of cool handmade arts and crafts to choose from.

Becoming a doctor requires imagining the obvious.

When I was in medical school, I worked hard; I was thoughtful about my patients; I got along well with most of the people I worked with. But my grades weren't as good as some of my colleagues' grades were. They were fine, but more often than I liked, I seemed to just miss the highest grade in my overall evaluations. Sometimes that was for blatantly unfair reasons, other times for reasons I understood perfectly. But most of the time, it was harder to tell why I'd just missed. I spent a lot of time thinking about how to improve, and asking people how I should be improving.

In the last part of medical school I was starting to get it. An ICU rotation gave me the biggest transition: I went from doing some of my worst clinical work (in that I was disorganized and confused in presentations and in my thinking about patients) to some of my best. A couple of other rotations towards the end of medical school also went well. Still, I wasn't sure exactly what had changed, and which of the things I'd done to try to improve had actually worked.

Now that I'm an intern, I still have a lot to learn. And I'm sure I'll still have many stumbles and falls ahead. But I feel more confident in a way that surprises me, but also explains a lot of my medical school experience. I recently realized that it took me until some point between getting my diploma and my 20th hour of internship to actually believe that I was going to be a doctor. In other words, until I became a doctor, there was some part of me that didn't understand that I was actually going to be one.

In fact, even during my first day on call the meaning of the job still hadn't 100% sunk in. I was just trying to keep up, to not do anything wrong, to keep my feet on the floor and my pulse within normal limits. Before I started, everyone told me to listen to the nurses, and especially with a bunch of ICU veterans like the nurses working with me, that seemed like great advice. Nurses were coming up to me and saying, "Mr T's pressure is dropping; I think we should give him a bolus of fluids." Great, I'd say. "Half a liter sound good to you?" I'd say, entering the order into the computer. "Mrs S's potassium is down," another would tell me; "Thanks, I'll order that now," I'd say, looking at the sliding scale to replete the potassium.

For most of that first day on call, this worked excellently. Our hospital's critical care nurses are excellent, my resident and attending were watching closely, and our patients did well.

At some point early in the morning, a nurse suggested another bolus of fluids on a patient. The patient had already had a fair amount of fluid through the day. I started worrying about what another half a liter was going to do to his lungs. "Actually, I'm hesitant to do that," I said to the nurse, explaining my reasoning. Together the nurse and I talked through an alternative plan, and I checked in with my resident. It was a tiny step, a tiny transformation, but I recognized it: actually, I was a doctor. The MD on my badge was more than some iconic token of my education.

Later, as I realized that I understood some of the physiology and basic science of another one of my patient's problems, and that my patient's nurse did not understand it in the way I understood it, I realized that those years of medical school did teach me something. It's not that her education and experience and observations didn't add up to anything. But it added up to something different. Patients are safer and better-served when nurses tell doctors when their medical interventions will cause unforeseen harm, and when they are partners in the conversation about what might be done next. But that doesn't mean that doctors, even new ones, can get away with just relying on the nurse to keep the patient well.

All of this is pretty obvious to an outsider, and probably to most medical students too. But now I realize that I hadn't ever 100% believed that I would become a doctor. That belief, I see now, is a big part of the intangible confidence that some of my colleagues with better grades had. It's part of how they looked like future doctors instead of current medical students. And when I at least mostly believed that I was responsible for being a doctor--as in my ICU rotation, and a couple of others--I did well.

Now I'm a doctor. And I actually believe it. As soon as I started believing it, I became a better doctor, in an instant.

Now, looking back and recalling that a medical student will, 98-99% of the time, graduate and become a doctor, I've been thinking about what part of me wasn't registering the obvious likelihood that I would also soon become a doctor. Some of the answer comes from who I was before medical school. The people who love me the most have always had great faith in me, and believed that I was capable of many things, but I don't think that when I was in my teens and up to my mid-twenties that anyone who knew me well would have predicted what I'm doing now. I thought of myself as an artistic person, and a political person, but not as a scientific person, nor as a person who would ever become such a normal thing. Willie Nelson instructed, "Mamas don't let your babies grow up to be cowboys"--instead, he sings, "make 'em be doctors and lawyers and such." I never thought I'd be a cowboy, but I didn't think I'd be one of those and-suches either.

