Sunday, August 21, 2011

Less Person, More Intervention

A couple days ago I was at an advisor's apartment to welcome students of the incoming M1 class. His wife, who has acute myeloid leukemia, was also present. By any statistic you can quote she has beaten the odds more than once. She's a tough one and still fighting on.

Almost 3 years ago when she first greeted me and others as freshly minted M1s, she was lively, warm, and motherly. Now, bald and weak from chemo, tanned as if her skin had been baking under a desert sun, and also on dialysis, she appeared so frail and mortal. I've seen this before - the frailties of the body, broken by disease and worn from treatment and intervention. But also peering through are the embers of a once-strong soul. I could tell through her heavy-lidded eyes that she wanted to be healthy enough to interact and engage with all of us, instead of lying on the living room couch. I could tell that behind her wearied smiles that she's fighting off her own suffering.

I read a blog article the other day by a doctor who experienced what it was like to be a patient. What he wrote seems to mirror some of the patient's I've seen. Being a patient in the hospital must be one of the most frustrating things in the world. You rarely fully know what's going on with you, nurses are poking you every 15 minutes to 4 hours, and doctors order things to be done on/to you as you lay helplessly. We just need to remind ourselves that, at the end of the day, we can go home. Our patients often can't.

It's easy to correct an electrolyte imbalance. It's easy chase a blood culture. It's easy to track labs. But it gets harder and harder to see patients as people and not a "bag of symptoms." You look at someone and you don't see a mother, a sister, a father, a brother. You look at someone and you don't see a baker, a chef, a nurse's assistant, a student. No, instead you see an alcoholic, a morbidly obese individual, a body part, an organ, a pulmonary embolism, a cancer. All of which is true, one can't objectively deny any of it.

But in the ICU (intensive care unit), I've seen people become less and less person and more and more medical intervention until all that's left is a body on a ventilator with an NG tube, a Foley catheter, an arterial line, a central line, and a telemetry attached. In that state the soul has probably fled and all that's left is a shell of a person kept alive, not for the patient's sake, but for someone else's (whether it's the family or the medical personnel).

A woman was brought in to the ICU today. Full code, meaning CPR and the whole deal. She should have been left to die in peace. As my senior resident said, "This is a special place of Hell that people are forced to suffer through when someone calls the code."

That said . . . people occasionally do get well enough to regain their humanity and go home.

Monday, August 15, 2011

Pandora's Hope

I've witnessed Pandora's Hope with my own eyes,
staring at its immortal form behind its mortal guise.
A blessing, a curse; making us toil long after the day is done,
pushing us harder through a battle that can't be won.
I can only guess at its motives and its reason
since its release from its God-wrought prison.

I have seen it visit you on the edge of death
as you lay gasping with each labored breath.
With your eyes tightly shut in silent pain,
Pandora's Hope burrows deep into your vein,
snaking its way from your arm to your heart
and leaving its eternal mark within your chart.

Defeated, futilely struggling, there you lay.
Can you even hear us and what we say?
Our words of strength reach not your ears,
in your unconscious darkness of pain and fears.
Lifeless are your feeble and atrophied limbs,
your vessel subject to Hope's every whim.

It's not your pain - your suffering - that Hope allays,
but rather our fears and insecurities that It keeps at bay.
And before we realized, before we even knew,
Hope, and Artifice, have crept their way into you.
Hollowed out, Pandora's Hope has made you its shell,
And all for us It traps you - here you dwell.

Monday, August 8, 2011

A Good Death

My last patient died yesterday when I was post-call (aka, I wasn't in to the hospital).

This morning when I logged on the EMR (electronic medical records), I thought it was odd that it listed him as "discharged." I thought to myself, "Why would anyone discharge him? He's far from being stable enough to go home!" Later during rounds, the attending told me and the intern taking care of him that he died Sunday night.

I wasn't surprised (he was in really really bad shape with zero hope for recovery) but it still shocked me a little. The family had decided to declare him DNR (do not resuscitate). Within 24 hours of his death, most/all of his family had flown in from all over the US to be with him in his final hours. He was put on palliative care right away, but since the palliative team doesn't work on the weekends (wtf is up with that?), my attending began standard administration of morphine to ease the pain. His breathing rate was high and the morphine actually brought it back down to normal. He died some time later.

I almost cried a little but it wasn't the time and place. I had only known him for about 3 days and we did everything right by him. As the senior resident later remarked, "I'd rather be dead than live on through that." His rights were respected (his son had the power of attorney) and by all accounts, he died a good death - quick, and not drawn out like with cancer.

What do you think? Is there such a thing as "a good death" and if so, what is it to you?

Sunday, August 7, 2011

Suck is My Life

Well that was a bust of sorts. Such is my life. :-/

Was supposed to get together with Dan today. When I got there, he had some of his (gay) friends present. They were kinda amusing, lol. He was trying to fix one of their computers, unsuccessfully. Then because we were all there and bored, we decided to go to the giant mall complex near his place. I never got to say what I wanted to.

Oh well. At least I bought some jasmine oolong tea (we went to a tea shop and I had been wanting to buy jasmine tea for a couple days now, what a coincidence, lol). And two of his gay friends play the cello, that's always a plus in my book, lol.

Saturday, August 6, 2011

The Good Life vs. the Long Life

A couple days ago a fellow JMS (junior medical student) and I were conversing. Yes, I am aware that my posts have all lately become medically-oriented; heck, who're we kidding, it's been this way for most of the last couple years, lol. Anyway, we were conversing about the kind of doctor we want to be - one who helps patients live a longer life, or one who helps patients live a better life (as in, better quality of life).

