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M.K. was 5’4” weighing it at only 100lbs, but she was feisty. You could tell she was a knockout before the cancer came. She had big blue eyes and blond pixie haircut reminiscent of Meg Ryan in her Sleepless in Seattle days. She had come to our care after noticing blood in her urine. Didn’t think much of it – she had been battling cervical cancer for five years and figured this was just another bump in the road in her fight against cancer. Thus far, she had been through surgery, radiation, and several rounds of chemotherapy. And despite the orange-sized mass protruding out of her left backside, she anticipated being out the door almost as soon as she came in. Unfortunately, the bleeding persisted. And then, her platelets dropped. A week later, the bowel obstruction came. Her tumor had grown into her intestine and she was no longer able to pass stool through a portion of her large intestine. The nausea and vomiting became so bad, she couldn’t eat or drink. A CT scan revealed that the tumor was now 4mm away from invading her spinal cord. A week and a half after she came into the hospital, the oncology team knew she would never leave alive. But M.K. didn’t.
Being human presents a big obstacle in providing good medical care. It is simply not in our nature to be the bearer of bad news. We want to impart hope, to heal, to cure. Unfortunately, there are many times in medicine when the only thing a patient needs is the truth. The cold hard truth.
Thus far in my short career in medicine, I have seen too many times what happens when doctors are afraid to tell patients and their families the truth. At best, a patient lives the last months of her life with the false belief that she will eventually get better. And she is subjected to the pain and discomfort of tests, procedures, and medical interventions that do nothing to prolong her life and everything to prolong false hope. At worst, it means a patient dies in a cold hospital room surrounded by white coated strangers, with tubes coming in and out of every orifice and ribs cracking under the force of CPR.
I have also seen the alternative. A great oncologist at my hospital always tells his patients the same thing when they first meet. “You are well now, and we will do everything we can to keep you well. But there will come a time when I will have nothing left to offer you. And when that time comes, I will say to you, we are done.” We had that talk this week with another patient, K.A. Because she had had time to think about it before, she was able to say, “Okay, I am done fighting. I just want to be comfortable. I want to live my last months at home with my horses and dogs and die surrounded by my family.”
The same went for M.K. and her family. Before we had The Conversation, her family wanted everything done. It didn’t matter if how futile or physically painful it was, they felt this obligation to do everything to prolong the life of their daughter. And the dutiful daughter M.K. was, she felt obliged to go along with it. Each time we walked into the room, the anxiety was palpable.
Then The Conversation came. M.K. and her family learned that with the way things were going, she would never make it to treatment. She didn’t have much time left and now we were asking M.K. how she wanted to spend the remainder of her life. The room swelled with sadness and tears that afternoon. But curiously enough, it also swelled with relief. The patient and her family had finally been given permission to let go. It was if they had needed to hear that it was okay to stop fighting.
The useless medical treatment was replaced by comfort care. The IV was taken away. The daily injections were stopped. The anxiety in the room disappeared. Shortly after, M.K. started to lose consciousness. It won’t be long before she’s gone, but when she is, her life will end in the most peaceful of ways. Without pain, surrounded by friends and family in a room filled with love.
Saturday, August 1, 2009
Sunday, July 19, 2009
Patience with Patients
From the beginning of medical school, we have been taught to extend the same attention, compassion, and skill to each patient we see. A noble expectation, no doubt. So what do you do when you have a patient that is so dreadful, so condescending, and so entitled, that every interaction feels like verbal assault? Let me tell you about S.M., a 61 year old female with newly diagnosed Endometrial Cancer. Her cancer was caught so early, that we were able to cure her with the most benign of GYN Oncology surgeries – a transvaginal hysterectomy. Now this is a surgery that is so minimally invasive, women usually head home the very next day. Wonderful news, right?
Not for this particular patient. S.M., a heavyset Caucasian woman with a wild coif of graying hair, was convinced she was on the verge of death from the moment she arrived onto our hospital floor. How dare we ask her to roll on her side so we could listen to her lungs! She was suffering! And it didn’t matter that she had doctors to guide her medical decision-making – she was going to tell you what kind of medications she wanted. “I only want Demerol”, she ordered, “And Tylenol too! But not the generic, it has to be brand name!” And when she needed her IV replaced, we were ordered to bring up the Anesthesiologist from the OR to do it. No mere nurse could come near her. It had to be a licensed physician who placed her IV. Within her first 24 hours in the Oncology unit, after having to wait about 5 minutes for a nurse to fulfill one of her many demands, she picked up the phone and called the hospital C.E.O. to complain. Everything was wrong with her care. The food was bad. It made her nauseous. She didn’t get the right pain medication. The care was sub-par. How could we treat a little old lady so egregiously?
