Office for Science & Society: From our Contributors

I have always found it bewildering that even the most demented patients, ones who barely know their own name, will be able to tell you that Barak Obama is the President of the United States.

There are a few standard questions we ask our patients in order to assess their mental status. Sometimes patients come in confused, either because they have baseline dementia from old age, are hypoglycemic (low serum glucose or sugar level), have had a stroke, or perhaps are acutely intoxicated with alcohol or drugs. The differential diagnoses for “altered mental status”, which doctors like to shorten to AMS, or confusion, are vast.

First, we want to know if the patient is awake, versus drowsy, or obtunded. Then we qualify the patient’s responsiveness. Is the patient responsive to verbal stimuli? Will they respond to their name? Or do they react only to noxious stimuli, such as inflicting pain by say rubbing their sternum.

Once a patient is responsive, you want to assess their level of orientation. Here come the questions. The quickest way to assess orientation is by asking three simple questions: What is your full name and date of birth? Where are you right now? What is the date today? If the patient answers correctly to the all three questions, then he is oriented to self, place and time. We call that “oriented x 3”. A patient who is awake, alert, and oriented to all three gets the “AAOx3” grade in their chart. If they are only oriented to self and place, but not to time, then their grade gets diminished to AAOx2, and so on.

To go a tad bit deeper into our mental status assessment, we ask more questions, which means spending more time with the patient! Something that unfortunately doctors are at times reluctant to do. One very common question we ask is “Who is the president of America?” This allows us to evaluate how aware the patient is of his surroundings, and if he is oriented both to self and to other people, because after all, it’s hard to forget one’s own name, although I have seen it happen.

Amazingly, even in the most inebriated, demented, or delirious state, I have yet to encounter a patient who did not know that America’s president is Barak Obama. One particular patient who barely knew his own name or age even knew that Obama was elected twice!

Flabbergasting and somewhat amusing at the same time. I wonder if the same goes for people with AMS in other countries.

Obama is still President, isn’t he? When you’re a resident you tend to lose touch with the outside world.

Melody Ko

Sometimes, I feel like my life comes straight out of a movie.

Imagine this opening scene: A young woman who appears to be in her late teens to early twenties hails a passing ambulance in the middle of the night, says she has done cocaine for the first time and isn’t feeling well. She then has a seizure and collapses.

The EMS (Emergency Medicine Services) transports her to the closest Emergency Department (ED), which happens to be Lincoln Medical Center where I work. Upon arrival to the ED, the patient had another seizure before going into cardiac arrest. It took the emergency team seven attempts to shock her heart back to a detectable and regular rhythm, after which the now unconscious and intubated (a tube was inserted into her airway and connected to a ventilator to breathe for her) girl was transported up with all her tubes and ventilator to the Medical Intensive Care Unit (MICU) where I was assigned to be one of her doctors.

When I saw her, she was already covered in a cooling blanket to bring her body temperature down. Our normal temperature is 37°C (98.6°F), with some fluctuations throughout the day. When it falls below 35.0 °C (95.0 F), a condition known as “hypothermia” sets in. At this point virtually all bodily functions are impaired.

There is, however, something called “therapeutic hypothermia.” Basically, it has been shown that for patients who survive cardiac arrest, lowering their core body temperature to between 32.0 °C and 34.0 °C for 12 to 24 hours immediately after the arrest improves outcome. Cardiac arrest leads to ischemia, a restriction in blood supply to tissues that causes a shortage of oxygen and glucose needed to keep cells alive. At a lower temperature metabolism is decreased so that there is less of a demand for oxygen and glucose. There is also a reduced risk of reperfusion injury which is caused by a sudden incoming of blood after a prolonged lack of blood supply, possibly causing neurological damage.

For three days, the identity of this girl remained a mystery. She had no I.D. and she was unresponsive. I knew that cocaine can have unpredictable effects, but it seemed surprising that a young woman could end up in this state by trying it “just once”. Cocaine is a stimulant obtained from the coca plant and can cause constriction and even spasms of blood vessels. While most cocaine users do not experience immediate serious consequences, for a few unlucky ones the first time is also the last time. They die from a heart attack due to vasospasm of the coronary arteries. Chronic users may think that the only thing they get from cocaine is a high, they may actually go through life victims of mini strokes with eventual fatal consequences.