Many of my classmates come from medical families. They believed they'd become doctors because the job and the social identity seemed natural to them. They might have resisted it when they were younger, in order to walk their own paths and not their parents', but when they returned to the path of medical training, the terrain was familiar. The medical students who didn't come from medical families often spent their lives, since they were children, working towards the goal of becoming a doctor. I think that many of these classmates, in both categories, always believed in their future as doctors, as soon as they walked into the hospital. They started to become doctors well before they were qualified to earn a medical license. That's actually sensible. You're 66% a doctor at some point in the third year of medical school; at that point you are really more a doctor than not.

When I look back and see the ways I was improving in the last part of medical school, I see that I was becoming a doctor, that the 85% doctor I already had become was directing my actions, even if my consciousness was still too aware of the 15% doctor that I was not.

It seems easier to imagine becoming an excellent and experienced doctor (which, nearly by definition, I am not) than it was to imagine becoming a doctor at all. The next part of my training will require more work, more cognitive strain, and a steeper learning curve than medical school ever asked of me. But in terms of how I see myself, and how I've had to change how I see myself, the hardest part might have just ended.

Thursday, July 12, 2007

My first patients...

I saw my first two primary care patients today, in the clinic that will be my regular clinic through the year.

I had two patients scheduled; the night before I read their records, nervous and excited, making notes about what past issues needed follow-up. In reality, one cancelled and one didn't arrive. Instead I saw two completely different patients.

I've had lots of outpatient experience, and I figured I'd be able to breeze through easily. I didn't. That was fine, actually--but it reminded me of how outpatient medicine looks easy at first, and then really isn't at all.

Saturday, July 7, 2007

8 random things

Photo: Cape Fur Seals, lovely pinnipeds, in Cape Town. Videos: opening sequences for the old TV show Emergency!
Chris from Methed Up tagged me with the meme of 8 random things, with the following rules:
"1. Each player must post these rules first.
2. Each player starts with eight random facts/habits about themselves.
3. People who are tagged need to write their own blog about their eight things and post these rules.
4. At the end of your blog, you need to choose eight people to get tagged and list their names.
5. Don’t forget to leave them a comment telling them they’re tagged, and to read your blog."

I'm leaving out 4 and 5... but here's #2.

1. My first language was Portuguese (but I stopped speaking it shortly thereafter, when my family moved back to the United States).

2. My college mascot was the Banana Slug.

3. Two of my favorite college classes: "Architecture of the Suburbs" and "Anthropology of Dance."

4. I am one of the two oldest people in my intern class, just as I was one of the two oldest people in my medical school class.

5. 44% of the kids who were in 9th grade with me dropped out by the time I graduated from high school. But none of my friends were among them.

6. My first career ambition (at age 4): to be a paramedic.

7. I'm a huge fan of pinnipeds.

8. I have started to think that I have become much more introverted than I once was, or perhaps I'm just realizing I was never as extroverted as I thought I was; either way, this is some part of the explanation for why I am not tagging eight other bloggers with this meme.

Sunday, July 1, 2007

How to declare people dead.

First step:

Examine the person who may be dead.

Their pupils should be fixed and dilated--that is, showing no responsiveness to light and remaining fully open. They should not have a blink reflex when something brushes against the cornea of the eye. They should have no heart sounds for one minute of listening. They should have no breath sounds, and no other evidence of breathing. They should be unresponsive to deep painful stimuli (e.g., pushing down sharply and rubbing the sternum--the middle of the chest). Especially if they have been brought from somewhere else rather than dying in the hospital, they are "not dead until they are warm and dead", because hypothermia can mimic death by slowing down and dampening down all bodily functions.


Write a note in the chart. Like all other notes in the chart, sign it with your name followed by "MD".

Declare the person to be dead by filling out a form for the hospital admitting office. Call the office and let them know the patient is dead. If need be, they can tell you your medical license number which you are supposed to put on the form; you've only recently become a doctor, and you can be forgiven for forgetting it.

If the death meets any of the criteria listed on the admitting office's form, call the medical examiner's office, who has the right to require an autopsy. You were told in intern orientation to make sure to get the name of which doctor at the medical examiner's office refused the autopsy, or at least which staff person you talked to. You might forget this part. Thankfully you can call back and the ME's office can remind you.

You're required to ask the family if they want the autopsy. The pathology residents require a certain number to graduate from their program, and they've asked you to please try to get autopsies. In theory, autopsies improve healthcare by showing what we might have done wrong, and showing whether our ideas about a person's medical problems were correct. Still, your own inner compass demands that you be gentle about this, and fortunately the vulture-like quality that might surround the request has been taken out of your hands, so that if the autopsy is obviously a dumb idea, you might simply say, "We are required to tell the next-of-kin for everyone who dies that you have a right to an autopsy, at no cost to you."