S.M. complained about anything and everything under the sun. So much so that after a while, I found it hard not to tune her out. Especially when I had a floor full of truly sick or dying cancer patients. Whereas normally I will pop into my patients’ rooms to chit chat throughout the day, I found myself avoiding hers like the plague.
By the afternoon of her second hospital day, she complained of worsening belly pain. And just like each exam before, she moaned and groaned when I touched her belly. The nurses and I rolled our eyes. Dutifully, I reviewed her vitals. Wait a minute. Her heart rate was up. I looked back at her labs over the last two days. Her hemoglobin had dropped 5 points since before her operation. A tell tale sign that she was losing blood somewhere. A CT scan later that night confirmed this. There was a large hematoma (blood collection) in her pelvic cavity where her uterus used to be. And it was making her sick.
The evening was spent stabilizing the patient. We transfused her. We did serial checks of her blood counts. We gave her pain medication. We did all the things we would have done for any other patient in the same condition. And in the end, S.M. was fine.
That night, I couldn’t stop thinking about this patient. She had been 36 hours out from her surgery before I noticed her drop in hemoglobin. Why? Was it just carelessness? Would I have missed that in one of my more beloved patients? Had I let her attitude affect the medical care I was providing? I knew the answer to these questions. I had let myself miss something in my patient, simply because I didn’t like her. And I was ashamed.
S.M. was discharged home on Friday. And thankfully I can say I strived to be a different kind of doctor after this incident. I know that I am limited by being human and I would be lying if I said I ever grew fond of this patient. But I learned a valuable lesson about keeping the practice of medicine separate from the emotions of human nature.
Not for this particular patient. S.M., a heavyset Caucasian woman with a wild coif of graying hair, was convinced she was on the verge of death from the moment she arrived onto our hospital floor. How dare we ask her to roll on her side so we could listen to her lungs! She was suffering! And it didn’t matter that she had doctors to guide her medical decision-making – she was going to tell you what kind of medications she wanted. “I only want Demerol”, she ordered, “And Tylenol too! But not the generic, it has to be brand name!” And when she needed her IV replaced, we were ordered to bring up the Anesthesiologist from the OR to do it. No mere nurse could come near her. It had to be a licensed physician who placed her IV. Within her first 24 hours in the Oncology unit, after having to wait about 5 minutes for a nurse to fulfill one of her many demands, she picked up the phone and called the hospital C.E.O. to complain. Everything was wrong with her care. The food was bad. It made her nauseous. She didn’t get the right pain medication. The care was sub-par. How could we treat a little old lady so egregiously?
S.M. complained about anything and everything under the sun. So much so that after a while, I found it hard not to tune her out. Especially when I had a floor full of truly sick or dying cancer patients. Whereas normally I will pop into my patients’ rooms to chit chat throughout the day, I found myself avoiding hers like the plague.
By the afternoon of her second hospital day, she complained of worsening belly pain. And just like each exam before, she moaned and groaned when I touched her belly. The nurses and I rolled our eyes. Dutifully, I reviewed her vitals. Wait a minute. Her heart rate was up. I looked back at her labs over the last two days. Her hemoglobin had dropped 5 points since before her operation. A tell tale sign that she was losing blood somewhere. A CT scan later that night confirmed this. There was a large hematoma (blood collection) in her pelvic cavity where her uterus used to be. And it was making her sick.
The evening was spent stabilizing the patient. We transfused her. We did serial checks of her blood counts. We gave her pain medication. We did all the things we would have done for any other patient in the same condition. And in the end, S.M. was fine.
That night, I couldn’t stop thinking about this patient. She had been 36 hours out from her surgery before I noticed her drop in hemoglobin. Why? Was it just carelessness? Would I have missed that in one of my more beloved patients? Had I let her attitude affect the medical care I was providing? I knew the answer to these questions. I had let myself miss something in my patient, simply because I didn’t like her. And I was ashamed.
S.M. was discharged home on Friday. And thankfully I can say I strived to be a different kind of doctor after this incident. I know that I am limited by being human and I would be lying if I said I ever grew fond of this patient. But I learned a valuable lesson about keeping the practice of medicine separate from the emotions of human nature.
