It's 4:15am

It's 4:15 am - time to get up.  By this time in residency - 3rd year - you're used to abnormal schedules and abnormalities of many kinds.  Life still throws you a curveball every now and then and you deal with it.  I still like what I do.  At the same time I'm glad I had a career before medicine to provide me perspective that there is life outside the medical career and that the sometimes "obsessive" ways we do things are but one way to approach work.  This profession can be all-consuming and it takes a lot of effort to balance work and personal life - that part never seems to get any easier.  You find that like hygiene ... balancing needs to become part of your daily routine or it won't happen.  

Treatment of acute pulmonary embolism in patients with lower gastrointestinal bleeding risk

Tomorrow (12/13/2012) at 8-9 am, I'm giving a brief conference presentation on "Treatment of acute pulmonary embolism in patients with lower gastrointestinal bleeds" at St. Luke's Episcopal Hospital in the Texas Medical Center, Houston, Room C030 on Level B1 near the Cooley auditorium (St Luke's Episcopal Hospital TMC).  I'm happy to have the opportunity to do this and I am fortunate to have received considerable advice and assistance from the attending physician (a gastroenterologist) on this rotation Dr. Lyone Hochman.  I like this topic because there is relatively little guidance in the literature and a potential for optimizing patient safety.  I may explore this topic further as well in the future.

Gastroenterology rotation

This month I started a gastroenterology rotation at a private hospital. I have the privilege of working with a very experienced and highly respected gastroenterologist attending physician. In terms of workload we see 2 to 4 patients and maybe one or two consults. The attending has more patients than this, of course. However discussing and supervising the "teaching" patient cases is relatively time-consuming for the attending physician and if there are too many teaching patients to be seen (not a problem on this part of the rotation), rounding and supervision becomes very rushed and sometimes not very useful from a training perspective. Fortunately we have plenty of time for observing procedures such as EGD's and colonoscopies. A third-year medical student is also rotating on the service. This medical student is extremely smart and very helpful. Depending on how many patients we have on our service or what lectures the medical student must go to, I may have the student see all the patients and then pre-round the the patients with him. At this hospital with hospital we (the residents and attending doctors) can addend medical student notes and depending on what the schedule is exactly, I may write a few complete or all of the progress notes and consult history and physical notes (documents). This way I can talk about the patients and pathologies with the student before we meet with the attending. The medical students On my service usually find this helpful and they are more prepared when the attending asks them questions about the patient and associated illnesses and treatments. I certainly learned a lot from teaching the material as well. I just started this rotation and thus far the cases have been relatively straightforward. I hope to see a difficult or complicated or unusual case soon because need to give a presentation next week as part of the gastroenterology conference. Although I'm not required to work on weekends for the gastroenterology service at this time, I am on call for the hospital where I'm rotating. I may see an interesting gastroenterology case during my overnight call because I see so many patients. Another possibility for the discussion at the hospital gastroenterology conference this coming week might be some of the cases from last month when I was on the transition rotation. Patients with cerebral palsy and spina bifida and other congenital conditions can have life threatening problems with chronic severe constipation not effectively treated with laxatives, bowel motility agents or rectal enemas and have surgical anatomical modifications to their GI tract in addition to daily motility agents or laxatives (such Polyethylene Glycol 3350 - brand name Miralax) to help prevent bowel perforation and other medical complications of chronic . For example, see the MACE modification (see http://en.m.wikipedia.org/wiki/Malone_antegrade_continence_enema).

On call today.

Today I'm on call 24hrs at a big hospital. During the day the various medicine teams and specialties admit their own patients and deal with any issues. I'll probably spend most of the day working on some case reports and then work with two interns to admit any patients that need to be admitted in the evening or overnight. I usually like call and hopefully today will be no exception.
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Update: That day's call went very well. We had five admissions between two interns. I was able to rest during the day as well as rest a few hours overnight.

Outpatient Clinic

This month I'm on the "Transition Medicine" rotation, which is a type of ambulatory (as opposed to inpatient) rotation. Transition medicine focuses on the transition from pediatrics to adult medicine for patients with chronic conditions such as cerebral palsy, muscular dystrophy, Down syndrome, cystic fibrosis, and congenital heart defects. Many of the patients I have seen are doing quite well and benefit from the specialized care and social services that Transition medicine offers. The rotation also has an extensive didactic component. I'm a little sad that this fun rotation is almost over.

--Ralf

Location:Houston, Texas

Home safety lesson - Arc-fault circuit interrupters (breakers) help save lives, but they are not a panacea.

