White Coat Notes | Elbrecht's Corpuscle

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Since their inception, movies and television have glamorized the life of a physician, often intertwining personal stories of said physicians with the heroic acts they perform and the inherent braininess required therein.

This is only a mild reality.

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Sure, physicians are by-and-large smarter than the average bear, but it is our tireless work ethic, attention to detail, and self-loathing which provides us the ability to make such a significant impact in the lives of our patients.

There is little glitz, even less glamour, and only the occasional heroic act in the life of a physician. But the combination of these traits keeps many of us going back to work every day.

No. I mean EVERY day. As in… working EVERY. SINGLE. DAY.

In case you can’t tell I’m currently smack dab in the middle of my second year of Residency (aka PGY-2)… a time I have affectionately termed, “The Rise of Magneto.”

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Man-of-Steel-Trailer-Images-Henry-Cavill-as-Clark-Kent

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Though some more recent medical dramas have included the lives of Residents, this middle ground in the hierarchy of medicine is poorly understood and recognized.

After completing medical school, newly-minted physicians in the US must complete a Residency before becoming a physician capable of practicing on their own.

In the US, simply completing medical school is not sufficient to become a physician; no hospitals or physician groups will hire you; no insurance will reimburse you.

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Instead, you must prove your worth, knowledge, and skills by completing a Residency in the specialty of your choice.

Alas, the general public is not fully aware of this transitional stage in the professional life of a physician. There is either “you are a doctor” or “you are not a doctor”.

And if the patient is sitting in a gown, on an exam table or on a hospital gurney, while asking for medical help and you identify yourself as their physician, “you are a doctor.”

Which, in fact, you are.

Confused yet?

Well, I am too.

Because now that I’m half-way through my Residency, I am starting to find myself straddling the line between being a naive Intern and a full-fledged Attending.

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The major reason Residencies exist in the US is due to the wide swath of information and skills needing to be honed in order to provide adequate medical care in the 21st century (and the 20th century before it.)

The sheer breadth of knowledge acquired during these training programs is paramount to fully understanding the capabilities, pit-falls, and intricacies of the human body.

It also introduces physicians to the longitudinal aspects of caring for patients and their families.

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One night while I was an Intern (PGY-1), I responded to an overhead page from the Emergency room; my assistance was requested in the care of a critically ill patient.

Not exactly “my” assistance per se, but by being the Intern on-call, I was part of the team responding to patients who have such a severe infection as to be called “Septic“.

The woman was non-responsive, cool to the touch, and seemingly every square centimeter of her body was swollen with fluid.

Her vital signs on the monitor were tenuous. A quick scan of her body revealed a tube protruding from her pelvis, most likely a surgically placed catheter to drain urine from her bladder.

The daughter sat at the bedside, quickly describing the course of actions she believed could have led to the current predicament.

Despite her seated position at the bedside, her fear was palpable.

I thanked her for the explanation and informed her we would need to pursue aggressive measures to save her mother’s life. Without hesitation, she consented.

Over the next several days, her mother remained unresponsive in the Intensive Care Unit, her life supported by machines to keep her lungs delivering oxygen to her swollen body; medications kept her heart pumping that same oxygen to every fragile cell.

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But one day shortly thereafter, I arrived in the ICU and the mother was no longer in the room.

The bed was barren, immaculately cleaned, and prepared for the next critically ill patient.

She had died overnight, her body unable to sustain life despite the most aggressive medical interventions, all while I attempted to regain my cellular integrity through several hours of sleep in my own poorly-cared-for apartment.

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Six months later, I was working in the office of an Oncologist (a doctor who treats patients with cancer) preparing to see his next patient. While thumbing through her chart, he described the course of events leading her to seek his care.

When we entered the room, I saw a familiar face. The daughter of the non-responsive woman I just described. She smiled and greeted me, though I instantaneously recognized her palpable fear.

The Oncologist was surprised and said, “you two know each other?”

I responded, “yes, I cared for her mother.”

