Monday, February 21, 2011

My Big Catch and the ER

For those of you who know me, you know that I am somebody who is very hard on myself (and, unfortunately on others sometimes as well.)  But, today, I had a moment that I am actually quite proud of.  I found it very fitting to share, especially after my last post sharing a story that reminded me of why I became a doctor, because today I had another one. 

I've been working in the emergency room recently, a great experience for an intern, as we see patients who can be very sick, but we see them from their initial presentation.  As an internist, I usually see patients in the hospital AFTER they have been seen by an emergency room physician.  There is a huge difference in the way you think of patient care in the ER vs. in a hospital admission.  As an internist I see, "Patient with a urinary tract infection with altered mental status and possible sepsis who needs IV antibiotics" with labs already drawn, imaging already done, and an assessment by a physician more experienced than I am (the ER attending) who already examined them.  My job is then to treat the patient for a few days, follow up results, make sure all of their other chronic medical problems are also continuing to be treated, and then discharge the patient to the appropriate place.  As an ER physician you see a confused patent who says, "It hurts when I pee."  At first you may think, well what is the need for an internist then?  The job of the internal medicine physician in the hospital is to make sure that first, the diagnosis was correct (which it often is not), the treatment plan is followed through (often times treatment plans are complicated and require changes and close monitoring) and to diagnose and treat any complications (of which there are maaannny).  As medicine doctors we often times criticize ER physicians for doing shotty work... for not working up a patient thoroughly enough, for not making the correct diagnosis.  After doing approximately 200 hours of ER time now, I realize that ER doctors offer a couple of amazing services to patients.  1.) Even if they are wrong about a diagnosis sometimes, they sure as hell do a good job of knowing when a patient is "sick" and when they are "not sick".  Even when a patient is admitted to me in the hospital and the ER doctors' intial gestalt is slightly off, the patient usually still belongs in the hospital.  That alone is a huge decision, and one that I have been learning a lot about with my time in the ER.  When I initially started doing ER rotations, I began my patient interviews with the mindset of an internist, with a focus on detail, on thoroughness. But it took forever.  Those are great things to do with patient encounters, but the emergency room is not the place for that.  Now that I have some experience in the ER doctor's shoes, I get what they have to do.  The ER doctor sees a patient and immediately is thinking the following:  First, "is this person dying in front of me?"  Second, "Does this patient even need to be here?"  Believe it or not half of them do not and are grossly misusing the "Emergency" part of "Emergency room". For example we get patients who present to the ER for viagra refills.  If you're a virgin and Beyonce just showed up at your door begging for you, then MAYBE you could argue emergency.  Maybe. Third, if they do need to be there, "can I treat them in the emergency room and send them home from here?" Or, "do they need to be in the hospital?  If so, do they need intensive care or not?"  They have to think that way, and think that way quickly, because when you have a line of 20 patients waiting in the ER lobby, you need to figure that stuff out fast.  You don't always have time to do a super thorough history and physical when you're the ER physician.  The core of the ER physician is always thinking:  Sick, or not sick?  It is not always the easiest decision to make in a quick situation.  I have gained a lot of respect for ER doctors after being in their shoes.  I have also learned a ton of good medicine and this experience has made me a better doctor.

However, on the flip side, my training as an internist and seeing the other side, seeing how patients fare once they are out of the ER and actually being treated for their ailments, really helped me today. 

It was just another typical day in the ER... a lot of "fast track" patients with ear aches, low back pain, coughs, viagra refills (and no, Beyonce was not in the waiting room.) , and a lot of legitimate medicine cases that we call "bread and butter":  Smokers with chronic lung disease having exacerbations, pneumonia, urinary tract infections, drunks.  I had just seen a couple of moderately sick patients and still had a lot of busy work, when my attending said to me "can you go see bed 2?  Should be real quick.  He's drunk."  We see a lot of drunks in the emergency room.  A lot of them are homeless (as was this patient) and just need a place to sober up and have a meal.  I sighed inside when given the assignment, "sure, of course I can see him."  I went to his ER bay and went to his bedside.  I began our encouter as I do with every ER patient, I introduced myself with a handshake, made sure I was pronouncing their name correctly, followed by "What brought you to the emergency room?"  His answer began with "Well, I fell off the wagon and I need help."  In my mind I already began to roll my eyes.  If I had a nickel for every time I had a drunk patient who came into the ER asking for rehab only to leave against medical advice I might not have any student loans left.  I continued into his history, it was very typical for an acute alcohol intoxication.  It would have been very easy for me to write him off and just walk away, order him some ativan, and discharge him.  But, I did my due diligence, and did what we call a "review of systems", where we ask a series of questions that cover all of the body systems to make sure there isn't anything else going on.  It turns out this patient had chest pain that morning.  Crushing, substernal chest pain, associated with shortness of breath, that didn't go away until he was in an ambulance on the way here and receiving oxygen.  Shit.  Why didn't he tell me about this as the FIRST thing that made him come here?  Sometimes patients have a different idea of what is important than we do as doctors.  It's not their fault... and that is why we do the "review of systems".  90% of the time the ROS only confirms that you already got everything you needed from the initial history, but once in a while, it totally saves your ass.

