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FOLLOW DR. KO: WHEN LIFE GIVES YOU LEMONS

tequila copy 2“ When life gives you lemons, make lemonade,” or so goes a proverbial phrase. But when the lemons come at the most inopportune times, I say forget about the lemonade; I need to make tequila. And when excrement really hits the fan, I make that tequila extra añejo. Let’s just say that there has been a lot of tequila.

The past couple of months have definitely been very trying. Those who have read my previous blog entry know that I faced some pretty impossible scenario regarding my visa to stay in the U.S. to continue my medical training. But after obstinately knocking on every door I could think of, both literally and figuratively, including that of the Prime Minister of Health of Quebec, I was granted an extension on my visa, a lucky exception, allowing me to stay in the U.S. and start my fellowship in Pulmonary and Critical Care Medicine.  It was a much hoped-for and prayed-for triumph, followed by a summer not without its challenges.

It is hard to believe that I started writing this blog as I entered medical school, and this summer marked the end of my training as an internal medicine resident. At the end of residency, one can choose to practice independently as an attending physician, or continue further training in a sub-specialty in a fellowship. I signed up for another three years of training to be a lung and critical care specialists.  Call me nuts. But this means that in three years, I will work with patients afflicted with various pulmonary issues, as well as manage some of the sickest people in the Intensive Care Unit.

July is always a chaotic month for doctors. An old batch of trainees leave, and a new batch of wide-eyed incomers flood in. Add into the equation apartment hunting, car hunting, money scrambling, and oh, how can I forget, studying for one of the biggest exams of my life, the American Board of Internal Medicine, or the ABIM. Everything was on a tight and carefully thought-out schedule, all the while living out of cardboard boxes.

Unfortunately, or perhaps fortunately, depending on how you look at it, doctors are humans, too.  We have lives outside the hospital, we get sick, we get hungry and sleepy, we laugh, we cry, we make mistakes, we try to make lemonades when life gets sour, but sometimes we get overwhelmed by all the bitter lemons thrown at us.

Well, I eventually found an apartment and even managed to move by myself, hopping over fences while carrying heavy boxes.  I moved some money around (euphemism for ‘I borrowed’) and got a car so I can drive between the three different hospitals where I will be working.

Then I found that that I had failed the ABIM on my first try. Never having failed an exam in my life, it was to my surprise that I did not die from failing one exam.  I learned that a bad test score does not equate a failed career and that there are always second chances. So here I am, ready for the challenges and fun that the next three years will offer. Let me dust off that nasty feces that was thrown at me, and cheers!

Melody Ko, M.D.
Fellow, Pulmonary and Critical Care Medicine

FOLLOW DR. KO: What You Never Knew About Canadian Doctors Outside Canada

IMGImagine me, a single thirty year-old living in the bustling city of New York, out at a bar on a Saturday night.
“What do you do for a living?” – someone inevitably always asks.

Sometimes, for fun, I make up stories. I tell people that I specialize in cleaning elephant poo at the Bronx Zoo or something ludicrous like that. It is so much more interesting than just saying, “I’m a doctor.”

But when I do say that I am a doctor, people’s reaction is usually “Oh wow.” They think that I must live in luxury on the Upper East Side, drive a Mercedes-Benz or some other fancy vehicle, and travel to exotic lands every couple of months. They picture a doctor, noble and heroic, who goes to work every day and saves lives. Countless lives. They would imagine me shouting out a patient’s blood pressure, cutting them open, performing chest compressions, while pearls of sweat drip down my face, the sweat of hard work, of responsibility, of grandeur. Then the patient lives, wakes up, and thanks me with hugs and tears.

Well, all that is flattering, but none of it is true. I do not save lives every day. As a matter of fact, rarely, if ever, a single act performed by one person saves any lives. Granted, there are days that I intubate or resuscitate a patient, but without my presence, someone else would have taken on the same tasks. Moreover, the outcome of resuscitations is rarely favorable. On most days, I go to work, spend a lot of time in front of the computer reviewing charts and documenting, adjust some medications here and there, auscultate a few chests and backs, order some lab work, curse at the printer for being jammed again, document some more, and call it a day. I am not saying that these actions are not important – they are – but in a smaller, less valiant way than what the public imagines.

Most people also do not know that just because you are a doctor does not mean that you have a job. According to the 2013 report from Royal College of Physicians and Surgeons of Canada titled “Too Many, Too Few Doctors? What’s Really Behind Canada’s Unemployed Specialists,” one in six specialists cannot secure employment in Canada. Not that there is no need for specialists. Those with joint pain know how long the wait list is to see a rheumatologist. Cancer patients have experienced the anxiety in waiting to be evaluated by a radiology-oncologist.

Finding a job is even more difficult for International Medical Graduates (IMG) such as myself. Allow me to take you on a tour onto an IMG’s journey.