Our unpleasant problem

A couple of years ago, I didn't know what an arc-fault circuit interrupter (breaker) was ... nor did I know that my home had one.  Now I realize that one of these devices seems to have prevented a fire in my home.  I must confess, the first time I heard about the device, I was not very happy.   We noticed that one of our "circuit breakers" associated with a children's bedroom started tripping for no apparent reason.  At first the breaker tripped every 2-6 months; then it started tripping every month.  Finally it was tripping every week, and then every day.  We tried unplugging everything from the related circuits, turning off lights.

Electrician - too expensive to solve the fault.

Eventually we hired an electrician to troubleshoot the problem:

Wesco Systems Electrical Services
1416 North Main Street

Pearland, TX 77581

Phone: (281) 485-9304

Fax: (281) 485-7311

 

TECL: #24619

(http://www.wescosystems.com/)

He noted that the circuit was protected by arc-fault circuit interrupter (breaker) such as the two shown below.  We had problems with another circuit in our home (built by Pulte in 2004) and he examined it first.  When he removed one of the light switches he found that it was very hot to the touch and the plastic components had become brittle.  He replaced that switch and then proceeded to troubleshoot the circuit in question.  He made sure the circuit was completely unloaded and that nothing was plugged in.  We then reproduced the problem for him by loading the circuit up with home computer equipment and by turning on lights.  The circuit soon tripped.  He then opened several of the switches and electrical outlets but did not observe any problem.  Because the electrician was unable to find a wiring problem that could explain the arc-fault trip after searching for 2 hours, he finally gave up.    He suspected that there was a wiring problem, but he said it would take many hours or perhaps days to test each circuit point (switch, outlet, light, etc.) and to identify the cause, if it could be found at all.  He was ready to leave when I suggested he at least try something to make some progress.

I suggested that he replace the arc-fault circuit interrupter because perhaps this device was defective and this was the problem.  Although he could not determine that the device was indeed defective, he replaced the original arc-fault breaker (which I suspect looked like the one with the yellow sticker (#1) in Figure 1, below) with the one with the yellow button (#2).  After this, we were unable to immediately reproduce the problem even by loading the circuit once again.  We paid the electrician approximately $650 and we hoped that this corrected the problem.  Considering that he spent several hours on trouble-shooting the circuit and replaced an arc-fault breaker, this was probably a fair price.

Figure 1.  Two Arc fault breakers (arc-fault circuit interrupter) are shown in the home breaker box and are labeled #1 and #2 in the image.  Two models are shown.  The top one (#1) has a yellow "Test AF" sticker.  The second one is below it (#2) and has a yellow unlabeled test button and was in the position of the circuit that kept tripping.   The top one (#1) is original equipment that came with the home (built by Pulte in 2004).  The second one (#2) was installed by an electrician in 2012 to replace a prior arc-fault breaker.

More disappointment

I told my wife that I that the electrician had replaced the arc-fault breaker and one damaged (burned up) light switch in a separate circuit and that I hoped this corrected the problem.   Unfortunately, the child bedroom circuit tripped again the next day.  We tried unloading the circuit and left just one small light connected, but the circuit tripped again.  The repair attempt above did not work.   We called the electrician above back to let him know that the problem had recurred, but we never heard from him again.  We knew it would be expensive to have him test every circuit, and we were not eager to spend thousands of dollars to test every electrical component in this rather large circuit protected by the breaker.  We used some ugly extension cords and flashlights in the meantime as we considered our next move.  It almost seemed like it would be cheaper just to replace parts of that circuit with new wiring than to trouble shoot the large amount of wiring where the problem could be hiding.  Although it was possible that there was a wiring problem, I was beginning to sour on the fact that we had an arc-fault breaker, and that it was required by code.  I would not be able to hire an electrician to replace it.  I did not feel comfortable replacing it myself either.  I considered that maybe this arc-fault breaker was tripping for a nuisance reason.  Perhaps there was a minor wiring or device problem and the breaker tripped for no real safety reason.

Very temporary workaround

Mysteriously, the circuit started to work a little bit.  We would only use it with very light loads (a fluorescent overhead light, etc.).  It would work for several hours and if the light was turned off, the breaker would not trip for several days.  When the arc-fault breaker tripped, we simply reset it.  This continued for about 10 months or so.  Sometimes the arc-fault breaker would trip and could not be reset without tripping immediately again.  However, if I waited a little while (minutes or hours), the arc-fault breaker could be reset and the circuit could be used at least briefly to put the kids to bed with their overhead light on.