The patient's initial EKG showed no changes consistent with a heart attack, but the labs 10 minutes later showed heart muscle chemicals had leaked out into their blood, a sign of significant damage to the heart.  This was a heart attack, but fortunately looking at the EKG it was a much more benign form, which did not require emergent interventional treatment.  The initial blood test for heart damage is very fast but it is not as accurate as other tests available, so it is protocol to follow-up with the initial test with a more accurate one.  The "ultra" came back 30 minutes later and confirmed the initial positive test.  However, it was almost double the initial value.  The patient wasn't in any chest pain, and the value stll wasn't THAT high.  The ER doctor (an attending with 10 years experience as a physician, and this particular doc is one of my favorites to work with) would not have ordered a 3rd EKG so early on in this patient's ER visit.  It is almost never necessary to.  But, I saw a patient in the cardiac critical care unit earlier in my intern year, who had a severe heart attack missed by the intern on call.  That patient ended up in my care and died in front of me, most likely because their severe heart attack was missed.  My gut told me to order another EKG, right then, even though the patient had no chest pain.  Their heart muscle enzyme levels had risen from the initial, and I was worried their more benign category of heart attack was evolving into life-threatening emergent heart attack.    I ordered another EKG.  The nurse argued with me. Sounding annoyed,  "Another one?  But we just got one." She was busy, I'll give her that, but this was a very clear demonstration of the gap between my education and a nurses education. The job of a nurse is a very difficult one, and I have the utmost respect for them (I was actually a nurses aid for two years before medical school), and nurses have taught me a lot as I have gone through my intern year.  However, now was a time when I had to actually use my "MD" and remind the nurse that I was the doctor in this situation and insisted on the EKG despite her rolling eyes and the body language of a rebellious teenager. 

I tended to some lesser acuity patients while the EKG was done.  The nurse brought the printed copy to me once it was done.  I noticed some very subtle changes, but they were very alarming ones to me.  A co-intern noticed them as well when my concerned eye ran it by their second opinion.  I immediately ran it to the attending who was seeing another patient who had a possible life-threatening emergency.  He was very busy, and he peeked at the EKG, noted the very subtle changes, asked me why i had ordered yet another one so early, and told me it was my call.  +Gulp+... "my call."  This was the real deal.  The attending was busy with a very sick patient, this was a very subtle call and I had no senior resident to back me up.  Shit.  I've been a "doctor" for 7 months.  Rough day at the office. My options were to let the patient, who looked incredibly stable on the outside, smiling, telling jokes, be as is and do nothing different, or two, call the cardiologist at home and make him come into the hospital to evaluate this patient.  I thought about it a few seconds, and I had almost no hesitation:  Call the cardiologist.  Err on the side of caution in this case considering the possible risks, and despite feeling bad for calling them in from home, they signed up for that job so I shouldn't feel too bad.  They listened to me on the phone, asked a lot of questions, and agreed they should come in to evaluate the patient.  Within 10 minutes they were there, lugging a bedside echocardiogram machine, "concierge at your service." they said jokingly.  I had worked with this cardiologist in the cardiac intensive care before.  I was glad it was him.  He looked at the patient's EKG, which as non-specialist internists and emergency medicine doctors we were hesitant to make a call on.  He made no hesitation.  He immediately decided to transfer the patient to the nearest invasive cardiac care center (our hospital normally would do the invasive cardiac treatment, but it was a weekend and nobody was there at our hospital.)  This was a big effing deal.  He called the invasive cardiac team at the nearby hospital on his cell phone, the ER attending was already initiating the emergent cardiac protocol, the nurse was on the phone dialing 911 for emergent EMS transfer.  We had 15 minutes or less by protocol to get all of the paperwork done, the patient started on a heparin drip (intensive medicine to prevent further clotting in the heart vessels), and the patient transferred out by EMS to the nearest invasive cardiac center.  When it was all said and done, I realized just how much I had learned from my training.  I would have never caught this 4-5 moths prior.  I would've missed it, and this patient's heart would have been damaged greatly for it.  In the worst case they could have even died within a week or two because of it once it was caught.  My fellow interns, the senior resident (who had been seeing other patients during this), and my attending were all so glad I had checked another EKG even though they probably wouldn't have.  At that moment I was really proud of myself. 

My friends, my family, my girlfriend, they all comment about me "saving lives", and usually I laugh because I know that for the most part I just help treat people's chronic conditions and don't really "save lives", but today I actually think I may have saved someone from, at the least, a horrible prognosis by catching something early.  I caught a big one.  It was a powerful display of how good my training has been. Despite all of my whining and complaining about working so many hours, and spending many nights sleeping in the hospital on call, I knew then why all of that was necessary.  I could have saved someone's life today. For real.  I am still a little bit high from the experience as I write this, and despite the cons of my job sometimes, as far as work goes I cannot think of any better feeling than this. 

Friday, February 18, 2011

Why am I doing this?