After repeatedly being placed on the wait list for Canadian medical schools, I decided not to wait any longer and pursued my medical education abroad, more specifically, at St. George’s University in Grenada. Without any kind of government subsidization, I searched for private loans and worked for a while to save up for the exorbitant tuition fee. After I obtained my medical degree, my initial plan was to return to Quebec, my home province where I would complete my residency. However, I found out that was impossible because Quebec requires all IMGs to have passed both exams of the Licentiate of Medical Council of Canada (LMCC) in order to qualify for residency application. Here is the paradox: one cannot register for the last part of the LMCC exam without having completed at least one year of residency. I gave up that option and eventually matched into a residency in Internal Medicine in New York. That was not easy either, as I was only allowed to pursue a specialty considered by Quebec to be “in need” in order to obtain the visa required to work in the U.S. From what I remember, the specialties considered to be “in need” by Quebec at that time were: Internal Medicine, Family Medicine, Oncology, Hematology, Rheumatology, Geriatrics, Plastic Surgery, Dermatology, and Anato-pathology. Most of these specialties also have a yearly quota, for example, Health Canada only allows four to five IMGs to pursue Rheumatology outside Canada.

Now I am almost at the end of my residency, and to my very pleasant surprise, I matched into a Pulmonary and Critical Care Medicine fellowship at Rutgers University in New Jersey. I did apply in Canada as well, however not in Quebec, because Quebec programs did not accept IMG applicants. Now comes the tricky part: I need Quebec’s endorsement and Canada’s permission to pursue the specialty that I am passionate about. Without Canada’s permission in the form of a letter called the Statement of Need, I cannot extend my visa and would not be allowed to stay and work in the U.S. Every October, Quebec and the rest of Canada come out with a list of medical specialties that they consider to be “in need.” If your chosen specialty does not appear on the list, your province or country will not issue that Statement of Need on your behalf. The result is you are without a visa.

Why not come back to Canada, you say? That was my original plan all along, but the length of training in Internal Medicine in the U.S. being two years shorter than in Canada, I cannot practice as a licensed internist in Canada unless I find an empty spot in the middle of a residency program. You can imagine how difficult that is, and the paperwork that is involved. So should I return to Quebec or Canada, you might find me working as an overqualified burger flipper.

Confused? That is ok. This is indeed a very complex and confusing process that my peers and I learn as we go along.

A Quebecois SGU classmate and friend of mine just matched into Rheumatology in NJ for which Health Canada had alloted five spots by this year. He waited with trepidation to see if he would be one of those five, and luckily he was. Another Canadian classmate of mine, also from Quebec, finished Neurology and wished to continue his training in Neurocritical Care but was not “allowed,” so now he is doing a fellowship in Epilepsy at Yale University. Prestigious position, no doubt, but not what he really loves.

Why are there only five spots allotted to Canadian IMGs who wish to train in Rheumatology abroad? It cannot be a question of funding because the Canadian government is not involved in our training in the U.S. And if Canada has not contributed a single penny to our medical education and training, why does the government restrict what we can or cannot practice? These are questions that we ask ourselves again and again because we do not know who would have the answers, if there is any answer at all.

As for myself, those who know me know how much I love critical care and appreciate pulmonology (respirology in Canada). After all these years of trial and tribulation, to finally arrive where I want to be is a truly rewarding feeling. I am now in the process of working things out, but as of this moment, a piece of paper stands between me and my chosen career.

Next time somebody asks me what I do for a living, saying that I work in the zoo might not be as far-fetched as it sounds.

 

