Tuesday, February 23, 2010

To Cry or Not To Cry

“One of the most common experiences in the practice of medicine is the experience of loss and disappointment…from the small nudge of a lab test revealing a medication is not effective, to the blow of a patient dying. It is a great deal for any caring person to handle. Yet most of this loss remains unacknowledged and ungrieved…The expectation that we can be immersed in suffering and loss daily and not be touched by it is as realistic as expecting to be able to walk through water without getting wet. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life. Protecting ourselves from loss rather than grieving and healing our losses is one of the major causes of burnout.”
- Rachel Naomi Remen, M.D. "Kitchen Table Wisdom"

My second to last call night on MICU was an emotional one. I learned a very important lesson that night. For the first time in my medical career, I gave myself permission to grieve, to acknowledge the pain of losing a patient. The situation involved a family discussion with a dedicated wife and her adult children. Her husband/their father had walked into the hospital 1 week ago with fatigue. On his 2nd day, he seized, breathed his stomach contents into his lungs, and developed a dreadful case of aspiration pneumonia. He had gotten so sick that his heart stopped. The code to bring him back lasted over an hour. The lack of blood flow to his brain during this time left him with irreparable brain damage. On this call day, we broke the news to his family. Mr. R would never be coming back. In fact, he was in the slow process of dying. His family was devastated. The room was filled with tears. His wife was inconsolable. “How can this be? He walked into this hospital last week!” she sobbed, tearing apart a used piece of tissue in her hand. After several minutes, she looked up, her eyes filled with tears and memories of love. “He was so healthy. You know we purposely did not get the paper delivered to our house each day? It was how we got our exercise. Every day, we would walk to get the paper. It didn’t matter if it was raining or not. Then we would come home and read it together.” It was this moment, the description of a small, every day event that got me. It reminded me that this patient was more than a body in a hospital gown. When I walked out of that emotionally-charged room, time stopped for an instant. As I walked out, I literally saw two paths in front of me. I could shrug this off and rejoin my co-residents, finish my work, and move on to dealing with other patients. Or I could choose to stop and allow myself to feel the gravity of this moment. For the first time in my career, I chose the latter. I walked into the bathroom. I burst into tears. As I sobbed, I couldn’t figure out why I was so upset. This wasn’t my family. It wasn’t my loss. In retrospect, I guess it was the picture of a man who was once very much alive and the very real love he shared with his wife. It was about the injustice of loss. It was about the feeling failure when, as a practitioner of healing, you have nothing else to offer a patient. Allowing myself to feel that sadness, albeit in the midst of a hospital bathroom, reminded me that I was human too. That I am not a robot in a white coat. That I myself am very much alive.

Wednesday, February 17, 2010

When Crabs Attack

Have you ever been so tired that you wanted to throw yourself on the floor and have a temper tantrum? Have you ever been so sleepy that you doze off mid-sentence? Have you ever been so zapped of energy that your 80 year old stroke patient can get out of a chair faster than you can? Welcome to Suckiest Call Night 2010.

I have been told before that I am one of those people with a “happy gene”. I am a glass half-full kind of girl and generally opt to see the positive side of everything. MICU call last night, however, was too much for even this eternal optimist to handle.

It’s one thing to pull an all-nighter doing what you love. OB call? Not a problem! I am running to deliveries, c-sections, seeing patients in Triage. The variety keeps me awake, stimulated, and always on my toes. MICU call (read: glorified secretarial work) is another story. Last night consisted of sitting in front of a computer admitting one patient after another. I sat up all night writing H&Ps, entering admission orders, following up on labs, studies, and vital signs. These are not the kind of activities that keep me awake after 24 hours.