Sunday, July 12, 2009
Gratitude
Being a resident makes you cranky. There are the 14 hour days that begin before sunrise. There is the constant reminder that you are on the bottom of the hospital totem pole. There are the attending physicians that only acknowledge your existence when you screw up – but never make the effort to ask your name. There is the incessant feeling that no matter what, you just don’t know enough… that self-deprecation that comes along with having to say “I don’t know” another time. There is the anxiety that comes with trying to manage a floor full of patients and the incredibly long to-do list that comes with it. And inevitably forgetting something important off the list. Intern year is just a humbling and ego-swallowing experience.
BUT…
Being a resident also makes you thankful. In the past three weeks, I have met a 35 year old female with cervical cancer so widespread, she had to have her uterus, ovaries, vagina, bladder, and rectum removed. I’ve cared for a 55 year old woman with ovarian cancer who went to the operating room only to have the surgeons discover that her disease was so extensive, they could do nothing but close her back up. I’ve cared for a 19 year old who was told in her home country that her ovarian mass was benign – only to present to us with a 20cm malignant germ cell tumor that was eating away her abdominal wall. I wiped the tears off the face of a 56 year old woman with end stage liver disease, chronic lung disease, and degenerative joint disease – who stayed with us for 15 days without a single visitor, get well card, or flower.
All of these women had problems much bigger than my own. Yet, each of these women, in their own ways, had hope. I watched them take joy in simple victories. Being able to eat and hold down solid food. Visits from loved ones. Freshly washed hair. Being able to get out of bed and walk to the hall. What I didn’t see, not once, was bitterness. Sure, there were sad moments, anxious moments. But there was never that “why me?” attitude I expected to find on the Oncology service. Instead I found women who face their realities with such grace, it leaves me humbled. It fills me with a resolve to quit my complaining and be thankful for the many, many blessings I have in my life.
BUT…
Being a resident also makes you thankful. In the past three weeks, I have met a 35 year old female with cervical cancer so widespread, she had to have her uterus, ovaries, vagina, bladder, and rectum removed. I’ve cared for a 55 year old woman with ovarian cancer who went to the operating room only to have the surgeons discover that her disease was so extensive, they could do nothing but close her back up. I’ve cared for a 19 year old who was told in her home country that her ovarian mass was benign – only to present to us with a 20cm malignant germ cell tumor that was eating away her abdominal wall. I wiped the tears off the face of a 56 year old woman with end stage liver disease, chronic lung disease, and degenerative joint disease – who stayed with us for 15 days without a single visitor, get well card, or flower.
All of these women had problems much bigger than my own. Yet, each of these women, in their own ways, had hope. I watched them take joy in simple victories. Being able to eat and hold down solid food. Visits from loved ones. Freshly washed hair. Being able to get out of bed and walk to the hall. What I didn’t see, not once, was bitterness. Sure, there were sad moments, anxious moments. But there was never that “why me?” attitude I expected to find on the Oncology service. Instead I found women who face their realities with such grace, it leaves me humbled. It fills me with a resolve to quit my complaining and be thankful for the many, many blessings I have in my life.
Monday, July 6, 2009
My First LEEP
The GYN Oncology rotation is one of the most dreaded rotations of intern year. You are relegated to spending 12-14 hour days on the floor managing moderately to very sick cancer patients. As the go-to person on the floor, all the abnormal vitals, labs, imaging, nursing concerns and patient issues come your way. Add the litany of paperwork each patient requires and this makes for incredibly chaotic days. What makes this rotation so hard is that, unlike other surgery rotations, we don’t get to break up our day with the fun of going to the operating room. We are 99.9% handcuffed to the Oncology unit.
So imagine my joy when my senior resident asked me on Friday to head down to the OR to do a LEEP procedure*. It was the end of a long week of scut work** up to my eyeballs. I could think of nothing better in that moment than the reprieve of going to the operating room and working with my hands to do something definitively to help a patient.
It had been more than 6 months since I had seen the inside of an operating room but I wasn’t too nervous. I mean, the attending doctor knew I was an intern. He would show me what to do, right? I head to the OR and meet the attending doctor and the fellow. We scrub, get into our sterile gowns, don our sterile gloves. After the patient is getting prepped and draped, the attending hands me the loop. “Here you go.” Then he sits back and waits. Hmmm. Here I am, standing between the patient’s legs, with the loop in my hand, not quite sure what to do next. How deep do I go? Where does my excision start? Where does it end? I mean, I am all about being proactive, but this is a woman’s cervix I’m working on. Not only do I not want to be the one to mess up her girly bits, but it’s now or never that I learn how to do this right. “Um, Dr. T? Think we can do some practice runs? So I can get the motion down right?” Fast forward to 7 practice runs later, yes seven, and I am ready for the real thing. My hand is no longer shaking from nervousness. I hold the loop in my hand, push down on the edge of the cervix, push the “cut” button on the bovie, guide the instrument up until the perfectly round surface of the cervix is excised. “Look at that. That is great cut!” says the attending and I beam. It’s silly what a sucker medical trainees are for positive reinforcement.