Melody Ko

FOLLOW DR. KO: Medical Mission to Haiti – Paul’s last days and a few highlights

It was one of those happy endings. Paul, albeit still frail, was now smiling, eating, and chatting with his family. When I first met him, as described in my last post, he couldn’t even breathe on his own. He had been lying listless in the Intensive Care Unit (ICU) bed for days, skin and bones, barely moving a muscle. It was New Year’s Day, and I couldn’t think of a better time to tell him that he was ready to be discharged home.
Paul was one of my first patients on a medical volunteer trip to Haiti earlier this year at Bernard-Mevs Hospital. Paul had been admitted to the ICU for acute respiratory failure secondary to an exacerbation of chronic obstructive pulmonary disease. I had made it my personal project to find him the best treatment regimen with the very limited resources we had. Often, especially at night, I was the only physician covering triage, the emergency room, the inpatient unit and the ICU, and I had only my pocket medicine book to rely on. That, and my own judgment.
It is pretty amazing how quickly a resident physician can grow when forced to think and act by herself without the usual close supervision of an attending, as is the usual case during residency. I remember my second night shift when, while all the volunteers went out to dinner, I was assigned to stay behind to woman the fort. With a mere one and a half years of experience in internal medicine under my belt, it was a tad daunting to be left in charge of the entire hospital. Lo and behold, an ambulance rolled in with blaring sirens, bringing in a young man who was in a motorcycle accident. Just as I was evaluating this patient, another ambulance pulled in, followed by another. Just like that, I was in the entrance of the hospital, surrounded by three ambulances and a crowd of spectators. Seeing as we had our hands full, the third ambulance was diverted to MSF (Médecins Sans Frontières) France which was about 15 minutes away.
As I gave instructions to stabilize the motorcycle accident victim’s neck with a neck collar to prevent worsening of potential cervical spine injury, I tried to gather some history about my second patient. “He has high blood pressure” was all that I could obtain from the paramedics. He was a transfer from another hospital, and apparently they couldn’t handle him so sent him to Bernard-Mevs. No one could tell me what his latest set of vital signs were, or what symptoms he had, so I jumped into the ambulance to take a look for myself.
The man did not respond when I called out or rubbed his sternum. He had no chest rise indicating air entry into his lungs. He wasn’t breathing, and he had no pulse. I immediately started chest compressions right there in the ambulance. A crowd of people gathered around, and one of the paramedics shouted out: “Doc, what do you want us to do?” It was then that I realized that I was the one in charge, and people were waiting for my orders.
We pulled the patient out and put him down on the ground in the driveway and tried to resuscitate him. I declared him dead after twenty minutes. Although the outcome was tragic, that experience gave me a confidence boost and taught me how to take control and be the leader of a healthcare team. Later that week I went on to run codes, manage patients in sepsis or severe infection, repaired lacerations, and made great friends along the way.
On the day of Paul’s discharge, his nephew and friend came to pick him up. They thanked me profusely and hung on to every word I said. “So is this going to happen again?” the friend asked. I told him that if Paul took his medications as instructed and quit smoking, the chances of having another one of these attacks would be decreased. I wasn’t sure what medications were available in Haiti, or how much they cost, so I told them to return to the hospital for another prescription if they could not find or afford those medications. They hugged me, and everyone was happy.
I left Bernard-Mevs Hospital the following day. Later, I found out that Paul came back to the hospital two days after his discharge, in respiratory distress. He ended up being intubated again, coded (lost his pulse), and died in the ER. I remembered the look of hope and trust on Paul’s nephew’s face whenever I spoke, and I could not help but feel like I had failed Paul and his family in some way, even though there wasn’t really much else I could have done.
At that point, I looked up to the sky. Two rainbows dashed across the heavens. It was beautiful. For some of us, life goes on.

Melody Ko

FOLLOW DR. KO: Medical Mission to Haiti – Paul, the patient who couldn’t breathe

Paul was a thin and frail-looking man in his sixties. He walked into Hôpital Bernard-Mevs accompanied by his teenage nephew on my first shift volunteering in Haiti. He was complaining of worsening shortness of breath for the past couple of days. He suffered from asthma, he told me, and confessed to a history of heavy smoking.

From Paul’s barrel-shaped chest and his long history of tobacco abuse, I thought chronic obstructive pulmonary disease, or COPD, was more likely than asthma. However, definite diagnosis would require a pulmonary function test during which the subject sits in a chamber connected to a spirometer that measures various pulmonary parameters such as lung volume during expiration and inspiration. One major difference between asthma and COPD is that the former responds to a class of medications called bronchodilators, whereas COPD does not. Also, people with COPD are usually accustomed to having a higher than normal level of carbon dioxide (CO2) in their body. That elevated level of CO2 serves as their respiratory drive, reminding their body that it needs to breathe. As a consequence, giving these patients high levels of oxygen could actually be lethal as oxygen suppresses that CO2 respiratory drive.

Screen Shot 2014-04-24 at 2.17.50 PMSince the initial treatment in asthma and COPD is similar, I went ahead and ordered the medications. Unlike back in America where I would simply click a few buttons on the computer, in Haiti I had to write down every single medication I wanted, including the route of administration and the dosage on a prescription pad. The patient, or a family member, would then to take that script to the pharmacy, pay for the medication, and bring it back to me so I can administer it to the patient. And if I wanted a repeat dose, I would have to write another prescription, and so on. No money, no meds. Of course, in cases of emergency where it’s a matter of life and death, Hôpital Bernard-Mevs would still treat, but the bill would somehow have to be settled later.

I wrote albuterol, ipratropium bromide and methylprednisolone on my prescription pad for Paul’s nephew to take to the pharmacy. He hung onto my every word and executed my orders like I was someone important. I guess to them I was; I was all they had. A shooting near the hospital distracted me away from Paul for a while (see previous blog), but I quickly came back to him, because he was obviously in respiratory distress and not improving. His lungs, which wheezed loudly on auscultation in the beginning, were now almost quiet. This could misguide a clinician into thinking that the patient is improving, but it is actually an ominous sign that the patient is fatiguing and about to crash.