Finally, on the third day, several family members showed up: Mom, cousins, aunts, uncles. They had flown in to the U.S. from their home country after discovering the girl was missing. The mom had some concerns that the patient’s abdomen appeared a bit distended, so an abdominal x-ray was done but was unrevealing. The story was a little odd, but we let the social worker handle the social issues.

For the next two weeks, family came to visit daily. Mom was always by the bedside, often teary-eyed, understandably. We were all glad that the girl seemed to be improving steadily, albeit slowly. By the second week, she was awake and could follow commands. Her vital signs were, however, unstable. She was persistently tachycardic (fast heart rate), and our attempt to extubate her, meaning to wean her off the ventilator and remove her breathing tube failed. She had to be re-intubated.

One evening, I came back to the Intensive Care Unit from the emergency department and found policemen milling about. Not an unusual sight in the South Bronx so I didn’t pay much attention. But then the nurse told me that they were there because she had found four bags of cocaine in the patient’s diaper!

Bewildered, especially since the abdominal x-ray had not shown any foreign objects, we immediately ordered a CT scan, a more sensitive test, and this time, there was no doubt. There were at least eleven more bags in her body, and one of them looked like it was leaking. No wonder she was so tachycardic, she was high this entire time! I was instantly reminded of the award-winning movie Maria Full of Grace, a Columbian-American film released in 2004 about a young woman agreeing to be a “drug mule” to make ends meet.

Well, the drugs had to come out. Safely. We contacted the Surgery department, the Gastroenterology department and Poison Control. Finally, it was decided that the best option was emergency surgery. She would have to be opened up so the drugs could be removed with special care taken not to perforate any of the bags.

Closing scene: I visit the patient after her operation. She’s still intubated but now has a red scar running down her abdomen. The packets as it turned out had been tied together with a plastic string, which is why they were not expelled earlier.

I said hi to the mom who was still at bedside. I wondered if she had known all along.

To read more of Dr. Ko’s posts, please click here. 

Melody Ko

When we see a patient for the first time in the hospital, it’s a good bet that they will already be on a number of medications. It is often a challenge to find out what drugs they have been previously prescribed and whether they are actually taking them. Most patients do not keep track of their health problems and do not remember the name of the medications that their doctors had prescribed. If you’re lucky, they may tell you that they are taking a little red pill at night and a yellow one in the morning. Even when they know what medications they are supposed to be taking, there is a high rate of noncompliance either due to forgetfulness, carelessness, concern about adverse affects, inconvenience, or often, just plain misunderstanding the instructions.

My least favorite part of the job as a physician is to make phone calls, as necessary as it sometimes is. Patients get admitted for problem x,y,z, but since I do not know them, I have to track down their primary care physician (thank goodness for the internet), call other hospitals where they had previously been admitted, or call family members. All this in order to obtain some background information about a patient.

Mr. Ortiz (not his real name) was brought in by ambulance after he fell in his apartment due to overwhelming dizziness. When he arrived in the Emergency Department, both his blood pressure and his heart rate were alarmingly low, and did not improve even after being given intravenous fluids, atropine and norepinephrine. After failure of drug therapy, a transvenous pacer was placed by threading a pacing electrode through his right internal jugular vein (in his neck) into the right ventricle of his heart. The pacer was set at a specific rate of 80 beats per minute to ensure adequate blood distribution by the heart to the organs.

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Some patients leave a greater mark on you than others. Miriam’s case didn’t just upset me, it wrenched my insides. The dreadful saga began innocently enough. Miriam (not her real name of course) had been admitted to my hospital for abdominal pain and vomiting. A pelvic exam was ordered to rule out pelvic inflammatory disease, a severe infection of the uterus most often a result of untreated sexually transmitted infections.

