Tuesday, June 21. 2005
Leeches
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.
... but fear itself
In the back of my head, I pictured it more like this.
Monday, June 20. 2005
One More Week!
On another, non-med school, note: I'd like to congratulate my Dad (or you could say I'd like to give props to my pops) for getting one of his paintings admitted to a gallery in the Washington, D.C. area. He is part of an art league that holds classes and has their own gallery space in the Torpedo Factory in Old Town, Alexandria. Each month their members can submit artwork to be placed in their gallery. A panel of judges pick from hundreds of pieces submitted each month. So he will have one of his paintings displayed thru June. Here's a really bad camera phone picture of his watercolor:
Here are also two pictures (in charcoal) he has done of my Mom. He plans on doing a third to submit for the Torpedo Gallery.
And on a final note: after I take the boards on Monday the 27th I will be going back to Northern VA to visit my Dad, celebrate a belated Father's Day, see his painting up in the gallery, and pick up my dog. Oh, and also to eat in the GREATEST Thai resaurant ever. I've overheard people at this place tell the chef/waiter/owner that they have lived in Thailand and this is the best Thai food they've ever had. Randall has expressed interest in driving up to eat dinner there and my Dad has given the green light for people to crash at our house. So I was thinking maybe Tuesday the 28th? I'll see if we can get a few people up there b/c the more people at the table the greater variety of dishes we can share! Just let me know.
Wilson, I hope you're settling back in ok. Post some pics when you get a chance to let us know what it's like out there!
day in the life
june 20. 2005. 7:02 pm. Surfing the web @ panara bread on the corner of 21st and Colley in Norfolk, VA.
Let me begin my blogging career by mentioning that Chan rocks. Not only did he just set us up w/ this most excellent system, but he is just a great dude all around. One of the most loyal and enjoyable friends I've ever had. In addition, he is the only private citizen I know who has his own personal orbiting satellite/camera (uhhhh, i hope that isn't classified info, randall???), and he let me commandeer it for a couple of hours to take this photo. I must say I was surprised to see that countries are actually labeled when you see them from space. I guess I always assumed that cartographers added the titles later. huh.
A few thoughts on ending 3rd year of Medical School. Tomorrow morning I will wake up to the 3-tone ring of my palm pilot, about 2 hours earlier than I want to wake up, jump in the shower, as usual, eat a bowl or two of meuslix, as usual, don my scrubs, clogs, white coat (more like a light gray these days), sling my stethoscope 'round my neck, and off we go. We'll round, first myself, then my resident, then her resident, then the whole team with our attending physician. There will be times when I feel like a doctor, when my attending will ask me to interpret a chest XRAY, and my entire team will stare with mouths agape in disbelief as I pick up a subtle finding (hmmmm, looks like we've got a pneumothorax here). I will stand a bit taller in that moment, tighten the rope of my scrub pants, adjust my pager, and gleam like a newly minted penny. And as all good things must come to an end, in a few minutes my senior will bid me recall the mechanism of action of some random drug, and I'll swear internally, "I have hated biochem, I am hating biochem, I will be hating biochem"... then I'll stand with my mouth agape and a blank look on my face, hoping the compassionate intern will whisper the answer from behind my interrogator. If she as also hates biochem, which I entirely expect, since she seems a sane and rational person, then I fall again into the mire of ignorance, perhaps to the delight of my smirking interrogator. This is a day in the life. And as Randall has recently reminded me, tommorrow is the last such day... the last day of our general medical education. Trippy.
Sunday, June 19. 2005
Not with a bang, but...
Well, I'm done with my last overnight call of third year, 2 days behind Amit! It should have been 2 days ahead of Amit, but apparently all the PA students scrambled to avoid our team and thus the PA that was on our team last month jumped ship, and took Amit's final call. Thanks.
I have to say, it could've hardly ended more anticlimactically. The code pager never went off once, my call room did not flood nor ruin my socks (yeah, I learned that a long time ago), and I only admitted one patient, who turned out to be destined for another service. It was definitely a far cry from my first night of call, nearly a year ago. I was on call for the nursery service on my very first day; I was given that magical pager and told to change into scrubs. An hour had hardly gone by when the thing started beeping at me, and my senior and I took off for the OR at a brisk pace. Within a few minutes, I was drying off and stimulating a newborn, urging her to take her first breath and cry. I don't think I'll ever forget that day.
Honestly, I'm ready to be done with this crazy race that is third year. I think I've taken my share of abuse and then some. I mean, in any other field, a year or two of seniority would really mean nothing. If I worked at a software development firm, for example, would I have to do anything and everything my coworker asked of me, be it do his work or even fetch dinner? I think residents sometimes forget they were in our shoes, and that it really wasn't that long ago. But unfortunately, I depend on them for my evals and my grades, and that's life.
It's a strange position we're in. Yes, a lot of the requests made of us are not appropriate. Yes, I should put my foot down and say no, especially in clear cut cases. It's hard to tell where the line is exactly though, and I do tend to err on the side of caution. I've heard some horrible stories where students fought to resist doing things that they should do, and we're all labeled lazy as a result. Or they figure out some weird way to punish us. It's all kind of passive-aggressive behavior, imo. On the other hand, as Amit says, I'm going to be a doctor in less than a year, and I better get used to taking charge and standing up for myself. It's probably too late for third year, but I'll start. We'll see if I can make a difference in the final two days.
At any rate, I like to think I am confident where it counts, at least for now. Yes, this patient needs florinef at least once a week, and yup, that patient can tolerate an ace inhibitor. As far as I'm concerned, seniority doesn't make a difference here. Maybe I'm being arrogant here, but as long as I've studied and looked up the latest research and guidelines, I believe I can confidently say I know what I'm talking about. I notice my attending agreeing with me more and more, too. So I think that's paying off... most of the time, anyways.
Oh, and I saw Batman Begins... awesome movie, thoroughly enjoyable. It's too bad they didn't set up the ending for a sequel though. ^.~