If this were back home, I would sedate the patient, put a breathing tube down his trachea and connect the tube to a ventilator to breathe for him. Paul was getting tired and I didn’t think he would be able to maintain his airway on his own for long. But I had never intubated someone without the supervision or at least the blessing of an attending physician, and there, I was by myself. Should I just make the call?

Just when I was hesitating, it was time for shift change, and the local doctor who was on duty came to take over. I was relieved to hand off the patients to someone more senior, and voiced my concern about Paul to this doctor.

“He is using his accessory muscles, his oxygen saturation is slowly going down, and I already gave him three rounds of nebulizer treatments, magnesium sulfate and steroids. I think we need to intubate him.” I reported, as a resident would to an attending.

This attending, however, was not impressed. “He doesn’t need to be intubated,” she retorted, “Just take him back to the ER and put him on oxygen.”

Although I did not completely agree with her management, I did not want to overstep my boundaries. After all, it was possible that due to lack of resources, Haitian doctors had a higher threshold for intubations and other more aggressive approaches. Just because I was used to doing things a certain way, didn’t mean that everyone practiced medicine the same.

Screen Shot 2014-04-28 at 11.02.50 PMA few hours after I had finally slipped into slumber from a tiring and eventful evening, a volunteer Critical Care nurse who was also one of my bunkmates rushed into our room to grab her Ambu bag, a device used to manually ventilate a patient who is not breathing. “They are tubing the patient, Melody. I came to get my Ambu bag because they couldn’t find one in the ER.” I jumped off my bunk bed, and still in my pajamas, ran out to the ER which was right across the volunteers’ rooms. Paul’s oxygen saturation had gone down to 70%, while a healthy person’s saturation should be more than 98%. He looked exhausted and distraught at the same time.

Kicking myself for not standing my ground, I wanted to remedy the situation as quickly as possible. I asked the nurses for etomidate, an anesthetic agent commonly used prior to intubating a patient. They didn’t have it. “Give me propofol then, do you guys have propofol?” They had a vial somewhere but couldn’t find it now. They finally brought some ketamine, an anesthetic agent, and succinylcholine, a paralytic drug. The nurses infused both medications into Paul’s intravenous (IV) line and I waited for him to fall asleep and stop struggling so I could intubate him without a fight. But Paul did not close his eyes, nor did he stop gasping for air. He was neither adequately sedated nor paralyzed. We probably didn’t have enough medications to put him out completely.

“You can go ahead and intubate now.” The attending instructed.

I could not believe that I was going to do an awake intubation. But it was either that, or Paul was going to asphyxiate.

It was a traumatic experience for Paul and for me. I saw him stare right into my eyes with horror as I propped open his jaws and pushed the endotracheal tube down his throat. The image of Paul gagging and gasping for air will forever be edged in my memory. So will the image of his feeble smile one week later when I told him that he was going to be discharged from the ICU (intensive care unit) and celebrate the New Year with his family. But that’s another story for another time.

 

Melody Ko

FOLLOW DR. KO: Medical Mission to Haiti – Flying Bullets

armed guard“Get down! Get down! It’s gunshots!” The local paramedic yelled out.

I was sitting at my desk in triage in the midst of writing a prescription for albuterol and ipratropium bromide for my COPD (chronic obstructive pulmonary disease) patient when I heard the shooting.  It was my first shift on a medical mission in Port-au-Prince, Haiti, and I was the only doctor covering the hospital that night.

Still naïve and incredulous, I thought the loud noises could’ve been, oh I don’t know, fireworks? Something that broke? The truth was, I had no idea.  Despite working in the South Bronx, I wasn’t quite familiar with the sound of gunshots so close to me. I nonchalantly peeled my eyes away from my paper script – something I wasn’t quite used to writing – since at home everything is computerized, and looked at the paramedic who had already ducked to the ground and was knocking on the wall to see if it was made of concrete or wood.

“Is this for real?” was all I could muster to say. This had got to be a joke, I thought. Where are we? In the movies?

“Get down! Get down!” He shouted again.

I then realized that this was no joke and quickly dove under my desk. The Haitian paramedic, although alarmed, had an amused expression on his face. I guess they go through this all the time. I saw him scurry gingerly along the concrete wall to get to the light switch and turn all the lights off. So there I was, in complete darkness, squatting under a desk in a local hospital in Haiti, hiding from flying bullets. We hid there for a while in silence. The only sound was the labored breathing of my COPD patient who was sitting across the room. He did not try to hide or even move from his seat; he was too out of breath.