Fault detected & Conclusion

One day, the arc-fault breaker started to trip frequently.   It simply would not reset, even if I waited a few minutes.  Finally it reset, but then it would trip again.  Then I tried resetting it twice in a row and my wife noticed an electrical noise and two bright flashes in a boys' bedroom.  The flashes seemed to come from an electrical outlet behind a dresser.  Upon closer inspection, the electrical outlet appeared to have some charring as shown in Figure 2 below:

Figure 2.  Cooper Wiring Duplex Receptacle.  Universal grounding duplex receptacle.  2-pole, 3 wire.  15A-125V, NEMA #5-15R.  MFG# 270W.  UPC #032664147807.  To right receptacle hole has a burned / charred appearance.  

I removed the receptacle and immediately noticed that the top right terminal appeared to have a poor connection with the copper wire and that terminal, the screw, and copper wiring appeared to have heat and oxidation damage as shown in Figures 3 (a)-(c) below.  The unaffected side of the receptacle is shown in Figure 3 (d).  It is difficult to estimate how hot this terminal became, but I feel fortunate that it did not catch on fire, and the arc-fault breaker helped protect me and my family from a possible house fire caused by overheated electrical wiring.   However, I should note that another circuit with an arc-fault protector did not trip when a light-switch terminal overheated and the body of that light switch pulverized from extreme heat (not shown here).  Thus, in the cases that I am aware, these arc-fault breakers tripped for 1 of 2 circuits with a wiring problem.  I'm not sure how many wiring faults are in my house.  I'm happy that the arc-fault breaker detected at least one of them that perhaps could have started a fire.  I replaced the receptacle and it is shown with its cover in Figure 3 (e).

Figure 3 (a):  Cooper Wiring Duplex Receptacle with heat damaged terminal visible on upper left and marked in red.  Terminal on right seems normal and serves as a comparison.  Noticed that the damaged terminal has a much darker screw and the copper wire appears to have slipped out from its ideal landing.  Perhaps when the receptacle was pushed into the wall slot the copper wire slipped out?  In any case, it appears to have been at risk of making a poor connection and heating up to create the fault.  A similar "burned" terminal was seen on a light switch on a different circuit.  I did not save the "burned" light switch.  Because the circuit with the light switch did not trip the arc-fault breaker, it is clear that the arc-fault breaker does not detect this type of electrical wiring fault consistently. Perhaps this type of circuit wiring is susceptible to poor electrical connection and subsequent overheating.

Figure 3 (b).  Receptacle with damaged (overheated) terminal shown at top.

Figure 3 (c)  Bottom of receptacle showing burned terminal bottom right. 

Figure 3 (d)  Normal side of the receptacle. 

Figure 3 (e)  Repaired receptacle with cover.

For more information...

For more information on arc-fault circuit interrupters (breakers), see the following sites:

• Wiki
• NFPA
• UL

Ambulatory Month

End of the rotation
I'm winding down my day here at 1 AM and thinking about how this month has gone. It's not quite over, but I have the evaluation notice e-mail in my inbox so the end-of-month or end-of-rotation can't be far away.  At the end of every rotation we are required to evaluate the rotation itself, the attending physicians, and supervising residents (if applicable).  I usually try to put down something meaningful.  It gives me an opportunity to reflect what I might want to do in the future to be a reasonably pleasant upper level resident someday.

The ambulatory itinerary 
All categorical Internal Medicine residents here at BCM spend a month in various outpatient clinics. I feel a bit like being a gypsy or traveler because there are so many different clinics.  For example, later today I will start at a VA infectious disease clinic in the morning before going to my regular primary care clinic in the afternoon.  Earlier this month I was at an outpatient neurology specialist clinic.  A couple of days ago, I was on call at St. Luke's admitting patients for a wide variety of conditions and writing orders for patients who needed adjustments to their therapy overnight ... this is probably why my sleep schedule is abnormal as I adjust from overnight back to day service.  Frequently this vagrant schedule means missing morning report sessions, noon conferences, and Grand Rounds because of the inevitable issue of closing out one's work at one site before moving to another clinic (or simply allowing time to travel across the medical center). Many attending physicians don't go to these teaching sessions and more or less seem to be unaware of them; they do have busy clinics to run, after all.

Benefits
The benefit of the above arrangement is that, as a resident, you see a variety of settings and probably learn a broader scope of outpatient care. Each specialty clinic has its own way of operating and unique set of patients from which to learn. For me it helps me remember diagnostic criteria and treatment options if I have seen at least one patient with a particular condition, whether liver failure or arthritis.  Another excellent benefit of the ambulatory rotation is that it allows time for life outside the residency program.  I spent a lot of time with my family this past month and that will change a bit on ward months.