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Very Sick and Nearly Dead

When caring for patients on an inpatient basis — that is, patients who are admitted to the hospital as opposed to seeing patients in clinic — there are many moments when you must have crucial conversations. For the most part, medical students are shielded from needing to carry out these conversations. As a medical student, I may have asked patients on admission about their code status. However, I never wrote orders based on my conversations. And if a patient stated that they did not want to be resuscitated in the event that their heart stopped or they could not breathe on their own, I always told the intern or resident so that they could confirm and document the conversation. I think it’s appropriate to allow students to begin asking these types of questions; I also think it’s appropriate (and legal) to have residents/interns confirm and do their own asking when a medical student initiates discussion of these topics.

There are other conversations that, unfortunately, become more familiar as one gets accustomed to inpatient medicine. The conversation with patients and families regarding goals of care is probably as heavy as it gets. At times, this conversation spans days. When taking care of patients who are all-of-a-sudden critically ill, it is often extremely difficult for this conversation to take place and families often need to be walked through the reality of the situation and the grim prognosis. Even with patients who are chronically ill, these conversations may take time.

One of the key pieces of information during these conversations is the severity of the condition and the prognosis. In my short experience I have found that patients and families react differently. Some will cling to your every word, writing down the way you say things and even making sure to write down your name. Others listen with a blank stare; they make you wonder if the are even listening. It is both the honor and the burden of the physician to accurately and effectively convey this information.

Unforunately, it isn’t always a burden we carry well. Too often, I hear doctors (myself included) described the state of a patient as “very sick.” I don’t know if there is a good answer to why we, as a profession, do this. Perhaps it is easier to say someone is “very sick” rather than that they “are dying.” Perhaps some of us view death as the doctor’s ultimate defeat — something that we sometimes refuse to admit. Perhaps we have our own personal issues with death and dying (consciously or sub-consciously) and treating a dying patient forces us to confront, or at least acknowledge these issues (consciously or sub-consciously). Regardless of the “why,” I think we ought to do a better job of communicating to families and patients.

I remember calling a patient’s daughter. I remember telling her that her father was “very sick.” As she tried to grapple with the words I were telling her, she asked me, “Is he dying?” As I sat holding the telphone handset to my ear I finally answered, “Yes, he is dying. I cannot say when. I cannot tell you if it is days or weeks right now. But he is dying. He is getting weaker everyday.” Five days later, after I had left the service, I learned that my patient had passed. And in finding out about his death, I found solace in the fact that I had done what I could to prepare the family.

As difficult as it is to hear that your loved one is dying, I think we owe it to our patients and their families to be prepared for whatever comes next — at least what we think is most likely according to our education and experience. Some patients and their families understand what “very sick” means. Others don’t. The words we use, though, are not important. What is important — what is crucial — is that we communicate effectively with our patients and their families.

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ASN Kidney Week 2013

Earlier this year Dr. S, the program director for our nephrology fellowship, found me in the hallway. He told me about the annual Kidney Week conference put on by the American Society of Nephrology (ASN). For the past few years they have been offering an increasing number of travel grants to residents and medical students who are interested in the field of nephrology. Fortunately, my program director thougth of me as I am definitely interested in nephrology. He told me if I wanted to try and apply, he would help me with the application process. Apparently, each applicant must be nominated by an ASN member and then provide two letters of recommendation as part of the application.

It was supposed to be held in November in the city of Atlanta, GA. Fortunately, I had already requested one of my weeklong vacations for the exact time period — and it was already approved. Unfortunately, I heard about the travel grant about 1 week before the deadline. Long story short, I applied and received the travel grant.

Fast forward to November and I found myself traveling cross-country to Atlanta, GA. I had never attended any national medical association meetings in the past so there was some excitement and curiosity about the unknown. I was definitely overwhelmed by the sheer size of the location. There was just so many nephrologists, nephrology fellows packed into the daily plenary sessions. The exhibit floors were always busy with booths from various companies set up. It was definitely easy to get lost in there.

