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.


  1. LOVE this, Dr. Keep the posts coming. You rock!

  2. Yes. And glad to see a new post - good account, good reporting, big heart (<3}

  3. You are keeping the first commandment of writing: be as honest as you are able. Go Jon!