*BEEP BEEP BEEP*... "Hold on, I'm really sorry, just one second, I have to call this back."  The pharmacist patiently waited as I called back the page.  It was one of the floor nurses calling to inform me that there was an upset family member who wanted to speak to me about their father's care.  I told her I would try to get by there as soon as possible but it might be a while because we were admitting patients from the emergency room. The emergency room physician had decided these patients required hospitalization and I needed to evaluate them before any other non-urgent tasks.  Obviously annoyed she asked, "How long, doctor?"  I knew she wasn't going to like what I said but I wanted to be honest, as giving too short of an estimate would not only piss her off, but most importantly it would make the patient and their family feel neglected by me.  "An hour or two."  A few seconds of silence... "Two hours!?"  I was already feeling frustrated by my day. With of course many more important things happening as I began my work, the day had begun with 15 sleep-deprived caffeine-free minutes waiting in line at the coffee cart because I was too lazy to make my own that morning.  I had chosen the "snooze" button instead.  I got up to the coffee counter,  "Exact change only now, sir."  The change register had broken just as I had reached the front of the line.  Exact change I did not have.  I ran 50 meters down the hall to break a 10-dollar bill at the quarter machine, came back, stood in line for another 10 minutes holding my pound of quarters, only for the register to miraculously work 30 seconds before I got back up there.  Hey, at least I had some laundry money now... blah.  Back to my story, I responded to the nurse "Yes, two hours... I have 4 new patients to admit from the emergency room before I can do anything else, I'm really sorry.  We are just incredibly busy today."  She barely said a word before I heard the +click+ on the other end.  I thought to myself "What a bitch. I guess she wants me to lie to her next time."  The pharmacist was still sitting next to me, so patiently waiting so we could go over the new medication orders for one of the ER patients being admitted to our service.   Some of their medications (that they were prescribed by our facility to take at home mind you) required special approval to use in the hospital. This would require that I page someone from pharmacy (yes, even though I had a pharmacist sitting next to me) and wait for their call back to get approval to use these drugs in the hospital.  What a pain in the ass... this is exactly what I needed to be doing when I had three other patients in the emergency room I still needed to evaluate and then write hospital orders for.  I really hated my job at that moment.  At the moment I hung up the phone with the nurse, a team of specialists I had asked to see one of my patients walked in and just started talking to me about the options and plan for one of my very sick patients.  The pharmacist waited, and waited... she was so patient.  I really respected her. She was incredibly intelligent and sweet, but she couldn't do jack shit unless I told her it was okay with me and put an order in the computer, yet half of the time she knew more than I did about the medications I was ordering.

As an intern, I am constantly interrupted when I am on a hospital ward rotation by just about everyone you can think of:  Nurses, pharmacists, specialists consulting on my patients, my senior resident reminding me of tasks I need to do or reporting updates, lab techs reporting critical values, patient's families calling needing updates, morning lectures, noon lectures, medical students who need my guidance and teaching.  I was curious about just how often I get interrupted and pulled in multiple directions so I decided to count how many times I got interrupted before I could finish admitting this one patient.  Admitting one patient to the hosptial requires me to read in detail through their chart, see the patient in the ER and get their history, do a physical exam, make an assessment of the situation, formulate a plan, write admission and medication orders, and consult any specialists that may be necessary.  The whole thing usually takes me 60-90 minutes.  During this process I was interrupted 13 times.  Thirteen.   That is once every 4-6 minutes.  I barely have any time to really get focused on one particular thing that needs my attention before I'm being pulled somewhere else entirely.  Wow, I sound like a whiny little... yea.  I'm whining.  Deep breath.

My first admission of the day... yet another drunk guy.  What was his admission diagnosis?  Homelessness.  We usually only admit alcoholic patients if they are actively withdrawing from alcohol, which can pose a physical risk to them, or if they are homeless and need a true live-in rehabilitation center (so we basicaly admit them so social workers can "place" them somewhere, and they sit on the service taking up an acute hospital bed for days).  My resident, who during this proces is in charge of "blocking" patients from the emergency room if we do not feel like they really need hospitalization said,
"I don't get it, this guy has a home and lives with his wife.  Why does he need hospitalization?"
"Maybe his wife kicked him out of the house for drinking too much thunderbird", I responded.  He half-chuckled at this.  Yes, we get jaded and need to find things to keep our humor after admitting our 5th alcohol intoxication of the week.  I was serious, though.  I figured there was no other explanation for why the ER would say this patient needed hospitalization.  He was a straight-forward case of acute alcohol intoxication.  Basically, he was just drunk.  Sure enough, he had been kicked out of the house by his wife.  His wife had basically dumped him in the ER and lied about a bunch of symptoms that would alarm the ED enough to admit him: Bloody stool.  Falling with head trauma.  Chest pain.  She had given a myriad of symptoms that did not fit together but she knew we would react to this history.  As the day went on, three out of my five new admissions were just drunks who needed to stay a night at "Hospital hotel".  I was interrupted probably 50 more times in my activities throughout the day.  I was also yelled at by radiologists for ordering expensive imaging that we eventually agreed was necessary after I explained my reasoning, yelled at by family members because the night-cover doctors didn't know enough about their family member last night, paged incessantly by nurses telling me my new drunk patients were demanding intravenous narcotics.  I was exhausted, and I was getting no pleasure out of my job.  I was beginning to ask myself, "Why am I doing this?" save a few curse words in between.