The intern assigned to her case was not comfortable performing a genital exam and looked to me for some help. A quick history was taken, but this being the South Bronx, we assumed that the lady was sexually active. As we were to learn later, that assumption was as wrong as could be. A strong reminder of the importance of taking a thorough medical history!

The usual procedure for a pelvic exam involves the physician inserting two fingers through the vaginal opening to palpate for any abnormalities. It quickly became apparent, however, that there would be no usual procedure here. Something was very different! At first I thought that perhaps I was out of practice because I just could not locate an opening. When I finally managed to find it, I was barely able to insert one finger. Even that caused excruciating pain. A speculum exam was completely out of the question. Was it possible that she was so nervous that her muscles were contracting in some extreme fashion? I didn’t think so. This didn’t feel like muscle tension and her anatomy just didn’t look right. It was time to call an expert.

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It was perhaps my sixth night shift in a row and I was starting to feel the accumulated fatigue creep up on me. Those fourteen-hour long night shifts tend to take a toll. Dressed in scrubs and my long white coat, my beeper tightly clipped onto my waist, a list of all the patients I was responsible for that night in my hands, I headed to the Emergency Department (ED) to take my first admission.

Another case of chest pain. Almost anyone who comes to the ED with complaints of chest pain gets admitted. First task is to rule out ACS or Acute Coronary Syndrome. The differentials for chest pain are wide and varied, ranging from heartburn to musculoskeletal ache to something more serious such as a heart attack. A heart attack, or in medical jargon, a myocardial infarction (MI), is one of the conditions classified as ACS. ACS represents a spectrum of conditions that is characterized by a sudden reduced blood flow to the heart. The majority of patients who get admitted for workup of a chest pain end up having nothing serious. Once in a while, however, we get a “real” case.

This patient was young. An African-American woman in her forties, no past medical history, no risk factors. I found her on a stretcher waiting to get a chest CT. A CT scan, or computed tomography scan, is a medical imaging procedure that uses a computer to take multiple cross sectional x-ray images of a person’s body. I’m guessing that the Emergency Physician ordered a chest CT to rule out a pulmonary embolism or an aortic dissection, both of which are potentially lethal and can cause chest pain. (more…)

Ever since I moved to New York City for my clerkship (part of the clinical training in medical school) at the Lincoln Health Center, I wake up every morning in a great mood. And that’s saying a lot because I have never been a morning person. After years of hitting the books, I am just so excited to finally try my hand at real medicine. So in spite of sleep deprivation, everyday I look forward to going to work, meeting patients, learning new cases, and performing minor procedures. Ok, to be fair, I shouldn’t call it “work” since I’m not actually getting paid for my training, but it just sounds better.

Real hospital life is not Grey’s Anatomy (for those who don’t know, it’s a medical drama), however. Not everyday is exciting or even interesting. As a matter of fact, some days, such as today, can be painfully mundane and frustrating. The Lincoln Medical and Mental Health Center, located in the South Bronx, caters to a rather unique subpopulation of America. Most, if not all, of our patients are on Medicaid, or have no insurance. Many don’t speak English, which I actually quite enjoy because I get to practice my Spanish with my patients, but it can sometimes make history-taking challenging, in which case we call for a translator. Unfortunately, due to the fact that many cannot afford to see a primary care physician (the equivalent of our family doctors in Canada), they show up in our Emergency Room (ER) for everything and anything because by law, we cannot turn them away.