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There were no heroic acts which changed the outcome of the mother’s life. Unfortunately, there were no heroic acts to perform for the daughter either.

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In our current “illness-based” medical system, which more handsomely rewards interventions while people are ill, even Family Medicine docs like myself tend to more commonly encounter patients when they are in need, rather than when they are well.

{This is more a by-product of when people tend to seek out care, rather than a desire on most physicians part, as Family Medicine is predicated on prevention of illness.}

And sometimes the wellness and illness intersect.

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Having completed two months of Obstetrics and Gynecology during my intern year, as a PGY-2 I have become “eligible” to work 24-hour shifts on the Obstetrics service.

The Rise of Magneto, indeed.

{By eligible, I mean the cap on my consecutive hours able to be worked is now 24… And I am assigned to work said shifts based on my availability. Which is truly, whenever. But that is Residency. So be it.}

Within the first hour of working my first OB-24, I delivered the baby of a woman I had never met, which is common on the Labor & Delivery service.

After ascertaining the baby’s general health and wellness while identifying the absence of suturing opportunities in the woman’s vaginal canal, I calmly congratulated her, welcomed her son to the world, and exited the room to tend to another pregnant woman.

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baby-after-being-born

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One week later I was working in the Pediatric Emergency Department, my latest assignment as a PGY-2, when my eyes were drawn to a patient’s Chief Complaint on the Patient Tracking Board.

It read “fever, decreased PO intake”. I scanned over to the patient’s age and read, “7 days.”

On my first night in the Pediatric ED I had seen another 7-day-old with fever and decreased PO (oral) intake. I ended up performing a lumbar puncture that night on that child due to a concern for meningitis.

Thankfully, the test results came back showing that the child did not have meningitis. It recovered quickly and was home within two days.

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But that experience had quickly alerted me to the need to act quickly and decisively in order to prevent a dire outcome.

So I clicked my name next to this latest 7-day-old child and quickly proceeded to the patient room to evaluate him.

When I opened the door and introduced myself, the mother and I instantaneously recognized each other. She was gently rocking the boy I had delivered only 7 days previously.

“Doctor, please help him.”

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I had only a week before assisted his exit from his mother’s womb. I assured his mother we would care for him and made my way back to the area where an Attending physician was awaiting my assessment and plan.

While I alerted my Attending to the intimate relationship I possessed with this child and his mother, a few of the other Residents and Attendings happened to overhear the predicament.

They all began to listen in as I outlined my plan to perform a Lumbar puncture to assure he was not rapidly deteriorating at the hands of a bacterial foe.

My Attending agreed, looked at me intently, all the while recognizing my whole-hearted investment in this patient.

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There are few instances in medicine as intimate as the delivery as a child, and to have that same child fall ill and somehow end up back within your care in a completely different hospital on a completely different medical service only a few days later, is the essence Family Medicine.

We can be seemingly ubiquitous.

Thankfully, the young boy, only a week into his life, tolerated the Lumbar puncture; his cerebrospinal fluid was absent of life-eradicating bacteria or virus; he was sleeping comfortably in his own crib again within two days.

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The transition from “medically knowledgeable but clinically deficient Intern” to “clinically seasoned and seemingly knowledgeable Senior Resident” is one fraught with pitfalls: sleep deprivation, anxiety-producing clinical scenarios, life-and-death struggles, and glaring holes in medical knowledge.

But at the moment of greatest despair, when the chips are down, the night can’t end, the day can’t come soon enough, and the struggle to become a good physician seems out-of-reach, the Intern becomes a Senior Resident.

And reflects back on the do-or-die nights, the life-and-death days, the thankful patients, the grateful families, the new-born babies first squeel, and the meaningful and life-long relationships created in the cauldron of uncertainty…

… bringing on The Rise from Intern to Senior Resident.

In my case, The Rise of Magneto.