At just about the moment I was considering suicide by candy bar and coffee overdose came an angel: Mister Smith.  I was given a very brief report from the emergency room... Mr. Smith had shown up to his regular doctor with a fever.  Nothing else.  Just a fever.  An elderly man in impeccable health otherwise, he had finally become fed up with this fever that had lasted him a week.  The doctor had dismissed his fever as a "virus" (which I might have done as well) but they did draw the proper labs.  He was called the next morning and told to report to the emergency room immediately because his body had such low white blood cells he would be unable to fight any infection. I looked at his records, and thoroughly examined his laboratory reports.  I was legitimately concerned for this man.  He had what we call "pancytopenia", where all of his blood lines, the red cells (which oxygenate your body), white cells (which fight infection) and platelets (which help to form clots when you bleed) were all dangerously low.  When I saw this information I drooped down into my chair.  I was pretty sure this patient had cancer.  There are a host of other things that can cause this presentation, a few of which are fairly benign, but most are not friendly.  The most likely thing for his age group was some sort of cancer in his blood.  When I first met this patient in the emergency room he was intensely anxious.  The anxiety in the small quarters of his room was like a hefty animate object that could be lugged from the air.  He had a little bit of healthcare knowledge... just enough to worry sick but not enough to know what was really going on.  My heart went out to him.  Being his intern, I had to explain to him what was going on, to explain the unknown.  This was impossible. I was left with a lot of "It could be ____, it could be ____, but we won't know until ____." It was highly unsatisfying.  To make matters worse, with his anxiety he was demanding that we all wear masks to protect him from our germs while his white blood cell count was so low.  Not a hospital requirement, but something I would probably recommend to my loved ones for the utmost safety.  I understood his anxiety and happily wore the mask... it's just that wearing masks and gowns and gloves removes a lot of personal interaction.  It makes everything sterile, pun intended.

As each day passed, Mr. Smith still demanded that we wear masks as we entered his room, and he seemed upset at each visit.  We still had no answer, but I knew the answer was coming:  The bone marrow biopsy.  It was a last resort, but would ultimately identify any cancers in the blood interfering with his body's ability to make new cells.  We had ruled out everything else that could be causing this.  A bone marrow biopsy requires a very large needle be pushed through the skin and fat, into the bone in the hip area, down through the bone to sample marrow in the cavity of the femur.  It can be very unpleasant.  I watched while the pathologists did the procedure, and Mr. Smith was making nervous jokes the entire time, faced down on his bed, asking me if i was still here watching "the vampires [you] orderded sucking [my] marrow out."  I at first reacted more defensively than I realized, explaining that I was only ordering the test for his benefit, and he quickly interrupted me, "I'm just trying to make some fun of this!"  I felt a little bit sheepish.  I also felt humbled. Here was a man who was facing a possibly life-threatening diagnosis, surrounded by people wearing masks, gowns, gloves, almost straight out of an alien or a horror movie, the largest bone in his body being penetrated by a huge needle to have the insides sampled, and he was making jokes with me.  This illustration of resilience resonated with me for the rest of the day.  I was touched by this man. 

Two more days passed, and the pathologists ("the doctor's doctor" I like to call them) called me with a preliminary diagnosis.  This man had an acute form of leukemia.  This sounds awful, but my heart was relieved.  This specific type of leukemia has the best prognosis of all leukemias in the short term, and he would have a very good chance of beating it.  Based on my calculations from the literature, he had approximately a 95% chance of surviving for 5 years and achieving full remission.  I knew this diagnosis meant good things to me, but the words "cancer" and "leukemia" are never easy things to discuss with a patient.  This would still require chemotherapy, and a very long hospital stay, and significant risks during therapy.  As doctors we like to look at things in "mortality rate", or "5-year survival", but these measures do not include the suffering that patients must go through to reach these numbers.  I asked the oncologists to give him the diagnosis, because they would be better able to answer follow-up questions about treatment, therapy, complications, what he would experience, and prognosis.  The oncology fellow told me she informed him of the diagnosis, and I felt relieved.  I felt relieved partially because it meant I wouldn't have to tell him, and also because I knew he got better care by having a specialist inform him of this diagnosis.

The next morning I was rounding on my patients, and I came to Mr. Smith's room, the sign on his room reminding visitors to wear masks, gowns, gloves, etc.  I got all dressed up for him so to speak, two knocks on his door, and walked in.  I was expecting a man calmed by his diagnosis, calmed by the good prognosis, that he had cheated many other conditions that could have essentially taken his last years away.  This guy was pissed.  He looked like he was about to throw a chair out the window.  I was taken aback.  I knew he was an anxious man, but even this was extreme for him.  He recognized me as I entered the room, even through the mask hiding my face and the yellow paper gown hiding my body.  He yelled my name and cursed, "What the FUCK is going on!"  I was caught off guard.  I expected a man comforted by what had occurred over the past 24 hours.  "Nobody is telling me what the hell is happening!  My blood cell counts are FUCKED, and I don't know what is going on!  I'm sick of this shit!"  I asked him if the oncologist had come by to tell him about his diagnosis.  He replied "Yea, they told me I had leukemia, and were smiling the whole time while I was scared as fuck and then told me they'd tell me more later.  What the FUCK!" He was not just frustrated, he was livid.  I write the curse words in bold caps only because he was emphasizing them very strongly.  It was patently obvious that the oncologist had also ducked the hardest part of this ordeal.  I felt very guilty at that moment.  Had I asked the oncologist to inform him only because I was too afraid to do it myself?  In hindsight, I still think it was appropriate considering the complexity of the disease, but now as his primary doctor I felt stuck between a rock and a hard place.  It was my responsibility to comfort him, to calm him down, to make him feel better about this situation.  I mentally took a deep breath (not actually), because I knew the next 10-20 minutes were going to stretch every ounce of knowledge and charisma that I had available to me.  It was very possible I was going to look very foolish and make this highly anxious patient, recently diagnosed with blood cancer, even more anxious and upset than he already was.