I was really grateful for the opportunity to attend. As a resident in a rather large university-based program I was surprised but really happy that a sub-specialty program director sought me out for this. I think it goes to show how much contact you get with your attendings here. And how much they want to help you get into fellowships that interest you.

I cannot over emphasize how important it is to find a residency that fits you. I definitely am not at the most prestigious university program, but I do know that, for the most part, I work with attendings who also care about our careers as well as the patients we treat.

*****

In the comments section of my previous post I did write that I wanted to think about and write a post about the number of hours we work as residents. I have not forgotten about it. And I still do intend to write a post about resident work hours.

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M, I See You

I have not been a very faithful poster on here. And I am sorry for that. It can be quite cathartic when I do post. Other times it is an amazing tool to vent or process the jumble of thoughts and emotions that plague me on almost a daily basis. Other days, I feel mindless and numb. To use the old cliche, it’s an emotional roller coaster. I’d like to begin this post by sharing a quote by Dr. Atul Gawande:

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.

I spent the entire month of September on the Medical Intensive Care Unit (MICU). The last time I had been there was last year — also in September — during my intern year. It was a new experience coming on as the senior resident. Fortunately for me, and the patients, there is an MICU fellow and attending above me. There are also usually a slew of experienced RNs more than willing to share their accumulated wisdom. Unfortunately, there are also less experienced ones who freely give away things as well. But that may be a topic for another time.

Prior to the month on MICU, I knew that I would be spending every 4th night at on the unit covering all the patients from the two teams. At capacity, that would be about 30 critically ill patients. I knew, also, that the month would include my fair share of very sick patients who ultimately lose their fight against death.

The very practical part about dealing with death when you are the senior resident on call is that someone has to do a death exam. Someone has to pronounce the time of death. And at my institution, that someone must be a licensed physician. Otherwise, you have to look around to other services to help you out in pronouncing. And you don’t want to have to call the Surgical Intensive Care Unit (SICU) attending to pronounce an expected death.

My license arrived in the mail about a week before I came onto the MICU service. And so I entered into the month with at least one less worry.

As the month began and I survived through my first week, I noticed I was averaging one death per on-call night. I supposed it was better than averaging one cardiac arrest per on-call night like one of the other senior residents. Though grim, pronouncing an expected death was a lot more peaceful than running towards a code blue at whatever god-forsaken hour of the night. Fortunately, I didn’t keep up with the 1-death-per-overnight-call rate.

It was definitely an adventure — albeit a tiring one. I had amazing interns and an awesome co-resident. My interns worked their butts off. I watched as they slogged through the long hours and always tried to smile and help with whatever they could. Towards the end of the month, both my co-resident and I thought we could see them burning out. It happens frequently on the MICU month. I tried offering words of encouragement where I could; admittedly I am not the greatest at it.

I remember when I was an intern going through my MICU month. I often felt like I was drowning and always trying to catch up. I hope that they were able to learn from their experience. I hope I was able to contribute to that learning. After all, teaching them is supposedly one of my responsibilities as a senior resident.

As expected with such a sick population, there were many cases in which I wished we could do more. We had our victories. We also had our losses. Regardless of the outcome, though, we had our lessons. And hopefully, they were lessons that have made us better doctors.

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Another Day, Another Loss

My patient died today.

It was my first death as the senior resident on the team.

Couldn’t help but think about what I could have done more.

After I was notified that my patient had passed, I went up to the unit.

The room was full of people. Slowly they trickled out. Two family members lingered, one was her brother who had been by her bedside for so many hours in the last few days.

I offered my condolences and offered my hand. He looked at me, his eyes red, and started shaking his head.

And then he hugged me. And thanked me. Thanked me for what I had done. Thanked me for my calmness through her dying.

And I hugged him back.