At 4:00am this morning, while admitting our fourth patient of the night, I was struggling. Sitting at my computer with a hospital chart laid out before me, I fought with every ounce of reserve I had to create an assessment and plan of care for my patient. It was a losing battle. The sentences on his note trailed off li..ke.. th….is….. It took me triple time to enter his orders. From the time I read his home medication on his chart to the time I looked up to my computer to re-order it on our computer, I had already fallen asleep. A quick second later, I’d wake up and forget what I was just about to order. I tried everything to stay awake. I tried stretching. I tried brushing my teeth. I tried eating. I even gave in and had some coffee. Somehow I pulled through the Suckiest Call without killing anyone. But I couldn’t help wondering what the impact of my resident fatigue was on the patients I was treating.

Around 5:30am this morning, I got my second wind. Great for getting me through the last 7 hours of work, right? The caveat, however, was that last night’s sleep deprivation had turned this usually cheerful, happy-go-lucky resident into cantankerous little bitch. I didn’t even recognize myself. I heard myself snap at the pharmacist on the phone. I grumbled under my breath about our half-hearted medical student. I felt my blood rising as my senior resident butted into a conversation I was having about a patient. I struggled not to roll my eyes when my attending embarked on his usual 20 minute long “teaching point” during rounds. I was tired, cranky, and in no mood for either inefficiency or intellectual masturbation. At this point, I was even annoying myself with my bad attitude.

By the time I leave the hospital, I had been up for approximately 30 hours straight. My eyeballs felt coated in sandpaper. My head was heavy and my facial muscles lacked the strength to smile. The only thing I could think of is my warm cozy bed. I was asleep before my head hit the pillow.

P.S. Just to end on a positive note, there was one great thing about last night. I discovered TEDS! These sexy little stockings (insert sarcasm), most commonly used in bedridden patients to prevent blood clots, are a dream come true to every on-call resident. They feel like a 24 hour long calf massage. Ahhh...

Wednesday, February 10, 2010

It's Oh So Quiet...Shhh...Shhh...

In preparation for the season's biggest snowstorm, schools have been closed, work schedules have been rearranged, grocery aisles have been cleared, and snow plows are rearing to go. Now, as the evening turns into night, guess how many inches are on the ground? A big fat zero! For a California girl who still sees each snow day through the awestruck eyes of a four-year old, this plain sucks! There goes my dreams of post-call snowball fights, sledding, and snowmen. Boo.

Instead, I wait for another night to pass in the MICU. It is suspicously quiet. My senior resident is sleeping in the call room (slacker!). The nurses are huddled in their social circles basking in their daily gossip (did I hear my name?). Patients are tucked away in their narcotized slumbers (can I have some?). And yours truly, the intern with nothing to do, has spent the last two hours engaged in some highly productive activities: eating and reading internet gossip. What could be more exciting at 9:30pm than Apple Jacks and Kendra's post-baby body secrets? (Uh, photoshop? Duh!) Or John Mayer spilling his guts about Jessica Simpson bedroom ways? (Remind to never hook up with that D-bag, by the way). Of course, now the sugar in my bloodstream has me antsy, antsy, antsy.

If there was snow out I could go run around in it until I tuckered out. Instead, looks like I'm hitting up perezhilton.com again.

Monday, February 8, 2010


Growing up, every child has fears. Some are afraid of the dark. Others are afraid of spiders. Still others are afraid of the boogey man. My childhood phobia was death. I was a morbid little creature and the thought of “the other side” instilled in me an unrelenting terror as my head hit the pillow each night. Sometimes I would be able to distract myself until sleep came. Other times, the fear of death striking me, my parents, or sister would chase me into the safe haven of my mother’s arms.