I spent twenty minutes with this patient, just trying to answer all of his questions, ease all of his concerns.   I was so glad I had thoroughly read up on his condition the night before, and glad I had one month of experience on the oncology unit.  I was able to answer almost everything he threw at me, some of the questions more challenging than others.  When we finally got past all of his tough questions, I was able to spend some time giving him some positive spin, and most importantly, some empathy to what he might be experiencing.  After this, for the first time in 5 days he addressed me by my first name, and he said in a calm voice, "thank you."  I told him that I was doing my job and that if he needed anything else I would be available by pager through his nurse.  I shook his hand and nodded to him and began to walk away.  I was almost out of the room when I was stopped by a "Hey... come here a sec."  I obliged and returned back to his bedside, "Yes, Mr. Smith?  Is there something more that I can do for you?" I asked.  "Take off your mask."  He said.  "I thought you wanted us to wear masks in your room because of the neutropenia, Mr. Smith...", "Take off your mask son."... a few second pause, "I want to see your face."  I didn't say another word, and I just pulled my mask below my chin.  He choked up.  His eyes were watering, but he wasn't crying.  He extended his hand to me and simply said, "Thank you."  We had a long firm handshake, and nothing was more powerful in those few seconds than silence.  I was utterly humbled. 

As I left Mr. Smith's room that day, I felt revitalized.  I remembered at that moment why I became a doctor.  Even though it is not always possible to bond with someone like I did with Mr. Smith that day, it forced me to realize that I had allowed myself to dehumanize many of my patients.  All of the drunks, coke-heads, morbidly obese, smokers who smoke cigarettes on their way out of limb amputations... they're all people with a story, who experience uncertainty, anxiety, fear.  I had let myself forget that at times.  I had forgotten why I was doing this. 

Thank you Mr. Smith, for helping me remember.

Wednesday, January 26, 2011

My Stages of Grief

This post continues on from my first one, "The Night I Became a Doctor".  And as a note for my future posts, I use a unisex "they, their" reference to patients in order to help keep private information confidential.  As much as I would like to make my stories more personal by using he/she pronouns, I feel compelled to use as little information possible so that I may protect a patient's identity. 

After staying up for 30 hours covering the unit, and most important to me at the time,  keeping someone on the brink of death alive through the night, I felt exhausted, almost zombie-like by the time I left the hospital.  I had a day off the next day.  I couldn't have been more thankful for the free time.

I took a quick nap when I got home, and then awoke with an almost annoying amount of energy and life despite only having slept for 3 hours in the past 35+.  Just being awake and not being at the hospital, not having another long shift looming the next day, made me feel revitalized.  I was living on adrenaline, and it felt great.  I stayed up late that night, I enjoyed the rare and blissful stress-free time by going to my favorite neighborhood pub, hanging out with my wonderful girlfriend, and staying up past my bedtime.  But, despite this, I still couldn't keep myself from thinking about my patient.  I (unfortunately in this case) had access to the electronic records at my hospital from home, and I kept looking at them periodically; Checking vital signs, following labs, noting how much drip medication was required to keep their heart going.  My girlfriend thought I was crazy... Being a nurse, she understood, but she still had to keep kindly reminding me that I was not at work that day, and that they gave me days off for a reason.  I never thought in my life that I would have a woman encouraging me to play video games instead of focusing on my job (yea, she's a keeper). I normally don't have a problem enjoying my days off, but this was a particularly difficult one. 

The day off passed, and I was back to the unit by 6am just like usual... it was a blur, almost as if I never had a day off at all.  Overnight, my patient had not done well.  They had deteriorated fairly quickly in the last 24 hours.  All of that work I had done to keep them going... trying to keep them alive, all for naught.  They were going to die.  My mind began to dart to blame;  My colleagues covering for me on my day off had done a poor job... they didn't have my anal attention to detail... they were to blame.  Or, no, it was my fault for not giving them good enough instructions before I took my day off, or maybe I had never made them healthy enough to begin with.  Shit, maybe I should have even called them on my DAY OFF (one of only four for the whole month) when I saw their vitals/labs going downhill.  And last, but certainly not least, and I am ashamed of this.  Very ashamed.  I even blamed my patient.  Why had they let themself get so fat?  Why so much smoking despite inordinate amounts of warning?  Why didn't they ever listen to a doctor about any of their choices previously?  Why did they have to end up in MY care knocking on death's door?  What the fuck was their problem?  Oh my... I was feeling anxious, guilty, angry.  Selfish.

I caught myself... I realized just how irrational I was beginning to think.  Only in hindsight, now, do I realize that at the time I was already going through the stages of grief. 

I knew this person that I had become invested in.  I had spent a lot of time conversing with them about their life... and then on the flip side I had spent what FELT like an inordinate amount of time trying to stave off death.  And now, I knew they were already gone.  I had gone through so many feelings in the last few days... Denial, sadness, anger.  Sound familiar?  The stages of grief are comprised of Denial, Sadness, Anger, Bargaining, Depression, Acceptance.

Denial:  The night I stayed up with so much enthusiasm keeping this patient "alive".  Sadness:  The 10 seconds prior to entering into, Anger:  Blaming everyone I could think of including the patient.  I was grieving over the looming death of this person and I didn't even realize it.  Bargaining never happend for me, but depression and acceptance would soon follow.  Sometimes people skip stages... I guess it's in my personality not to bargain.