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The Cycle Continues

I’m finally coming up to the end of the 1st month of PGY-2. This month has been spent on the Endocrinology service, an Internal Medicine subspecialty. One of the fears I posted about last time was that there would be interns who now look to me to answer questions on management. This fear has not yet materialized. That experience has been deferred — at least for now. There are no interns on the endocrinology service this month.

During this fast-ending month, I have only met a few interns. My first month leading a team with interns begins in just a few days. It has been fun meeting the few that I have. It has also been fun watching them from afar. I feel that I should be amongst that new group of incoming interns. The year just went by so fast. It also makes me nervous thinking of how fast this and the next year will go as well. But, I suppose, I can deal with that later.

This month, I have also seen a different side of medicine. This is my second month on a consult-only service. This means that the Endocrinology is not the primary team for any patient staying in the hospital. It’s a consult service. The primary team, if they have an endocrinological question, can call us and ask for help.

I”m slowly beginning to understand how residents feel when interns call with consults. Sometimes it is downright frustrating. I realize that my picture of a consulting service is skewed, though. As a resident, consult requests mean more work. For us, this month, it meant that we had more patients to see in addition to the ones we were already scheduled to see in clinics. That’s it. Each consult is more work.

I am told that this isn’t the case in the “real world” after residency. Consult services love consults. And if the consult is a simple case? Even better! Each consult represents another case that can be billed.

Ideally, residents should probably look at each consult as the ability to learn more. But that’s a perfect-world scenario. When we are already overworked, who wants another case to see afterwards?

The other day, as I sat together with a group of second year residents, we talked about the new interns. We talked about how they looked so nervous, how they asked some odd question, etc. And then we laughed as we realized that the residents ahead of us likely did the same thing last year around this time.

And so, the cycle continues.

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Two More Weeks

And I’m freaked out.

In about two weeks I transition into the role of a senior resident. I will be charged, on certain in-patient months, with leading a team with two interns. It’ll be my responsibility to teach, guide, and correct.

There are days when I feel like I am starting to come around — that I’m becoming the doctor I want to be. Then there are other days — days when my first and foremost goal is making a decision that will not negatively impact a patient.

I was recently charged with a patient who came in with a heart attack. He received multiple stents. I first saw him the day after the stents were placed. He was full of energy. He even wanted to go home! I examined him — all was well. His angiogram site looked good — no bleeding or hematoma.

A little after noon the patient’s nurse came up to me and let me know the patient was having some chest pain and that she was getting an EKG. I nodded and went on my way.

A few minutes later she came to me with the EKG. Knowing the patient had come in the day before with a heart attack and had multiple stents placed, I stood up and walked towards the chart rack so I could compare the EKG with old ones.

Comparing the EKG with the one taken hours earlier, I froze. There were significant — at least to me — differences. I stared some more.

I called my senior and showed him the EKGs. He thought the differences were significant too.

My senior called the fellow, who told us that the changes were significant and to call the attending.

Within an hour the patient was being wheeled back to the cath lab to undergo a repeat angiogram. The attending had agreed. The changes he saw in the EKGs were concerning to him as well.

I was right this time. I noticed something important and pushed it up the chain. But I realize things could have easily gone south. What if the nurse did not bring me the EKG? What if I looked at it and didn’t recognize that the small differences were something to pay attention to?

In just two weeks I won’t be able to hide behind the fact that I’m “just the intern.” When other services call and ask, “who’s the senior?” That’ll be me.

And I’m freaked out.

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Too Late — Part 2

Part 1 can be found by clicking here.

*****

It was a few weeks after I had said goodbye to Helen. I remembered her. I can’t say I stayed up at night thinking about her or what became of her. No one does that — at least no one does that for long. It’s too difficult. It’s too much of an emotional toll. Besides, we see too many patients.

I remember coming back from a day off. When I returned and logged onto the computer in the morning I was surprised to see Helen’s name on my list of patients to see. I looked around the resident workroom, found the senior resident on my team, and asked, “What happened? She’s back?”

