Medicine used to be easy. A patient would come to you, sick, and you would do everything you could do to make the patient live, and honestly, more often than not, the patient would die (or heal, I suppose). There were no antibiotics, IV fluids, vasopressors, insulin drips, or mechanical ventilators. If you couldn't eat, no one could shove a tube past your ligament of Treitz or run a catheter into your superior vena cava and force food into you. If you couldn't breathe, no one would even think of cutting a hole in your throat to point a tube at your lungs. If you had crushing chest pain and fell over, no one would cut a hole in your groin and thread a balloon into the tiny vessels feeding your heart. If it was your time to go, you would go. The doctor couldn't save you.
Today marks the end of third year rotations for me. What a weird feeling. Sure, I have a big exam on Friday, and in August I take the step 2 (the next part of my licensing exam). My last day was pretty low key. I tried to figure out why one of my patients had a hypoglycemic spell, and whether another one was ready to try eating. We discussed the finer details of how neurosyphilis presents. Should we give this lady some blood for her sickle cell crisis? Rounds were moving briskly.
We came to this patient who has been our service all month. Dying of cancer, she was a mere shell of the vibrant woman who existed only a few months ago. The cancer had stolen all of her immune system from her, much of her blood and most of her coagulation system. We had been fighting a futile battle to keep her alive despite her complete lack of response to her cancer treatment. Finally, yesterday she had a stroke. But even a stroke can't kill you these days. So there she sits, 85 years old and at the end of her life, in a foreign room where everyone who talks to her wears masks, and who touches her wears gloves. Where the focus of her life has suddenly changed to chewing properly and how the sores on her back get bigger, from raising her children right and making a life for herself.
We had a conference, and the family finally decided to let her go. Let her go, but with antibiotics. Maybe IV fluids. She'll be unconscious, and mostly pain-free, but nonetheless, she will take a long time to die. Weeks maybe. What a painful choice to make. We have awesome power to save lives with antibiotics and pressors and fluids and ventilators. Amazing power. Power so great, I sometimes wonder how people even die anymore. With that power, though, we have to make these choices. We have to decide just how much we want to let go. It's not an easy choice, and it certainly isn't a simple one. Ok, you want to let your loved one go, but where do we as doctors stop? Would you like us to perform chest compressions? Shock the heart? No? How about intubate or ventilate? No? How about labs, or respiratory therapy, or fluids, or insulin, or heavy sedation, or...
Even we have limits, though. We won't kill. Take the most tragic person on our service. Eighteen years old and a brand new mother, this girl lies in a hospital bed. Helpless. Victim of a devastating neurological/autoimmune disease, she has become completely blind, paralyzed and in constant agonizing pain. She's in so much pain that the lightest touch causes her to cry out, and throwing our entire pharmacy at her doesn't ease it even the slightest bit. She's had over a dozen doctors try to fix her in this "visit" alone. I put visit in quotes because she's been at the hospital for three months now, with tubes feeding her and breathing for her. She's allowed to breathe on her own for two hours a day. Two hours a day. She can still hear, and she could still talk if not for the hole we cut in her throat to insert her breathing tube. Everyday we stop by, say hello, ask her if she's still in pain. We change some medications, talk to consulting doctors, and move on. Everyday, she lies there, staring into nothing, listening to the sounds of the TV. 18 years old. I try to imagine what I would be thinking about if I were forced to be locked in a room day in and day out, without being able to see anything or do anything or talk to anyone. I don't know.
Not that I'm suggesting we kill her by shutting down her vent or stopping her feeds. Even I'm not that cruel. It's not an easy position to be in, though. The fact of the matter is, she will not get better, and being in the hospital this long, it's only so much more time before she catches the bug that will eventually kill her. Until that day, she will mostly likely continue to be in constant pain.
I tell myself that with these awesome machines and medicines we have, we will save lives, and that the tradeoffs is that we're going to have some sad stories to tell. It's an awesome priviledge, and a painful one sometimes.