This patient's family had been visiting almost every day during the hospitalization.  I had called and spoken to them on the phone numerous times, including while taking a break from chest compressions to tell them they needed to come to the hospital ASAP.  We had also bonded in our own way after the code with family meeting decisions.  They had made it clear that their family member would never want any suffering, not to be kept alive by machines, and that they probably never would have wanted the first "Code" I wrote about in my first post.  After a fairly short, very reasonable, and well understood conversation on both sides, the decision as made to "pull the plug" so to speak.  The patient was being kept alive on a ventilator, on multiple drips of powerful medications to keep their heart and circulation going.  These remedies are routine in an ICU setting, but they are far from natural... we were essentially keping this person alive artificially.  The second we took them away from any of these remedies they would pass within minutes.  The family knew this, and that is exactly what they wanted because keeping them on these therapies meant more suffering with almost no hope for recovery of a good quality of life.   So what did they want?  A quick, painless death with dignity.  But, they didn't want to feel like they were withdrawing all care at once, so we formed a plan. 

I had a meeting with the nurses to inform them about how we were going to hande this. They already knew what was going to happen before I even came out of that meeting with the family.  They were sharp.  They had been through this so many times.  Here I was, the person they looked to for orders, the person they called at 3am when they had a problem that was out of their scope of practice... and yet I felt so naive and inexperienced in their presence during this time.  I barely had to say anything to them.  They already knew.

We had decided to pull the breathing tube and turn off the cardiac drips shortly after but not simultaneously, with the three closest friends/family at the bedside.  Everyone else was cleared out of the room to wait in the family waiting area.  I was waiting around the outside of the room pacing, my resident had the afternoon off and I was on my own.  One of the nurses came up to me, her eyes gave me a soft and nurturing look, and I being someone who almost never looks away, our eyes met, and with just enough silence to let me collect myself she spoke, "Are you okay sweetie?...  This might be a while... just go do your work. We'll take care of it."  I felt so clumsy, but I felt so relieved at the same time.  I wasn't really that "okay", but I told her I was "okay" to save face, and began to make myself busy around the unit with this patient in the back of my mind the entire time.  About 40 minutes later, the same nurse came by to me and silently handed me a small printed EKG strip.  Flatline.  They had passed.  I knew what I had to do now.  I had never done this before, but it was my time to go into the room and pronounce the patient dead.  There were still the three closest friends/family members at the bedside.  There was no heart monitor on, no vital signs being displayed in the room... they wouldn't know for sure if the patient was dead until I told them.  I walked into the room... fortunately we were all familiar with each other by this point and we had established some trust.  They recognized me and asked me almost immediately, "Are they dead?  We think they might have passed in the last couple of minutes..." Two of them let out a sigh of exasperation, almost simultaneously.  The closest to the patient said in a voice of defeat, "Just tell us it's over".  My heart broke.  They all scanned my every move, attended my every sound.  I explained to them that the patient had likely passed by the EKG flatline, but that to be absolutely sure I had to examine them (which might seem strange to some families, so I explained all of the steps I would take before I did the exam).  They all had visceral and palpable responses to my news, despite the fact that they knew what was coming; they had been waiting for this.  I let the room fill with silence for about 15 seconds to allow the situation to display its weight.  I then listened for heart sounds, I watched and listened for breaths, I checked for reflexes, shined a light in their pupils, felt for any hint of a pulse.  Nothing.  "I'm sorry..." I looked up at the family who had been awaiting in agony.  "They have passed."  I gave a few seconds and then looked up at the clock.

"Time of death, 1:59"

Those were the hardest words as a physician that I have ever spoken. 

The one who had been closest to the patient thanked me and hugged me, fairly vigorously, a man who had been quite stoic throughout this process... a few tears slowly trickling down his cheeks. I used every ounce of energy and manhood that I possessed to fight off even a single tear in response.  I was their doctor.  I had to remain strong.  I shook hands with the others and nodded my head in acknowledgement of their loss.

I was sad.  I was already feeling the next stage of grief:  Depression, before I even left the room.  I wanted to cry with that family member so badly... but I knew it was selfish.  Crying would have let me release my own emotions, but I needed to stay strong and professional for that family.  I used every ounce of energy to hide my feelings.   

I left the room, closed the door, never to see the family or the patient again.  Their body would be cleaned, tagged, and bagged up  by the nursing staff, a job I had once done myself as a nurses assistant prior to medical school.  I did not envy their task.  I was not the same that day after I left the room.

Normally I would be chomping at the bit to leave early on a day during this grueling rotation that pushed the limits of work hours with our 30 hour shifts every three days; but it was almost unfortunate that I had a short day of work that day.  I would have rather had another 30 hour day so as to stay busy while unknowingly trying to deal with stage five of grief (with my stubborn self skipping bargaining):  Depression.

I thankfully quickly went through the depression in the next day... reminding myself that unfortunately people must die.  Sometimes people die and there is nothing you can do about it.  Fortunately this person had a family/friend-unit that cared about their wishes and let them die the way they would have wanted.  We should all be so blessed. 

Once I had processed my patient's death, I became uncomfortably aware of my own mortality.  I thought about how little I had done to work on my own life the previous month or two, and reminded myself that my life could end before I knew it.  It reminded me that I should try to get the most out of every day that I was given, even if that whole day was spent caring for the passing of another.  I accepted "my first death" fairly quickly after that, and found privilege in the event. 