The first time I pronounced a patient’s death was on my Oncology rotation. The patient was a morbidly obese woman in her 60s. She had had months of abdominal pain and bloating, decreased appetite, and vaginal bleeding. Unfortunately, her mistrust of doctors kept her away until she finally presented to Triage struggling to breathe. By the time she got to us, her body was found to be riddled with cancer. Within a week she was bed bound. She waxed and waned out of consciousness. The cancer had spread to her lungs (making every breath a struggle) and her bones (making every movement excruciating). I was working in the Oncology office when the nurse came to tell me she had passed. For a split second, my childhood fear of death made my stomach turn. Knowing she was going to pass soon, I had already been prepped by my senior resident on what to do to make her death “official”. But could I do it? I took a deep breath and walked into her room. When I saw her body, I knew immediately that she was dead. She look pale, gray, and waxy. I shook her gently while calling her name. I rubbed her sternum with my knuckles. No response to verbal or painful stimuli, I thought. I shined a flashlight into her eyes. Pupils are fixed and dilated, with no response to light. I grazed a piece of gauze across her eyeball and she did not blink. No corneal reflex. I placed my stethoscope on her chest and listened for a full minute. No heart or breath sounds, no chest rise. I looked up at the clock. “Time of death, 2:21pm” I heard myself say.

Being as über-sensitive as I am, I always imagined that my first death would leave me an emotional wreck. However, in this patient, it was the first time I had seen her at peace. It was the first time I had seen her lie still without struggling, wincing in pain, or gasping for breath. Now, after 2 Oncology rotations and 6 weeks in critical care, I see death in a completely different light. I’ve come to learn that there are such things that are worse than death. And for these patients, death carries with it a sense of peace and an end to suffering. My childhood fear disappeared that day.

Wednesday, February 3, 2010

"It is not inertia alone that is responsible for human relationships repeating themselves from case to case, indescribably monotonous and unrenewed: it is shyness before any sort of new, unforeseeable experience with which one does not think oneself able to cope. But only someone who is ready for everything, who excludes nothing, not even the most enigmatical will live the relation to another as something alive."

- Rainer Maria Rilke

Culture Clash

The new year has me starting off with back to back rotations in the Intensive Care Units. Last month it was Surgical ICU (SICU). This month it’s the Medical ICU (MICU). Let me tell you – the only thing these units have in common is the name.

Now it is common knowledge that Surgery and Medicine clash in their beliefs about patient care. And I am not one to bash other departments because, well, that’s just neither nice nor productive. But man, my two experiences couldn’t be more different.

The SICU was intense. Patients being rushed to surgery with dead bowel, opening up infected wounds at the bedside, procedures on the great vessels, chest, lungs – it was literally a matter of bringing people back from the brink of death. Take M.W., a 45 year old man with, as they say, really bad protoplasm (read: shitty luck or bad genes, you decide). He had a family history of hypertriglyceridemia (a type of fat in the blood). Although he had been followed by doctors and was compliant with his medication, one day his pancreas just gave up. He developed the worst case of necrotizing (dying), hemorrhagic (bleeding) pancreatitis (angry pancreas) that I’ve seen in my short medical career. In the month I was in the SICU, he was taken to the operating room 5 times, had 3 bedside debridements of dead pancreas, was coded and received full CPR twice. He repeatedly dropped his heart rate to the 40s. He had also been living with an open abdomen for 3 weeks. Every day on the service I thought for certain, “This man is going to die.” Today, longing for the company of my surgical colleagues, I ventured down to the SICU. And guess what? M.W. is breathing on his own, talking, off life-sustaining blood pressure medication and most certainly will walk out of the hospital. Wow.

The MICU is a different story. Now if there is ever a place that will make you depressed about the state of the world today, it’s here. In my 1 week on service, I have seen 3 suicide attempts (one via antifreeze cocktail), 1 drug overdose, 3 end-stage complications of drug and alcohol abuse, and a crapload of patients dying from cancer, heart disease, and stroke. Of course, there were a small handful of patients who actually got better. The frustrating part for me was that all of these patients had issues, psychiatric or medical, that a trip to the operating room couldn’t fix. As MICU residents, our only tools are an arsenal of drugs and the tincture of time. There are wonderful physicians who are smart and patient and love the thinking behind this type of patient care. God bless ‘em because for me, thinking is simply not satisfying without the doing. I guess I’m just built like a surgeon.