If the family wants the autopsy there is a consent form. Walk them through it. Once they've consented, sign your name, with "MD" after it.

Based on your earlier phone call, the hospital admitting office fills out the death certificate and pages you when it's time to come down to sign it. Bring the rest of the paperwork also. If you get caught up in something and lose track of time, they'll page you again.

Fortunately, they're there all night. At 4:30 am, as the morning lab results are just starting to trickle in on your MICU patients; as the x-ray tech wheeling around the portable x-ray machine is calling out "X-ray!" as he presses the button to take the morning chest x-ray from outside your patient's room; as he goes and pulls the x-ray plate out from under your sedated and ventilated patient's back, and moves to the next room to repeat the process; and before the sun begins to illuminate the glassed-in walkway between one part of the hospital and another, you can take the elevator down to the little no-windows office with cubicles and dull flourescent lights.

The admitting office workers are sitting in one of the back cubicles with stacks of paper around them. At that time of night one of the admitting office staff members might be doing a crossword puzzle when you arrive. But they know right where the death certificate is; your arrival is a key item on their to-do list, because it has to be done before they can release the body to the funeral home. Don't fill out any of the information on the form--they do that, and anyway, you'll just mess it up. If you start filling out the address and time and date information, they'll have to start a new death certificate. So just sign it with your name, followed by "MD".

Then, when you have a moment:

Recognize that the structure of modern society is to make life and death themselves medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities. The "MD" proves the certificate's legitimacy as a reflection of an actual biological fact.

The birth certificate is not simply an extra voter created by a political machine, but an actual person with a beating heart. The death certificate is not a way for someone to escape their creditors or start anew in another city or make an insurance claim; it reflects one body's stopped heart. The doctor declares a biological process to have definitely begun, or to have irrevocably finished; the declaration of biology is necessary for the legal and political legitimacy of the state. A modern state must be able to keep track of who is born and who dies. This is an important distinction between wealthy nations and impoverished failing ones.

A person who was born without a birth certificate is a person without a legal identity. And a person who is dead but does not have a death certificate is a body in limbo, kept in a hospital morgue until the form is signed with "MD". Without this the body can not be buried; our funeral rituals of helping the person to pass from this life into whatever follows can not take place until a doctor signs the form that verifies that the person has indeed left this life.

Taking the elevator, back up to the ICU, you might think how strange it is to hold a doctor's power. The fact that declaring death requires your presence, your examination of the body, your ritualized declaration, your signature on the forms, are all part of how we wrap death in our own forms of modern technical expert solemnity. You understand why it's a good idea to be sure that someone is dead before you declare them dead, and why a doctor is called on to make sure. Still, to find yourself called to verify the death of a human body that everyone knows is dead is a strange task. You understood that the power of prescription, and the knowledge you hold, and the social role you play, all give you power in the hospital and in the world. But you might now realize for the first time that you are also an official of biological fact, called on by your state to be the neutral observer, to translate the natural world into civil forms and statistics.

As I was taking pre-med classes, one of my dearest friends was going to get married to his then-girlfriend, who had also become a dear friend. They asked me to officiate at their wedding. Of course I was deeply honored, and went immediately to the internet to get myself ordained as a minister--because for the state, sealing the bonds of love requires other distinct forms of authority.

But I also asked them, "Why did you think of me?" Among the things they said was, "Well, you're, like, a doctor." And I said, "No I'm not!" (I still hadn't got through organic chemistry. The outcome was still deeply uncertain.) And they said, "Well, almost." And I said, "Anyway, what does that have to do with anything?"

They tried to explain, and I think what they meant was that by virtue of simply aiming to become a doctor, I had acquired a kind of gravity, a seriousness that was different than their other friends. Or perhaps even more likely, by announcing my intent of becoming a doctor, I had begun to publicly acknowledge the part of myself that wanted to play that kind of role within my community and my society.

That was a long time ago. The daughter they had well after their wedding now has opinions about tacos, burritos, and their relative merits. After all that time, I finally have actually become a doctor, and I have taken on that ceremonial gravity in other ways.

"...I examined him and found his pupils to be fixed and dilated; he had no corneal reflex; he had no heart sounds for one minute; he had no breath sounds, no air movement apparent at his mouth, and no chest excursions; he did not respond to sternal rub or firm pinching. Time of death: 4:45 pm.

Joe Wright, MD. Pager #81987."