It still didn't make it easy...

Saturday, December 25, 2010

The Night I Became a Doctor

I graduated from medical school in mid-May, so, I have technically been a "Doctor" of medicine for 7 months.  However, when the first day of my internship rolled around, I didn't really feel like a doctor... I felt like a medical student who suddenly had an inordinately large amount of responsibility.  There's a reason we go into residency to be trained after medical school rather than immediately go right into practice:  We are not even close to being ready to treat patients on our own straight out of medical school.  For those of you reading this and wondering how many times a scared, brand new intern has taken care of them, or their family members, do not fear; we do have our hands held until we are ready to be autonomous.  However as internship goes on we are expected to, and we do learn fairly quickly to fly solo.  I want to recount the night that my training wheels truly fell off...

It was just another 30-hour call day in the Cardiac Intensive Care Unit... I strolled in at 6am with all of my patient notes pre-typed, my preliminary morning plan for each patient already thought out on my 5 minute walk to work, caffeinated sumatra running through my tired veins.  At 7am I had been rounding on my patients for about an hour... quickly going through routine checklists in my head in preparation for presenting information to our attending physician (tha boss, think Dr. Cox from Scrubs) by 8am.  The previous night's call team notified me that a new patient had come in that morning and as I was the intern on call I would be the one accepting the patient.  I quickly glanced over their information and recognized that they were the same person I had transferred out of the unit the day prior.  I had done so because I (and our team, head physician, etc.) had thought them to be stable enough to no longer require intensive care.  I was puzzled... and also worried.  Had I done something wrong?  Had I transferred them improperly?  Was their health now in danger because I rushed them out of the ICU before they were ready?  Did I forget to prescribe all of the proper medications on their transfer to the regular floor?  This was the first time I had felt this kind of worry and it churned my stomach.  I quickly dropped my morning routine and looked in their chart, flipping back to make sure I had done all of the transfer orders correctly, that my transfer summary for the accepting team had all of the necessary information for them to continue their care appropriately.  I could find nothing that I had done that would have put them in danger, and I told myself that I made the right decision, and at the time they were appropriate for transfer.  You can't always predict how people will do, especially patients as sick as this particular person.  I continued on with my morning routine, and while I was two rooms away, I glanced up at the huge monitor with everyone's EKG strips running by and theirs was incredibly erratic.  Their heart was in ventricular fibrillation, a heart rhythmn where the two large chambers of the heart that pump blood to the lungs to be oxygenated, and then the oxygenated blood to every organ system in the body, are pumping so quickly that they make virtually no force.  It is 100% fatal if the rhythmn is not fixed and fixed emergently.  Another physician and multiple nurses were already in front of their room and someone yelled, "We need a crash cart!"
I quickly moved to the room where a nurse was already doing chest compressions, and my senior resident was running the "code" (when a patient needs resuscitation of some form).  My body was so jacked up on adrenaline at this point that I felt like I could have lifted a car. I was also now very fearful that perhaps this was my fault.   I relieved the nurse doing compressions and started doing them myself. This was quite a large patient so I hopped up onto the bed on my knees crouched above them in order to get more force on my compressions.  I could feel their rib cage crunching as I pushed down deeply and then subsequently let the chest wall recoil... I had likely broken their ribs, and I knew it;  It felt awful.  All around me people were scurrying around, giving orders, pushing heart-restarting IV medications.  I had done chest compressions before as a medical student, but this was the first time as a physician that I was doing this on my patient that I had been taking care of.  As I was up on the bed, breaking my patient's ribs to keep their circulation going I almost felt like I wasn't in my own body because it all felt so surreal; Just 24 hours earlier I was chatting with this person about their pets, their significant other, how they were so excited just to go home even if they likely would die of heart failure within the year.  I liked this person, and we had built up a rapport.  And now, I was watching them die as we desperately attempted resuscitation.  They went in and out of fatal heart rhythmns for about 90 minutes... requiring multiple shocks, periodic chest compressions, and very high amounts of IV medications designed to keep the heart/circulation going.  I didn't think they would make it.  By the time we finally got them stablized my arms and shoulders were sore from the exhaustion of giving so many chest compressions.  We had to emergently send them for a procedure which would place a balloon pump just outside of the heart which would assist their circulation temporarily. 

While they were at the procedure, I was frantically looking at labs, chest x-rays, notes, etc. fearing that I had somehow made a mistake.  It turns out the patient had gotten an infection that night and it tipped their already very weak heart over the edge.  There was no way to predict this happening... It just... well... happend.  I was relieved after convincing myself I did not harm this person, but the bottom line was that they were now even sicker than before and it was again my job to get them well enough to leave the hospital.  Or was it?  The majority of "codes" do not end well, usually with the patient either expiring while suffering the discomfort of a tube shoved into their lungs, people breaking their ribs with chest compressions, being shocked multiple times (the amount of pain that a single shock creates was once described to me by a patient as "a mule kicking me in the chest"), or surviving only to suffer their last few days/weeks and never make it out of the hospital alive.  Should we do everything medically possible to keep this person alive with such a poor prognosis?  That is a discussion for its own blog post, but I felt it important to at least note the presence of this always existant delimma.  Eventually the family decided to not resuscitate with compressions/shocks if this were to be necessary again.