As many of you undoubtedly already know, a major difference between practicing medicine in Canada and in the U.S. is liability. Doctors here have to constantly worry about covering their posteriors. The combination of people’s financial difficulties, lack of education, and doctor’s over-cautiousness from fear of lawsuits resulted in this patient that I saw today: A middle-aged woman who showed up in the ER because of a skin lesion on her foot. She was subsequently admitted by the ER physician to our department in Internal Medicine, meaning that she was hospitalized for further assessment and treatment. As I read her chart in the morning before going to see the patient, I perused different possible diagnoses in my mind: cellulitis (a type of skin inflammation and infection), angioedema (rapid swelling of the skin and underneath the skin), dermatitis (itchy inflammation of the skin)…

When I saw the patient and examined her, I was flabbergasted and befuddled. What exactly are we looking at here? Where is the lesion that was severe enough to warrant hospitalization? Then my attending physician pointed the culprit out to me. Ladies and gentlemen, please hold onto your seat because you will not believe this. The “emergency case” was a callus! That’s the thick, hard skin that you get when you wear shoes that are too tight! I was absolutely stunned and stayed so for the rest of the day. This woman was there, taking up bed space, billing thousands of dollars to the government, when what she really needed was a pedicure!

Why was this patient not sent home by the ER physician? Maybe he or she wanted (us) to make sure that it was not something more serious out of paranoia; you don’t want to get sued for negligence later on, or maybe the emergency doctor was just functioning on auto-pilot that day and admitting all the patients, sending them off to different departments. Who knows? But when I asked my team of physicians why this woman was here because she shouldn’t be, their answer was: You’re a student, and even you know that.

There is a reason why people say that July is the most dangerous month to go to the hospital. Every year, on July 1^st, newly minted M.D.s, fresh out of medical school, don a long white coat, heavier than the student’s short coat, perhaps representing more weighty responsibilities. At the same time, the most experienced senior residents graduate and move on, leaving behind residents who have not logged in as many hours, or seen as many patients to take over.

Surely, this new shift in residents, along with the fact that we, the “first-years,” know nothing (or at least that’s how we feel and that’s what we are told), has an impact on patient care, complications and death rates. Lack of medical knowledge isn’t necessarily always to blame here. The former first-year residents get promoted to senior residents and have to adjust to a whole new range of responsibilities and adapt to a different pace of work. At the same time, the new interns, who so far had mostly been shadowing doctors as students, all of the sudden need to take charge. Unfamiliarity with the hospital’s computer system can also result in prescription errors and duplicate orders.

Dr. John Young and his team from the University of California in a study published in the Annals of Internal Medicine, has actually shown that hospital death rates increase from 8% to 34% in the month of July. Scary, I know. Especially for those who get sick during this precarious time. On the other hand, hospital administrators are well aware of this phenomenon and are taking the necessary measures to minimize the effects of this transition. In my program, for example, two senior residents are specifically designated to monitor and coach the new doctors. Instead of seeing patients, they peruse the halls to make sure that the interns get the help they need and provide guidance if needed. Morning reports and noon conferences are temporarily canceled to give us more time to finish our work.

Nevertheless, the hospital is definitely more hectic than usual in the summer months, with a lot of us looking like headless chickens running in circles. Not ideal, but inevitable in order to train and produce new doctors. In July we are headless chickens; by next April the same headless chickens might save your life. . Try not to get sick in July.

Melody Ko

The hole on the bottom of my left foot has finally closed up. Now all that is left is some scar tissue and hyperkeratinized skin, more commonly known as a callus. After physical trauma, such as friction or injury, dead skin cells in the most superficial layer of the skin proliferate as a protective mechanism, resulting in the esthetically not-so-pleasing hard skin. Sometimes these calluses disappear on their own with time, other times interventions are required, chemically with salicylic acid, for example, or mechanically by rubbing with a pumice stone. Although I could certainly do without it, the sight of my scar and callus brings back fond memories of Thailand, where I spent a month backpacking before signing my life away to Residency.

It happened during a three-day trek in the jungle near Chiang Mai, the northern capital of Thailand. The trek started with a promenade on elephants through the woods and into the river, then a hike up nonexistent paths under the unforgiving Thai sun, with our backpacks weighing on our backs and sweat dripping from every pore. It was the most gruesome three-hour workout I have ever put myself through. One of the trekkers even vomited from overexertion.