A Life of Intimacy

Posted on December 23, 2015 by Elbrecht

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There is an inherent level of trust between a patient and their physician. Having been a patient multiple times in my life, I believe most of this trust is simply necessary to survive. The general public has blessed physicians with a trust known to few other callings.

“You are the doctor, what do you think I should do?”, is a statement I have had echoed to me during my brief career as a physician.

This level of trust is necessary to provide adequate care to any patient. A patient who does not trust their physician is highly unlikely to share their most private information, some of which may be necessary to actually help a patient.

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But if the relationship between the patient and physician is strong, whether it has lasted 20 minutes or 20 years, a level of intimacy is created which is nearly as vibrant as that which comes from the most passionate kiss.

The type of intimacy between two lovers and that which is created between a patient and their physician is incredibly different, but having now been a part of each of these three roles, I can genuinely report each is quite intimate.

Passion defines the level of intimacy found between two lovers, allowing lives to become so intertwined that an existence without the other is simply no existence at all.

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Trust defines the level of intimacy found between a patient and their physician, allowing even the most treasured hopes and fears to be revealed.

Care defines the level of intimacy found between a physician and their patient, allowing a level of insight into a near-stranger’s life unmatched in the rest of human existence.

Which is where I currently find myself. In a life of intimacy.

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I backpedaled on my life’s trajectory when I was 24 years old. Having imagined myself becoming a clinical psychologist since I was a teen, I studied to become one in college, and then decided to hone my basic skills in a group home in Cambridge.

I never seriously considered becoming a physician, until I found myself lodged in the life of a unique social intervention.

In the subsequent decade, I have learned more about the human body than I imagined possible, all the while protecting and practicing the skills I expected to use as a psychologist on a daily basis.

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Now I find myself learning some of the most intimate aspects of near-stranger’s lives.

Their hopes.

Their fears.

Their disappointments.

Their transgressions.

From the patient’s perspective, I am the one whom they want to trust so they can stay healthy or recover from whatever ailment currently disturbs them.

From the physician’s perspective, I am the one who cares whether they can stay healthy or recover from whatever ailment currently disturbs them.

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A 20-year-old woman cried in the exam room. The tears streamed down her face as she recounted leaving her grandmother’s home, where she was raised, because their relationship had abruptly dissolved.

She cried for the loss of their relationship; the loss of a grandmother and mother, one-in-the-same.

As her tears subsided, I listened and encouraged, supported and reflected, all the while feeling priviledged to be trusted in such a way. She hoped their relationship would be salvaged some day. Somehow. Someway.

At 32-weeks pregant though, she had another relationship to care for. So we used the ultrasound and listened to her soon-to-be-born daughter’s heart beat.

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A middle-aged man sat disrobed in front of me. A man I had never met in my life. He came to me for a physical evaluation with life of minimal medical maladies.

Except now he has a broken heart.

A broken life.

A broken sense of where he fits into the world.

His wife of 37 years died.

His home is barren.

He sleeps alone.

No one responds when he speaks.

The “chief complaint” listed as the reason for his visit was Physical Exam.

The intimacy afforded by the level of trust he put into his physician, in this case me, allowed his physician, in this case me, to care for him in ways unable to be documented.

When he left the exam room, he gave me a hug and said, “I will be alright Doctor. Thank you.”

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Every physician has similar experiences, each of which permeates their being, acting as an enzyme on the basic proteins constructing their DNA; allowing them to care for an infinite number of their fellow man; potentially when no one else will.

A life of intimacy is not for everyone, as it can create an enormous amount of unrecognized emotional strain.

But if done correctly, a life of intimacy can also create an incalculable strength, derived from the emotions of near-strangers, who seek a relationship unlike any other known to man.

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The patient-physician relationship is intimate in ways unlike the intimacy sown with a passionate lover.

A life of intimacy. A life.

The Birth of Magneto

Posted on September 13, 2015 by Elbrecht

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After hurriedly caring for two newly admitted patients, while receiving pages from nurses about the other patients already admitted to my service, I took a moment to “run my list.”