After we were fairly certain that the shooting was over, we slowly emerged from our hiding spots. A few ventured out to see what was going on. No one was sure where the shooting had come from. Some speculated that perhaps one of the hospital guards, stationed outside the metal gate of the hospital, was the one who fired the shots after seeing something suspicious. Or perhaps he was the one who got shot. When I suggested that someone go check on our guard to see if he was ok, no one budged. It was self-preservation.

Although Haiti is now in a “rebuilding” phase after the catastrophic earthquake that took away hundreds of thousands of lives and changed the lives of millions on January 12, 2010, many areas of the country still remain dilapidated and crime-infested. Hôpital Bernard-Mevs where I was volunteering is located in an area called Solidarité in the capital of Haiti, and it wasn’t considered a particularly safe area. In order to protect volunteers and locals alike, the hospital is constantly under surveillance by guards armed with machine guns. No one was allowed in or out of the hospital gate without the guards’ approval.

Volunteering abroad on a humanitarian mission had been a dream of mine since my teenage years. Lack of real medical skills and especially lack of funds prevented me from taking a trip sooner. But finally, this year, using my Christmas vacation time and thanks to the generous donations of family and friends, I went on my first medical mission with an organization called Project Medishare (http://www.projectmedishare.org/), an affiliate of the University of Miami.

Hospital

Little did I know that on the first night of my first medical mission, I would be dodging bullets! After the excitement of the shooting died down, I remembered that I still had a patient to tend to. Paul was a thin and frail man in his sixties. He came complaining of worsening shortness of breath for the past couple of days and he did not look good. I quickly resumed my work.

The adventure was just starting.

 

 

Melody Ko

FOLLOW DR. KO: Counting Needles

needleThere she was in her bed, face buried in her pillow, her rear end pointing directly at me. I’m not sure what she was doing in that position. Rosa was a woman in her fifties, but with her pigtails appeared much younger. I don’t remember the reason she was admitted to our service… probably for “altered mental status” secondary to drug abuse. What I do remember, is that she came with a whole lot of junk and even more attitude.

By junk, I mean morsels of food, random pieces of paper, countless lancets (small needles used to prick a diabetic’s finger to check their blood sugar level), a myriad of prescriptions, new and old. All that was scattered all over her bed, and Rosa was sitting on the edge of said bed, dosing and almost falling off.

“Mrs. Rosa, I am Dr. Ko. Would you like to lie in your bed? Let me help you clean this up.” I offered kindly.

“Do not touch my stuff!” She snarled back at me and gave me a look of contempt, insisting she would clean up her bed when she was good and ready. Fine. I left and went on to see other patients. When I returned, Rosa was in the same position I had initially found her in, sitting on the edge of the bed, her head rocking back and forth, dozing off. My second attempt to assist this patient to lie down was rejected with even more disdain than the first. I tried cajoling, reasoning, humoring, and nothing worked. She sneered at me through her toothless mouth and eyed me up and down with what could truly be genuine hatred. Then she said: “Your mother must be so ashamed of you. I bet your own mother hates you. You are a disgrace to this world and you ought to rot and die.”

Ouch! What on earth? Working in the South Bronx, you need to have a thick skin. People can be rough, rude, and aggressive. Often times they are under the influence of various substances, other times, well, maybe no one ever taught them kindness. With experience, you learn to shrug the insults off, or even befriend the unfriendly. But it was the middle of the night, and I was tired and not in the mood.

My patience was wearing off. I called my intern and this time, I was the one to snarl: “Where are you? You need to be here to deal with your patient!”  Then I grumbled to the nurse: “The needles need to be taken away!” The nurse looked at me helplessly, knowing that the patient wouldn’t let her come close. I got even more annoyed. “Call security if you have to, the needles cannot stay!”

The intern came running while I was hissing away. “This patient was admitted half an hour ago, why weren’t you here? I’ve been here this whole time dealing with your patient.” I scowled at her. “I’m really sorry, I’m on it.” The intern whispered. I felt bad. I had become a bossy and mean senior who takes out her frustration on those of lower rank. I’m sure the intern was tired, too, and just taking a break. After all, this patient wasn’t in a critical situation and didn’t need to be seen right away. As a peace offering, I stayed with the intern, and the two of us spent almost two hours with the patient trying to obtain her medical history, perform a physical exam, and yes, put those needles away.

Eventually security came and Rosa agreed to put the lancets away, but only if she picked them up one by one and counted each and every single one. She fell asleep a couple of times while counting, and would have to start all over again.

The following morning, I rounded on her last and found her in that “modified downward facing dog” position. She was covered in sweat, groaning in pain and vomiting. I recognized heroin withdrawal right away.

Methadone is a synthetic opioid given to alleviate the symptoms of opioid withdrawal. While methadone acts on the same opioid receptor as heroin and morphine, it provides a more subdued “high.”. Rosa knew that, and as miserable as she was going through withdrawal, she did not want the methadone. (And we couldn’t force it down her throat). She knew better and demanded morphine, and she wanted it to be administered via IV push, meaning in a quick push through the intravenous line, which would produce a more immediate and potent “high”.