If you had to choose one, would you choose a good life or a long life? Of course ideally we'd want both and patients often demand both. But try as hard as they can, they're only human and in the short run will almost always sacrifice a potentially long life for a good life. This got into a discussion of medical philosophies. In medicine we can do many things to prolong life but often at some cost of a good life. In some surgical specialties, such as orthopedics, they work on getting people back to their normal baseline or in some cases improve upon that - that is, an increase in their quality of life.

It's not easy being a patient. Some of my friends simply don't understand that. You can't just tell a patient to take xyz drugs for their health problems and expect them to be even 67% compliant. It's not easy taking 5+ different medications every day, each of them taken at different times and some with certain conditions/restrictions. It's easy to forget which ones you've already taken and which ones you forgot to take. On top of that, you have to maintain a more restricted diet and have a exercise regimen at all. Because, as we all know, medications only gets us so far; the rest of the way is all on our own. And with each pill we have patients take, with each side effect they may present, we decrease a patient's quality of life in order to increase their lifespan. One could argue that we increase quality of life over the long term too, but in the short term it still kinda sucks.

So is there some way to have one's cake and eat it too? Yes. In pediatrics, the general rule is that kids are usually healthy. The goal (in primary care peds) is to keep kids as healthy for as long as possible, and hopefully transition them into healthy adults. The other JMS who's on the same service as I am this month currently has a patient who's about my height but weighs 198kg . . . That's over 400lbs!! This morning I just looked at her (the patient) and thought, "If I hollowed you out, I could fit about 3 of me inside of you."

This woman also has some young kids, all of whom are normal-sized for their age. The other JMS recounts to me, "Did you see her kids? They're all normal. No kid starts out life that fat. What's the difference between them turning into her? Oh yeah, 18 years."

So if I truly desire to go into peds, I have about 18-21 years to prevent my patients from turning into their parents and developing the same health problems their parents either have or will have. It's possible. It won't be easy, but it's possible. I don't think we honestly try hard enough to counsel patients on preventative medicine - eating right, exercising, not smoking, cutting back on drinking, safe sex, etc. It's difficult in primary care, I know, what with the 15-20 min office visits. That's practically impossible! But we must still try.

Perhaps I'm being too idealistic. I wonder if it'll all crush me.

---TANGENT---
I'm meeting Drew for coffee tomorrow. Perhaps this time I'll dredge up the courage to tell him how I truly feel about him. Hmm . . .

I'll let you all know how it goes, maybe . . . lol.
---END TANGENT---

Thursday, July 28, 2011

Patients as Diseases

Yesterday I had a sudden strange epiphany: we tend to treat patients as diseases. The people who've come into the hospitals have "become" their diseases. We're more likely to say something like, "my diabetic patient" as opposed to "my patient with diabetes." Subtle difference perhaps, but a difference nonetheless.

It just hit me. Outside of their diseases - there sole reason for coming into the hospital - I knew next to nothing about my patients. I didn't know that my HIV patient was once a baker and a tanner (it said so in his chart). I didn't know that my DVT patient lives with his son and grandchildren (he randomly told me one day). I didn't know my patients as people, only as pathologies. It suddenly didn't sit particularly well with me.

On the one hand, by focusing on their pathologies, I can do my job more efficiently and figure out what's wrong and how to (hopefully) fix it. But on the other hand, there's so much more to the patient than their diseases and there's an element of humanity that's somewhat missing. I mentioned this to one of my friends who's on the same rotation track as me, and he says, "Welcome to the real world."

Yesterday my attending and I were rounding one of our patients with diabetes. She'll likely need her toe amputated because it's basically dead and rotting. And she started crying. My attending says to her (paraphrased), "You have become your disease. You have to get your life back and control this, don't let your disease control you. Knowing what it is is half the battle. The hard part is what you do, and I know it's not easy. But you must not let your disease control you."

We're all so wrapped up in the medicine, in the problems, that we fail to see the bigger picture of the world we live in. I don't know if knowing my patients as people would contribute to better patient care. Maybe it would help me understand how and why one of my patients became so obese that she could no longer sit up, roll on her side, or walk. And maybe, just maybe, it'd give me that small window of opportunity to help my patient manage her health once she leaves so that I never see her again.

Monday, July 25, 2011

Nothing to Do

"Nothing to do." NTD. At the end of our day, we leave a small blurb to the night team taking over on our patients. That's the phrase for most of our patients since we already did the majority of their work-up during the day. Basically all the night team has to do is monitor our patients and make sure nothing major goes wrong, lol.

Anyway, last week I felt like a total bum. The new attending I'm working with is starting here brand new and was getting used to the system. She didn't really let me do as much as my first attending and she relied on the PA a lot. That's okay, I understand. But for the better part of that week I felt like I didn't have any "ownership" over my patients, which I didn't like. So for most of last week I had "nothing to do."

I'm regaining that again now and most of what I did under my first attending. One of the things I did do last week was call ID (infectious disease) consults. A lot. We kept getting patients with unknown sources of infection and whatnot. On Saturday, the ID fellow and Dr. P (remember him?) came by to round on our patient. I hadn't seen Dr. P in a long while, so it was great to see him! :-)

Anyway, my pharmacist friend linked this vid to me and I like it a lot:


And I'm not sure where I found this vid, but it's also very cute. :-)