By the time we get the patient cleaned up and out of the OR, it has been a mere half hour that I have been gone. But I was re-invigorated. Re-inspired. My quick surgical jaunt reminded me of all the operating that awaits me over the next four years…
* A procedure in which the surgeon shaves off precancerous lesions from the cervix using an electrically-powered loop
**Scut work: the glorified secretarial, errand-running, busy work that makes up the day to day life of an Onc intern (as described above)
Sunday, June 28, 2009
Day One
What a week. Who knew the jump from being a medical student to a resident could be so big? My first day was Wednesday. I donned my long white coat and headed out the door at 4:30am to begin my rotation on GYN Oncology. I started pre-rounding on my patients, collecting vitals, lab results, fluid ins and outs – nothing I hadn’t done before as a medical student. After rounds, when the attending physician, fellow, and resident headed down to the OR, is when the terror began. All of a sudden my pager goes into overdrive with calls from the nurses. “Patient A is complaining of pain – what do you want to write for her? Patient B is tachycardic, what do you want to do? Patient C has drainage from her incision site, can you come take a look at it?” And as I stand at the patient’s bedside, a nurse and two nurse assistants eagerly await my response. I look down at the patient. And yes, I see a stapled incision down her abdomen. Draining pinkish fluid. Crap. Now what?!? As their eyes burn holes into the back of my head, I think to myself, “Man, I wish my last surgery rotation wasn’t 10 months ago…” Trying to use my brain was like trying to pedal the wheels on a very rusty bicycle. It just didn’t…want…to…work…
“Would you like me to place a pressure dressing doctor?” The clouds parted and the light of heaven shone down on me that moment. “Why yes, nurse! Yes, I would!”
As a brand spanking new intern, that’s the moment you realize that:
1. You are no longer a med student.
2. You are calling the shots.
3. You have no idea what you are doing.
Can you say PANIC?!?
Many times, my non-medical friends ask me if life in the hospital is really like what they have seen on T.V. Their idea of practicing medicine is composed of the life-saving heroism on ER, the incestuous romance of Grey’s Anatomy, and the intellectual masturbation of House. I am here to say that it is all baloney. If you really want to know what residency is like, the show to watch is Scrubs. And my present life resembles Season 1. The intern that doesn’t know what she’s doing. The nurses who go through this every June and graciously fill me in on the many things I don’t know. (“Doctor, I think you want to write for Morphine 2mg every 4 hours for her breakthrough pain, right?”) The senior physicians who expect you to know it all already (or at least pretend to).
Somehow, I think all of us medical students have the idea that when we start residency, our brains will somehow already be filled with the basic information necessary to take care of patients. Ha! If only it was that easy, my friends.
“Would you like me to place a pressure dressing doctor?” The clouds parted and the light of heaven shone down on me that moment. “Why yes, nurse! Yes, I would!”
As a brand spanking new intern, that’s the moment you realize that:
1. You are no longer a med student.
2. You are calling the shots.
3. You have no idea what you are doing.
Can you say PANIC?!?
Many times, my non-medical friends ask me if life in the hospital is really like what they have seen on T.V. Their idea of practicing medicine is composed of the life-saving heroism on ER, the incestuous romance of Grey’s Anatomy, and the intellectual masturbation of House. I am here to say that it is all baloney. If you really want to know what residency is like, the show to watch is Scrubs. And my present life resembles Season 1. The intern that doesn’t know what she’s doing. The nurses who go through this every June and graciously fill me in on the many things I don’t know. (“Doctor, I think you want to write for Morphine 2mg every 4 hours for her breakthrough pain, right?”) The senior physicians who expect you to know it all already (or at least pretend to).
Somehow, I think all of us medical students have the idea that when we start residency, our brains will somehow already be filled with the basic information necessary to take care of patients. Ha! If only it was that easy, my friends.