“Just give her the morphine and get her out of here.” My attending said. “She has no other medical issues.” So we gave her the morphine to calm her symptoms. And as per protocol, we offered her options for her drug dependence: Detox programs, rehab, support groups, etc. Rosa was not interested. “Well, there is nothing else we can do for you, Rosa, medically, you are cleared and you will be discharged from the hospital.” But Rosa refused to leave! Well, I guess when you get free food and board and free drugs, why would anyone want to!

New York is one of the most generous States in the US, offering free or almost-free healthcare to the underprivileged like Rosa who are on Medicaid. Not having a job does not have to mean not having food or money. Social security sends monthly checks and food stamps, and all healthcare costs are taken care of. Each day spent as inpatient in the hospital is about $4000-6000. For Rosa, that fee would be covered by tax payers.

Finally, she did agree to leave the following day because it was her birthday.  She would take her needles and count them somewhere else.

 

Melody Ko

FOLLOW DR. KO: The Unfortunate Case of the “Drug Mule”

Screen Shot 2013-12-31 at 6.08.10 PMOn a crisp Saturday morning, Internal Medicine Residents from all over the state of New York trickled into the University of Rochester’s School of Medicine, sporting ties and dresses in lieu of their usual white coats and scrubs. In their hands they clutched a precious cargo, a cylinder that protected a poster to be used for a presentation about their research or about an unusual clinical case.

I was among the ninety-seven young (when does one cease to be called young, I wonder?) residents who had been selected to present their work at the annual New York American College of Physicians’ abstract competition. I had to rush to the airport right after work on a Friday afternoon, and then with barely six hours of sleep, (no, six hours is not enough) drag myself up and out into the cold air of Rochester, firmly gripping my poster, all the while wondering why I was giving myself all this extra work on my only free weekend of the month.

But then, as soon as I got a glimpse of other young physician’s work and ideas, my somnolence evaporated. How stimulating and motivating it was so see the talent out there! I especially remember one resident who was doing a double residency in Internal Medicine and Pediatrics. One residency is a daunting enough task, but two! And then I watched in amazement as he juggled his research poster with one hand, and his toddler with the other. It never ceases to amaze me how people can raise children and be in residency at the same time. His poster illustrated two years of laboratory work during which he exposed mice to different degrees of radiation and then extracted their stem cells to measure the relationship between the radiation exposure and the death of the cells. Fancy stuff. When I asked him how he had time for residency, family and research, he simply replied: “I don’t, really.”

My presentation was not nearly as fancy, but did make for what I figured would be a captivating story. It was about a “drug mule” I had encountered during my rotation in the Intensive Care Unit (ICU). She was a young woman barely out of her teens who was brought into our Emergency Department after suffering a seizure on the street. She subsequently went into cardiac arrest and was brought back to life after more than twenty minutes of CPR. Before her heart stopped, she was able to tell us that she had tried cocaine for the first time.

While in the ICU, our patient was kept on mechanical ventilator support for over a week because she could not breathe on her own. A number of people claiming to be her relatives showed up daily to visit, and her alleged mother raised concerns about my patient’s enlarged abdomen. We did an abdominal X-ray and saw nothing unusual. Eight days later, a nurse found pellets of a white substance in her diaper! That’s when we opted for a CT scan and found numerous other drug pellets that had not been picked up on the X-ray. It turned out that she had been paid to smuggle a load of cocaine into the U.S., probably never realizing the risk she was taking.

I found only one study comparing the sensitivity and specificity of different imaging modalities for detection of concealed drugs in the human body. A CT scan, although costly and laborious, is definitely the way to go when someone is suspected of concealing drugs in their body. This is especially so when there is imminent danger to the individual’s life, as was the case with our patient. Given that one or more of the drug pellets had already burst, a steady stream of cocaine was leaking into her system causing havoc.

When I first set out to become a doctor, research was not at all on my mind. I wanted to be a clinician, to be with patients. Forget about lab rats and data collection, forget about grant applications and writing papers. That “stuff” wasn’t for me, so I thought. But that changed during my third year of medical school, when I first got my feet wet in research on Transient Ischemic Attacks. Despite the small role I played in the project, I felt an indescribable satisfaction from giving back to the scientific community. I was, in my own very small way, contributing to the advancement of Medicine!

The judges seemed taken by my presentation about the cocaine overdose. I felt I had told a story, showed images, presented some data, and had effectively conveyed the message I wanted my audience to take home. However, I had to rush back to the airport before the announcement of the winner of the poster competition was made. I had entered this contest for fun, really just “for the heck of it”. But then a very welcome surprise came through my phone as I was to board my plane: I had won! Out of the fifty-seven contestants in my category, I came in first. Certainly worth the plane rides and the early mornings! All those years working at the McGill Office for Science and Society had seasoned me properly!