At 2AM on a Thursday morning, my brain required a succinct “to do” checklist to assure nothing of importance had been forgotten. Fortunately, I simultaneously happened upon my senior resident, Jacob.

He calmly asked how things were going, having left me hours before, in a trial by fire, to go about the business of running an in-patient service on Nightcall. Not that he had abandoned me, but rather, he had given me the reigns of our service and asked that I not make any decisions which caused him to question my ability as a soon-to-be second year resident.

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I collected my thoughts and began rattling off updates, allowing both of us to check off a multitude of things on our list. As I made my way to the middle of our list, I let out a quick a deep sigh.

He gave me a quizzical look, to which I responded, “I need to go check on Ms. Smith’s EKG. I was supposed to do that two hours ago.”

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Jacob and I had been paired to work together for these two weeks since our schedule for the year had been published months earlier. It was likely intentional, as Jacob had been identified as a leader within our program, and thus someone from whom I could learn to become a solid second year resident.

Though several years my junior in age, I respected Jacob’s work ethic and pride in our residency. Despite the long hours, occasionally ungrateful patients, and stress of balancing work and a family life, he kept a positive attitude and welcoming countenance. I could easily imagine him becoming a Chief Resident, one of the designated leaders of our program who toiled in an effort to provide stability in a world of chaos.

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My response prompted his characteristic comforting Arkansas twang, “Oh, don’t worry, Magneto. Ms. Smith is just fine.”

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As a part of friendships, work relationships, and familial bonding, nicknames are a nearly ubiquitous part of life. Having been given a multitude throughout my years, I quickly realized Jacob had provided me the latest in a long line. But unlike most of them, which were derivations of my first or last name, and typically of little creativity, “Magneto” provided me a cache not previously recognized.

I let out a quiet chuckle as Jacob informed me he had wandered up to Ms. Smith’s room at midnight, the time I had told him an EKG would be performed to determine if her pacemaker had been deactivated, allowing her to pass into death comfortably. Once there, he learned of my own creativity, which christened the birth of Magneto.

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I first met Ms. Smith three weeks earlier, when I was working during the day as one of the interns on our in-patient service, Clin Med. At that time, Ms. Smith was struggling with advanced heart disease, a quartet of pathologies which I termed the “Unholy Alliance”; her heart provided her four diagnoses, which together carried a high level of morbidity and mortality: congestive heart failure, atrial fibrillation, coronary artery disease, and pulmonary hypertension.

Each of these diagnoses were intimately intertwined with the others, but I had yet to see any one person carry all four. During our initial encounter, Ms. Smith was easily conversive, despite her need for supplemental oxygen, and seemed ready to battle her disease and proceed well beyond her 63 years of life. On that day, she was flanked by one of her adult sons who reflected her success as a mother.

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The night I earned my nickname, Ms. Smith was flanked by that same son, as well as her two adult daughters, several grandchildren, and a couple friends. They wished to be present in her final moments.

Between these two days, Ms. Smith had a brief, but meaningful improvement in her clinical status, allowing her to return home. But her heart quickly worsened and she ended up admitted to our service again, this time in more dire circumstances. It was immediately recognized that her final days were upon her and the one daughter who did not live in Columbus was summoned from California.

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The final daughter’s arrival from California harkened a transition in care for Ms. Smith. She had made it known if she were to have a decompensation in her status, she would not want to be maintained indefinitely.

So while her mental status waned as a result of her poorly functioning heart, we provided her some medication to prevent it from going haywire, and more importantly, did not deactivate the pacemaker embedded in her chest. Her heart kept pumping despite the malignant nature it now carried.

When the daughter arrived earlier in the day, a decision was made to stop the medications and turn off the pacemaker, allowing Ms. Smith a nearly painless transition into death.

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But when I arrived to work that evening, I was notified Ms. Smith’s pacemaker was still quite functional. The nurse paged me, reporting she had waved a magnet over Ms. Smith’s chest, performed an EKG to determine if her heart was still receiving the electrical impulses from the pacemaker, and found the characteristic pacemaker spikes on the EKG print out.