Helen, I had learned, had returned to the hospital. Her sister had brought her in because she didn’t feel like she could take care of her. I was puzzled. Wasn’t this the same reason she came in before? Hadn’t we discharged her to a skilled nursing facility? The answer to both of these questions was a yes. Apparently after some time at the nursing facility Helen had decided that she wasn’t happy there. So she left. And went back to live with her sister. Déjà vu.

When I finally went to see Helen I was surprised at how she looked. She appeared as if she’d lost significant weight since the last time I saw her. She was also using oxygen. She looked physically and emotionally tired.

“Hi,” I said to her as I walked in. She looked up at me and managed a smile. She remembered me. I asked her what had happened. I learned that she had never made it back to the Oncologist. Something came up. I didn’t hear what exactly came up, but she dismissed it — she wasn’t interested in chemotherapy anyways. She had talked to her family and they had decided that palliative care would be the best option. She had also chosen to be DNAR — which meant that in the even that her heart stopped or developed an arrythmia or if she was unable to breathe on her own, there would be no “code blue” called, no chest compressions, no mechanical ventilation. I told her that I understood, and that we would respect her wishes. As she had expressed interest in palliative care, I told her I would get in touch with our palliative care team and ask them to come and speak with her.

Because of her condition, I was fairly certain that the palliative team would take her onto their service for in-hospital hospice care. But I wasn’t sure when she would be accepted as this usually depends on bed availability. I made the call to the palliative care team and was able to speak directly to the attending who said that Helen would be seen as soon as possible that day. I thanked him and continued seeing the rest of my patients. Within a couple hours, I had received a page from the palliative care attending. Helen was accepted. She could be trasnferred to their unit before noon.

I was excited. She wouldn’t have to wait days for a bed to open up. I thanked the attending and assured him that I would get the necessary paperwork, or computerwork, done as soon as I could. I also went down to see Helen. I wanted to share the good news myself — that she would be taken care of on the palliative unit where the staff was very good at comfort care. Again, she smiled. I explained that as she was transferring to another team, I would no longer see her. There would be a new team of doctors taking care of her. But she asked if I would still come and visit her. To be honest, I was a bit surprised about her request, but I told Helen that after her transfer, I would come by when I had a few minutes.

At the end of the day, I opened up her chart on the computer. I was making sure that all of my documentation was correct. I also noticed that the Palliative Care Attending had also left a note. He wrote that he had spoken to Helen and her family and felt that she was deteriorating and had hours to days left. I was happy for Helen. At least she was now where she would be best taken care of, where the goal of care would be comfort. I realized, though, that if she really only had hours to days that I would have to go and visit her soon if I were to honor my word.

The next few days were a blur. We were busy. We were slammed with admissions on call days. On non-call days I had to leave by noon to another hospital where I had my clinics in the afternoon. But every once in a while I made sure to find out that Helen was still on the Palliative Care unit. When things finally settled down and I found myself with a few moments of downtime, I walked over to the palliative care unit. It had been days since I last saw Helen. This time I would visit her, not as her doctor, but as — well, I didn’t know what exactly I was visiting as. I wasn’t her doctor anymore. And I don’t think I could say I was visiting as a friend. But she had asked me to visit her and I had agreed. So there I was.

Walking the unit, I kept looking out for her name.

Nothing.

I made another round on the unit to make sure. Her name was nowhere to be found.

I learned that she had passed away just hours earlier.

I was just too busy. There were too many things to do. I was too late.

And that’s the story of a women named Helen1.

On some level, I feel like I let her down. I couldn’t keep a simple promise to come and make a visit. It’s easy to say that I was “too busy” and that there were “too many” things to do. But one could always argue that if it were a priority, then I would have visited her. But maybe there was a part of me that didn’t want to see her. Maybe I wanted to avoid coming into a room as the doctor and realizing I had nothing to offer — nothing that would make a difference. Perhaps, though, all she wanted was some company. Perhaps she had come to terms with her imminent death and she wasn’t looking for a cure — instead, she was just looking for a fellow human being.

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