Who would have thought back then that I would be representing the state of New York at the National American College of Physicians conference? Not me.

Melody Ko

FOLLOW DR. KO: Staying up late…Worrying…

PICFB.tmpIt is now midnight, hours after the end of my shift, and I just texted the night resident from home to ask for an update about my patient who went into diabetic ketoacidosis (DKA) this afternoon.

DKA is a potentially life-threatening complication from uncontrolled diabetes and is more prevalent in those with Type I Diabetes, otherwise known as Juvenile Diabetes, than in people who suffer from Type II Diabetes wherein insulin resistance is acquired later in life.

In DKA, the body does not have enough circulating insulin, a crucial hormone in carbohydrate or glucose metabolism. When insulin is not around to allow glucose to enter cells and be “burned” for energy, the body resorts to burning fat, which then results in the formation of “ketone bodies” such as beta-hydroxybutyric acid which render the blood acidic. The human body is amazingly adept at buffering any changes in the pH (a measure of acidity or alkalinity) of the blood in order to maintain homeostasis, which explains why “alkaline” or “acidic diets” advertised to change the pH of the blood and hence mitigate diseases have no scientific validity.

However, in the case of severe insulin deficiency, the system does eventually get overpowered. A cascade of complications ensues, some of them catastrophic: dehydration, abdominal pain, vomiting, electrolyte disturbances, and labored breathing called “Kussmaul respiration”, the body’s last attempt at ridding the excess acid by exhalation. Stupor, coma and death may ensue.

Before the advent of insulin therapy in 1922, DKA was virtually always fatal. Today, the death rate has dropped to less than 2% thanks to scientific advancement. Nevertheless, DKA remains a medical emergency and is often managed in the Intensive Care Unit, hence my concern about this patient whom I shall name Paul.

Paul is a young man in his early 30s who has not been lucky. Born deaf and mute, diabetic since childhood, he looks frail and thin. He relies heavily on his mother to communicate with the outside world, which makes him appear child-like, and yet he exhibits maturity and patience when it comes to his illness. Day or night, whenever I go to see Paul, his mother is at his bedside without fail. Also without fail, Paul always greets me with a nod, and never protests against the myriad of tests and blood draws that he has to endure.

On admission, Paul’s chief complaint was abdominal pain and shortness of breath. His blood glucose was abnormally low, probably secondary to taking his usual dose of insulin despite decreased appetite and food intake. His was given extra glucose to correct his hypoglycemia, meanwhile his chest x-ray revealed an ugly picture of severe pneumonia obscuring almost half of his lungs. Intravenous antibiotics were immediately started. Probably through the hustle and bustle of shift changes, somehow Paul’s blood sugar level was overcorrected and he went into DKA which was subsequently successfully treated.

To my dismay, Paul’s blood sugar crept up again and he again developed DKA. I made sure he was being properly hydrated intravenously, started him on a continuous insulin drip, and checked his labs periodically. I felt bad for drawing this poor young man’s blood so many times, poking him left and right. I also had a pang of guilt for perhaps not having supervised my interns more tightly to minimize the chance for error.

I am quickly learning that being a senior resident comes with a whole different level of responsibility, a weight that I carry with relish but also with a tad of apprehension and caution. With no senior above me to verify what I do, except for the attending physician, I double and triple check my work, my orders, afraid that I might have missed or forgotten something. But I also stay later because I care more and enjoy my job more.

Finding a healthy balance is always a challenge in medicine, and now more than ever. After a few hours, I had to put my trust in my colleagues and sign over to the night team to continue the management of my patient. Probably still hypervigilant from being a new senior, I texted my co-resident from the night team to make sure that Paul is ok. She might call me obsessive-compulsive instead of vigilant, and she would be right.

I trust that Paul is in good hands and accept that I cannot single-handedly do everything. Instead, I will now rest my mind and body in slumber to refuel for another day.

Melody Ko

FOLLOW DR. KO: End of Intern Year

Melody and patientIt seemed not so long ago that I had to ask my second-year resident about everything.

The nurse paged me about a patient with high blood pressure; I asked my second-year which medication I should dispense. A patient complained of shortness of breath; I asked my second-year what to do. My prescriptions wouldn’t print; I asked my second-year what was wrong with the printer. It felt ironic to me how one day I was nothing but an annoying medical student, and the next day everyone was calling me “doctor,” and yet I didn’t feel any different.

This time, however, I do feel different. In a few days, on that notorious first day of the month of July, a new batch of Interns will come in, and I will be that second-year that they come to for answers.

Unlike in Canada or other countries where first-year residents are merely called “R1”, the hierarchy in the American medical field is further underscored by the terms “Intern” and “Senior.”