Only five minutes earlier, I was informed our Clin Med service would be directly admitting two patients; these two individuals would not be coming up from the Emergency Department, where an initial assessment had been completed, but rather were being either transferred from an outside hospital or being sent in from home by one of our colleagues.

This would require assessing the patients while they were already on the floor being cared for and simultaneously providing orders by which the nurses could care for them.

Dealing with one of these would be a trial in and of itself, but dealing with two simultaneously, while responding to pages about other patients on our service, would be quite a task. Jacob asked if I could handle it, to which I responded in the affirmative.

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The lone impedance I saw was Ms. Smith’s pacemaker. So I hurried up to the 6th floor, walked into her room, greeted her family, and confirmed I would be deactivating her pacemaker. They thanked me for our team’s care and focused their attention on their dying mother.

I excused myself for a moment, proceeded to the nurses station, rifled through a drawer beneath a bay of computers showing the electrical activity of every heart on the 6th floor, and grabbed a large, doughnut-shaped magnet, measuring 8cm in diameter.

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Having been informed the nurse had attempted to deactivate it earlier and realizing the two direct admits were awaiting my care, my eyes began searching the nurses station for something I could use to secure the heavy magnet to Ms. Smith’s chest.

I found a strap with which I felt I could secure the magnet and walked back into Ms. Smith’s room. I greeted her family again, proceeded to her bedside, and lowered the gown from her left shoulder.

I intertwined the strap in the middle of the doughnut-shaped magnet and secured it around her shoulder, resting it snuggly against her upper left chest wall. I raised the gown back over her shoulder, informed her family I would return in a few hours to check on her, and proceeded from the room.

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After leaving Ms. Smith’s room, I found her nurse, asked her to perform an EKG at midnight, and informed her I would return shortly thereafter to assess Ms. Smith.

When Jacob christened me “Magneto”, it was two hours after I had planned to see Ms. Smith again. He had made his way to the 6th floor at midnight to check on Ms. Smith’s heart.

He informed me the EKG had, in fact, shown the pacemaker to have been deactivated, as I (and Ms. Smith) had wished. But deactivating her pacemaker was not like pulling the batteries from the back of a remote control, leaving her lifeless. It had simply removed the support needed to keep her heart beating more than 60 beats per minute, the lower level of “normal”.

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Jacob relayed she was still alive, with a slowly beating heart, when he had gone to see her. We proceeded to run the rest of the list, I informing him of the status of our two directly admitted patients, and he of Ms. Smith imminent demise.

I left him and grabbed the elevator to the 6th floor. I slowly walked towards Ms. Smith’s room, the lights in the hallway dimmed appropriately for the time of night.

I knocked on the door, entered, and found her family members still gathered at her bedside, though overtaken with fatigue. They had made her room a makeshift resting place, blankets on the ground, tired bodies resting amongst each other, each of them soundly asleep.

And there was Ms. Smith, laying peacefully in her bed, continuing to have slow, agonal breathing, her heart surely winding down.

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As I quietly left the room, careful to not disturb her children and grandchildren, I took a deep breath and let out a sigh of relief.

I strolled through the darkened hallway, making my way towards the nurses’ station, but ran into her nurse before reaching my destination. She was on her way to assess Ms. Smith herself.

I informed her of my findings and asked her to keep me updated.

Five minutes later, I received a call from the nurse stating she entered the room, found Ms. Smith’s agonal breathing to have ceased, and was unable to feel a pulse. She had died.

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I returned to her room some time later, having made another round through the Intensive Care Unit to assess the health, or lack there of, of the patients who were there. Her family was all awake, having been alerted to her passing, and profusely thanked me for our team’s care.

They thanked me by name and title, but were not aware of The Birth of Magneto.