Once the patient returned to our unit from the procedure they were still barely hanging onto life, requiring a ventilator to help their lungs exchange oxygen with blood, a balloon pump and numerous medications to keep their heart pumping with enough pressure to circulate blood to the brain and vital organs, as well as many other intensive interventions.  I spent the next 24 hours micromanaging every aspect of this patient's care (while also covering the other 11 patients in the unit); their cardiac medication drip rates, the amount of blood to filter and remove from their body per hour to prevent fluid overload, ventilator settings, etc. I stayed up all night most likely annoying the nurses with my overly-detailed involvement in this particular person's care.  I was not going to let this patient die on my watch.  The nurses in the ICU are very knowledgable and often times make great suggestions for care that I listen to.  But this patient had highly complicated physiology and the nurses were questioning my decisions quite often; a lot of the management was counterintuitive when compared to simpler cases.  Three months prior I would have been swayed by this... I would have doubted myself, I would have called my senior at 3am and woken them up for help.  Not this time.  I never once had to call my senior resident for help.  I had this.  I stuck to my guns because I knew what I was doing, and I educated the nurses as to why we were doing things the way we were.  "Maybe you should call your resident?".  I politely acknowledged their suggestion and asked them to continue with the current plan.  They gave me that *I hope you know what you're doing, intern* look, but as the wee hours passed we all saw the improvement and they gained my trust.  I also began to trust myself.  I knew this patient was likely doomed no matter what we did, but I clung to every small victory as tightly as my patient was clinging to life.

I started to struggle to stay focused at around 4am.  I had been up for almost 24 hours and I still had about 9 to go.  People always ask how we as resident physicians make decisions that affect people's health after having been up for so long.  Honestly, sometimes I don't know how we do it either, but when there is a sick person in front of you, you wake up.  The things you might miss at 4am when sleep deprived are almost always minor and have very little effect on the overall care of the patient.  You don't miss the important things.  You just don't.  I decided to take a nap at 4, hoping to get about an hour or so of sleep before waking up to round on all of my other patients and finish any minor tasks on other patients in the unit before their doctors came in the morning. I laid down in the creaky twin bed, close enough to the ICU that I could still hear the ventilator alarms and cardiac monitors... not the best sleeping environment but I would've been happy with sleeping on the hard floor in the midle of the ICU at that point.  Within 20 minutes I was in twilight sleep and then my pager went off.  I turned to the edge of the bed like a zombie and picked up the phone to call the number back.  I used my fingers to feel the keypad on the phone and dial by feel so I wouldn't have to turn the light on.  "This is Dr. Wiebe" I said sleepily, "Hey doctor... I'm sorry to disturb your sleep but you forgot to sign one of your orders." (Those are the kinds of things you forget to do at 4am).  I got up, put my white coat, shoes, and pagers back on and walked back into the unit to sign my order.  I was awake again.  So much for getting a nap.  The nurse sheepishly apologized for waking me again, likely having been subjected to a few unpleasant encounters with cranky sleep-deprived physicians she had paged at 4am before.  I told her it was fine and joked, "If those damned interns would just sign their orders..."  She laughed.   I wanted to throw my pager in the toilet, but it was my own fault for not signing the order.  I decided to use the extra time to pre-type some of my notes and organize all of the events over the last 24 hours that I would need to summarize with great precision and brevity to the attending physician.  At about 7am my senior resident, who had been sleeping one floor away, came into the workroom yawning and holding two cups of coffee, one he had bought for me, knowing I had been up all night micromanaging the unit while he peacefully slept for about 7 hours.  It was a thoughtful and very welcome gesture.  I updated him on all of the nights activities, most importantly our very sick patient who was not only still alive but had significantly improved clinically overnight.  His eyes lit up with a bit of surprise.  He said he was half-expecting them to pass overnight.  He was proud of me.  I am often quite hard on myself in my academic and professional endeavors, but I was actually quite proud of myself that morning.  I had run the unit and taken care of one of the sickest patients in the hospital all on my own, and I had done it well!  I still have so much to learn and know that I should never get in over my head, but this experience made me realize just how far I had come in the last 6 months.  It was a grueling call night, but I would never give up that experience for some extra sleep.  It made a man out of me and I will be a better clinician for it.  When the other interns/residents came into the ICU that morning, one of the interns asked, "How was your call last night?" I responded semi-sarcastically, "I think I became a doctor last night..."  He laughed knowingly. I savored the thought for a few moments before starting my morning routine again, still 6 hours from going home to sleep...

Friday, December 24, 2010

New Blog!

So, I have been recently inspired by my friends and family to start writing a blog.  My friend Yasmin has a beautiful blog for her budding photography business, my friend Katie has a blog that details her experiences as a teacher and a new mom, my father blogs about his intellectual curiosities...  they are all fascinating and a wonderful way to get a deeper look into their lives; what they do, how they think, and their experiences as human beings.  I recently graduated from medical school, and am now a medical intern at a very large hospital in Los Angeles, CA.  It has been suggested by the aformentioned that this might make for interesting blogging material.  I realize this subject has been detailed ad infinitum in various media formats, so I will attempt to give my own spin on my own personal experiences as a doctor in training.  I hope that the few of you that will actually be able to tolerate my dreadful literary skill, my incredible lack of wit, and downright general mediocrity will be mildly entertained and maybe even learn something from this blog.