“Internship” is often said to be the toughest year of residency, during which the young doctor with her newly donned white coat has to prove to the world that she is tough enough to be a doctor. And of course, being at the very bottom of the feeding chain (because medical students aren’t even on the radar), interns, or first-years, are given all the “scut work.”

Scut work is basically tedious and what one might consider menial tasks that no one likes to do but which have to be done. Common scut work includes calling a patient’s primary care physician to obtain their background information, faxing papers, waiting for papers to be faxed back, drawing blood, bringing the blood sample to the lab, filling out paperwork, running around the hospital looking for a cane because the patient cannot be discharged without one… the list is endless, and so are the hours. Mel checks IV

I remember being awakened in the middle of the night by interminable pages. Feeling frustrated over a dispute with a nurse; angry because of a rude and aggressive patient; incompetent about not being able to figure out what was wrong with a patient and discouraged about just being a cog in the wheel.

And then one day, recently, I heard a code. A patient had crashed. I ran to the scene where my co-intern Dr. Aaron Pickrell was already giving chest compressions to a patient who had collapsed on the floor, and giving nurses orders. In that split second, I felt pride for my colleague and friend. I rushed to his side and took over the chest compressions. We asked the nurses to get the patient’s finger stick to check her blood sugar level, checked the patient’s blood oxygen level with a pulse oximeter, ordered dextrose, glucagon, epinephrine, ordered the respiratory therapist to administer oxygen… Of course it was not perfect, and it was messy, but there we were, “little interns”, acting like doctors.

More experienced residents and attendings arrived shortly, and guided us in our efforts to save this woman’s life.

Yes, this time, I do feel different. I feel like a doctor.

FOLLOW DR. KO: A Man’s Last Days

hostpital bedMelody Ko, MD

For days, even weeks, he had been relentlessly asking anyone who would listen to help reposition him in his bed. Move him up. No, turn him more to the left. Wait, lift the right leg higher, lower. It was non-stop. The nurse tried to do her best, but could only shake her head, because he was never content.

To be fair, he did look very uncomfortable all the time, but we didn’t know how to make him feel better; until one day, we didn’t have to worry any more.

 Let’s rewind the clock.

I didn’t know this patient very well, because I wasn’t his assigned physician, although I did round on him every morning with my team. What I knew was that he was very, very sick. Only in his forties, he was missing one leg from an amputation at age fourteen due to osteosarcoma, a type of bone cancer found in the pediatric population. On top of that, he suffered from diabetes and hypertension, two diseases so common in my patient population that we call them part of the “Lincoln package,” Lincoln being the name of the hospital where I work.

Less than one year ago, our patient had trouble passing urine, and was diagnosed with metastatic prostate cancer. The disease had already spread to his vertebral column, compressing his spinal cord, requiring surgery to relieve his excruciating pain.

When I saw him, he was cachexic, a syndrome characterized by extreme weight loss, weakness and muscle atrophy, all hallmarks of someone suffering from advanced cancer. The oncologists had already done everything they could; they had used their whole armamentarium of chemotherapeutic drugs including casodex, zometa, and taxotere, as well as radiation. There was no improvement. Not that I know much about cancer treatment, but apparently, all the big guns had already been tried.

When his mental status started to fluctuate (see previous blog for a description on how to assess mental status), we knew that he would not make it out of the hospital. As if this were not enough, his condition was further complicated by an infection from the back surgery he had undergone a few weeks prior. A fluctuant mass started to grow bigger and bigger underneath the incision site, indicating the presence of an abscess, or collection of pus. His electrolytes were out of whack and difficult to correct, most likely related to a hormonal disorder caused by his cancer, called Cushing’s Syndrome.  Simply put, it was a medical mess.

Fast-forward a few days.

I was on call one evening and received a page from the nurse that this patient’s heart rate was elevated. When I went to evaluate him, he appeared more confused than usual, and complained of pain. His cousin had come from out of town to visit him and was in tears by his bedside. I went to his IV (intravenous) pole and increased the rate of his morphine drip so he would get more of the narcotic via continuous infusion. I wasn’t 100% sure that his tachycardia, or fast heart rate, was due to pain, but at that point, I didn’t think that anything else mattered.

Later that night, before I went home, I returned to check up on him. He was muttering incoherently by himself, alone in his room. When I asked if he still had any pain, he said no. I was glad that perhaps I had helped alleviate his pain with the increased dose of morphine.

 The next morning, I was told that he passed away a few hours after I left.

Intellectually, I knew I did the humane thing to alleviate the suffering of a dying man. But did I perhaps accelerate his passing by turning up that morphine drip? We’ll never know. I’m learning that medicine is not white or black. It is many shades of gray. And the shades are separated by a blurry line.

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