Life Sustains Us

Posted on May 3, 2015 by Elbrecht

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Part of the training to become a Family Medicine physician requires the Resident to have the ability to successfully assist a woman in the delivery her child. Depending on your religion, culture, and/or understanding of human biology, when the baby exits the vaginal canal and lets out its first cry, its life has begun.

Being a part of this experience has led Family Medicine to adopt a credo of “from the cradle to the grave”, as we have the unique blessing to care for patients from the beginning of life until death becomes us.

Nearing the end of my Intern year as a Family Medicine physician, I have now had the opportunity to train as a physician on the Obstetrics and Gynecology (OB/Gyn) service two times. The first four weeks occurred in the first half of my year and were a whirlwind of stress and re-introduction to a field of medicine which I had barely survived as a student.

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During those four weeks, I constantly found myself on edge, not only because of my experiences as a student, but because I found myself as the least seasoned member of a team responsible for making sure each and every baby let out its first cry.

While a sense of relief and pride would wash over me when each baby boy or girl let out its first little squeal, most often while I was still holding it in my gloved hands, I was still tasked with several steps to assess the health of the mother after handing off the baby to the pediatrician who stood awaiting my delivery.

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Those additional steps were the cumbersome parts I would rehearse in my head while staring intently at the woman’s vagina as I used my fingers to create the space needed to assist the baby’s head from tearing perineal tissue. Often times, my mind would go blank as soon as the baby made its way into my arms.

After what seemed like an eternity, which properly calculated only totaled 4-5 seconds, I would begin assessing the mother’s health, including any vaginal lacerations which may need repair, massaging the fundus of her uterus to determine the likelihood of a postpartum hemorrhage, and carefully tugging at the umbilical cord still attached to the indwelling placenta.

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Typically within 10 minutes I would have transitioned from the foot of the bed, having delivered the newborn and the placenta, as well as completing the necessary postpartum assessments, to clickety-clacking away at the computer to document the successful delivery.

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My second go-around on the OB/Gyn service was nearly identical in substance to the first four weeks: women of different stages of pregnancy coming into Labor and Delivery Triage to be told if they were or were not in labor, often requiring me to perform speculum checks and cervical exams; actively laboring women begging for epidurals and anxiously awaiting their newborn while I paid hawk-like attention to the monitors assessing fetal heart tones and uterine contractions; rounding before the crack-of-dawn on women post-delivery, assessing their postpartum needs; and imparting my seemingly minimal medical and clinical knowledge of Obstetrics and Gynecology to the even less-knowledgeable medical students I was tasked with teaching.

But while the substance of the second four weeks was nearly identical, my experience as a physician training in this foreign world was markedly different. By the time I showed up for the second-go-around I was a substantially different physician; it is utterly unconscionable how much things had changed in five months…

how much things had changed in me…

how much things had changed in me as a physician…

how much things had changed in me as a physician responsible for the care of a pregnant woman and her unborn baby…

how much things had changed in me as a physician responsible for the care of a pregnant woman and her unborn baby while being the leader of the medical team.

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Suffice it to say, it was an overwhelmingly different four weeks. And by no means was I the lone physician paying excruciating attention to the women and their unborn babies, as I was assisted/supervised by a 2nd or 3rd year OB/Gyn resident and Attending physician, but the knowledge and experience I acquired during the initial four weeks allowed me a level of comfort in my own capabilities that I had not anticipated.

The knowledge and experience in regards to the medical aspects of physiology, biochemistry, and anatomy involved in OB/Gyn were certainly at the forefront of increasing my comfort level, but it was actually my knowledge and experience of the other members of the care team that proved to be my greatest asset.

Not that other medical services in the hospital don’t have exquisitely trained nursing staff, but the OB nurses are in a class all by themselves… and if you don’t respect that, they will bury you. Bury you in a world of cervical checks, bleeding vaginas, and spasming uteri.

Think about that for a second… spasming uteri. It used to give me chills even thinking about it… but that was way back when… when I was still learning about how life sustains us. Now I know to give some gentle uterine fundal massage. And run the pitocin wide open.

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