Sunday, June 21, 2009
Signing My Life Away
This week marks the start of intern year, the first of my four year residency program. I’ve waited for this day my entire life and I am both excited and thrilled to begin a life of taking care of patients in the most intimate of ways. I also start this process, however, laden with fear and trepidation. Sure, my dream of being a physician is being realized. But so is four years of 80 hour work weeks, sleep deprivation, and little to no time for anything but medicine. As a medical student, I’ve experienced this life. On my surgery and OB/GYN rotations, I walked through life like a zombie. My schedule was simple: work-sleep-work-sleep-work-sleep. My fatigue and lack of exercise made me moody and irritable. My lack of food made me skinny. My lack of time with family and friends made me lonely. My lack of “me” time made me depressed. What brought me comfort during these times was the fact that in a few short weeks, my rotation would end and life would return to normal. Fast forward to today: I am about to start a four year long rotation. Shit.
We spend our adolescent and young adult lives trying to figure ourselves out. What makes us happy? Fulfilled? Balanced? Content with who we are? And when I hit 30, I felt like I finally did it. I had my best friends and a supportive family. I had my love of yoga and running. I had a burgeoning interest in cooking and wine tasting. I had my love and memories of international travel.
It seems like a cruel joke that now that I’ve figured out how to live my life to the fullest, I have to give it all up. It is difficult to think of my very full and complex life being reduced to one dimension.
I guess the new challenge, now, is to figure it out all over again: Happiness, the condensed version. Appropriate for an 80 hour work week.
* Check out the very appropriate article in New York Times this week by Dr. Pauline Chen: http://www.nytimes.com/2009/06/18/health/18chen.html?em
We spend our adolescent and young adult lives trying to figure ourselves out. What makes us happy? Fulfilled? Balanced? Content with who we are? And when I hit 30, I felt like I finally did it. I had my best friends and a supportive family. I had my love of yoga and running. I had a burgeoning interest in cooking and wine tasting. I had my love and memories of international travel.
It seems like a cruel joke that now that I’ve figured out how to live my life to the fullest, I have to give it all up. It is difficult to think of my very full and complex life being reduced to one dimension.
I guess the new challenge, now, is to figure it out all over again: Happiness, the condensed version. Appropriate for an 80 hour work week.
* Check out the very appropriate article in New York Times this week by Dr. Pauline Chen: http://www.nytimes.com/2009/06/18/health/18chen.html?em
Sunday, June 7, 2009
The First Day of the Rest of My Life
The day has finally come… I am officially a doctor! A physician! An M.D.! And I have my beautifully crafted diploma sitting beside me to prove it! I will no longer be a mere medical student at the bottom rung of the hospital hierarchy. Today is the day when I am bestowed the honor and privilege to hold a person’s life in my hands. Wow… I better not mess it up.
I didn’t think I would feel different after my medical school graduation. After all, it’s just another day, right? But walking on that stage, being hooded in front of my family, friends, and mentors, was something else. It finally hit me. I have had this dream of becoming a doctor for the last 20 years (seriously, check out my fifth grade notes on becoming a “docter” when I grew up). I’ve studied. I’ve taken tests. I’ve worked all hours. And now that day is here. It’s a remarkable and powerful feeling to finally reach a goal that has been out of your grasp for so many years. While a thousand different thoughts and emotions are running through my head, one thing I know for sure. I am going to be the best physician that I can be. I have worked too hard to become anything less than that.
While I can’t deny I am on a graduation high right now, today is also bittersweet. It’s the day that I leave everyone who means anything to me for a life unknown on the Other Coast. I take with me only my fiancé and rainbow of emotions. Will I like my residency program? Will I like my co-workers? Will they like me? Will my suturing and knot-tying be up to par in the operating room? Will I remember how to deliver a baby? Will my patients have confidence in me? Do I have confidence in me?
Stay tuned to find out.
I didn’t think I would feel different after my medical school graduation. After all, it’s just another day, right? But walking on that stage, being hooded in front of my family, friends, and mentors, was something else. It finally hit me. I have had this dream of becoming a doctor for the last 20 years (seriously, check out my fifth grade notes on becoming a “docter” when I grew up). I’ve studied. I’ve taken tests. I’ve worked all hours. And now that day is here. It’s a remarkable and powerful feeling to finally reach a goal that has been out of your grasp for so many years. While a thousand different thoughts and emotions are running through my head, one thing I know for sure. I am going to be the best physician that I can be. I have worked too hard to become anything less than that.
While I can’t deny I am on a graduation high right now, today is also bittersweet. It’s the day that I leave everyone who means anything to me for a life unknown on the Other Coast. I take with me only my fiancé and rainbow of emotions. Will I like my residency program? Will I like my co-workers? Will they like me? Will my suturing and knot-tying be up to par in the operating room? Will I remember how to deliver a baby? Will my patients have confidence in me? Do I have confidence in me?
Stay tuned to find out.
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