Singing with the Lahu Children

We managed to reach our destination for the day, a small hill tribe village inhabited by the Lahu people, before the sky opened up with a torrential tropical rain. The Lahus hosted us for two nights in one of their bamboo huts. Since there was no electricity at night, we occupied ourselves with Sangsom Thai rum while our guide played the guitar under candlelight. Going to the bathroom was an adventure of its own. With only my dying flashlight to light the way, I had to carefully go down a slope made muddy and slippery by the rain. Then came a balancing act on a few wobbly steps to descend to the “washroom” which consisted of a hole in the ground for our bodily wastes. In this part of the world, squatting is the way to go. The washroom was also equipped with a tub of water for flushing and washing. No paper of course.

As I gingerly stepped down the wobbly and slippery steps, I kept muttering to myself: “Be careful, do not fall, do not fall.” Lo and behold, I fell and slid all the way down. That was my first injury of the trip: A big road rash on the back of my left shoulder. Although it was only a superficial excoriation of the skin, open wounds are prone to infection, especially when you’re in the wilderness and caked with dirt. Luckily, one of the other campers had packed some iodine solution so my wound could be cleaned and disinfected. The wound eventually healed without complication, and I have a scar on the back of my left shoulder to remind me of my voyage to the Lahu toilet.

My left foot, however, was not so lucky. On our last day of the trek, we walked barefoot to a river for some white water rafting. The water wasn’t exactly clear, but more of a muddy yellow color, perhaps partly from all the wastes oozing from houses on the banks. Later that evening it was back to our hotel in the city where I was finally able to take a hot and thorough shower. That’s when I noticed I had a tiny splinter on the bottom of my foot! Being a doctor now, I figured I would just take it out myself. So off I went to my toiletry bag to take out a pair of tweezers that I normally use for my eyebrows and I rummaged through a travel sewing kit for a needle. Being a properly trained physician, at least in the mind of those who granted me a degree, I rubbed alcohol on my skin and on my makeshift surgical instruments, and then proceeded to operate. I’m not sure if the entire splinter came out, but I wasn’t too worried about it. I kept applying topical antibiotic on the small wound, and that would be it. Or so I thought.

In the course of the following few days, the small wound that I had created turned red and slightly purulent, meaning containing pus. The infection was really small and I deemed it insignificant, not much different from a pimple. I squeezed out the pus and continued applying topical antibiotic ointment, thinking that it would go away on its own. Then the redness started to spread. The pain intensified. A week later, the middle of my very small wound had turned black, a sign of necrosis. Necrosis is premature cell death in living tissue, and can result from infection or poor blood circulation. If left untreated, it can progress to gangrene, meaning that there has been tissue death. Treatment is debridement of the dead tissue, or possibly even amputation of the gangrenous limb. Without medical attention, it can be lethal.

Neither death nor amputation struck me as an attractive prospect so I decided I had better drag myself to a hospital, quite literally, since I could hardly walk. By that time, we had made our way to Pai, a lovely northern village best known for its high hippie concentration. Just as I suspected, the doctor prescribed an I&D which stands for incision and drainage, or incision and debridement, a procedure that I have myself performed multiple times. The doctor makes an incision with a scalpel over the abscess to let the pus drain, then uses a pair of forceps to go inside the cavity and clean out the residual pus and dead tissue. All this under local anesthesia, of course. Except that the process of getting the local anesthesia is rather painful, or so I had heard from patients I had treated. They were absolutely right, as I now learned. After the I&D, the cavity is packed with sterile gauze, to be changed daily, which meant that I had to go back to the hospital every day. I left the hospital with a hole in my foot, one week’s worth of oral antibiotics, and a newfound appreciation for what I had put my patients through.

So that is the story of the hole in my foot, and now I have a hyperkeratinized scar as a souvenir. It is not my only one though. Throughout the rest of trip, I fell from a motorbike, the number one tourist killer in Southeast Asia; got stung by jellyfish multiple times while scuba diving; scraped my knee while deep water soloing (a form of free rock climbing on sea cliffs); scratched myself on sea rocks, sea urchins. I have marks all over my body from all over Thailand.

It was a wonderful trip. Residency should be a breeze.

Getting an I&D in an Emergency Room in Thailand