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Again, MICU

This year I was one of the “lucky” residents who were assigned two MICU months and two CCU months.

I am finishing my 2nd year of residency in the MICU. It has been a long and exhausting month. My last call was probably my most emotionally draining one.

The call day had ended and I soon found the MICU empty of other residents. I was the senior left on duty. Around 10 pm, one of the nurses came up to me and told me that an arterial line was no longer functioning properly. The line was needed as the patient was on a couple medications to support her low blood pressure and the arterial line provided an accurate measure of her blood pressure. This patient also needed frequent blood draws to check her pH, CO2, O2, and HCO3 levels in her blood.

I asked the nurse to get things ready and I would attempt to try and place another line. After notifying the attending, I started scouring the MICU for our ultrasound machine. Knowing that the patient was on pressors (medication to maintain blood pressure), I figured her artery might be small and I would use any help I could get.

To make a long story short, I made 3 attempts with the help of the ultrasound. First attempt I got a red flash of blood in my catheter that indicated I had hit the vessel. However I could not successfully advance the guide wire. As I re-checked the location of the vessel on the ultrasound, I realized that her vessels were clamping down even tighter. I had to try further up her arm for attempts #2 and #3.

After three attempts I threw in the towel. I paged my attending and asked for help. He came back and suggested we try a femoral arterial line instead of one in her wrist. Having never placed one I was eager to at least try. In the end, though, the attending ended up placing one.

Minutes later, the patient would code. She went pulseless and chest compressions were immediately started. We brought her back. But she would do it again later that night. The second code was not successful. And in the early morning hours I phoned sleepy relatives to deliver the fatal news.

The following morning as rounds began, one of my interns notified me that Mrs. X had approached him. She wanted to withdraw life support on her husband. She would later do so and request that the intern and attending be present as they disconnected him from the medications and ventilator that kept his body alive for the past week.

I watched as she wailed and cried over her husband’s body. And slowly and quietly we walked away; because we had to move on to other sick patients.

We moved on to a room where a young body lay motionless. A mother was hysterical saying that it was “too soon.” There wasn’t a dry pair of eyes in that room as our team walked in. And I watched as my attending deliver blow after verbal blow. The patient was past any intervention. There was no surgery or medication left to try. Expected reflexes were absent. There were no signs of spontaneous breathing; the patient was fully dependent on the ventilator. Our medical advice to the family? Withdraw life support. Despite initial vehement protestation by a grieving mother, the family finally made the decision to withdraw life support late that day.

One of the family members looked right at us and said, “I don’t know how you can do this every day.”

Sometimes, I wonder that too.

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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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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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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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Too Late — Part 1

She was an elderly woman; I’ll call her Helen1. Her hair was silver. She smiled pleasantly as I walked up to her bed in the emergency department. But her eyes betrayed her. Her eyes were dark and solemn. When I asked Helen how she was doing, she told me she was “alright.”

I picked up her chart and noted that it was her first time here. Fortunately, though, she had brought her records from her previous hospitalizations. We discussed why she had come, what had previously been done for her at the other hospital, and what her goals were now.

She had been recently diagnosed with advanced, metastatic cancer. I learned that her oncologist had wanted her to get a PET scan — a scan that would allow them to see the extent of her metastasis. I also found out that the reason she had come to my hospital (or maybe I should say the hospital I work at) is that she had lost her home in a city over an hour away. With no other options, she had moved in with her younger, widowed sister who lived just down the street. And now, she presented to this emergency department. Because this was the closest, large hospital. I also learned that a big reason for coming into the hospital is that her sister just couldn’t take care of her. The patient needed help. Her sister needed help.

We admitted Helen and over the next few days ordered a few tests and reviewed outside records. We knew she had a fluid collection in her lungs (pleural effusion), but we didn’t feel it necessary to put her through the risk of a procedure as she was breathing well without any oxygen. We got our Oncology service involved and they actually scrapped the idea of doing a PET scan. They said it wasn’t necessary. Reviewing outside records they already knew this was metastatic cancer — a PET scan would no longer change management of therapy at this point.

I remember walking in to see Helen shortly after I was notified by the Oncology resident that they had already spoken to her with her options. The Oncology resident told me that their note was in the chart. Of course, I reviewed it before I went in.

As Helen lay in her bed, I asked her if she had been seen by oncology already and if they had talked to her about what could be done. I knew the answer already, but I often let my patients tell me. Sometimes it’s a good thing as this allows me to get an idea if they actually understand the situation.

In Helen’s case, she understood — for the most part. She told me that there were two options: chemotherapy or no chemotherapy. If she received chemotherapy she would probably live about 1 year and have to go through side effects. If she chose not to have any chemotherapy, she wouuld have about 6 months. What the oncologist had said was that for patients with her scenario, the mean survival was 6 or 12 months depending on therapy vs non-therapy.

I suppose it’s common for patients to hear phrases like “mean survival” and forget that we are talking about averages. They apply it specifically to their own case. It makes sense. I’d probably do the same thing. But there’s a reason most doctors never give out solid predictions. We give ranges on purpose. We understand that patients never read textbooks — and so they present in strange ways or with little variations and surprises.

I stood at her bedside. Silence filled the air. Helen offered up another smile and said, “It’s ok. I’m 88. I’ve had a good life.” All I could do was offer up a smile. She told me she was leaning towards no chemotherapy. She didn’t like the idea of all the side effects. But she would have to talk to her family first. She would call them and give her answer to the oncologist in a week’s time.

I nodded. We had found a nursing facility for her to go to. There was nothing we could offer her at this point other than some pain medication for the pain she had in her chest. I couldn’t help but think that she should have come in sooner. But would it have made a difference? What if she had come in before the cancer had spread anywhere? Would she have chosen chemotherapy then? Would her old, frail body have taken those medications? Would she have been able to afford the treatment?

Too many “what if’s.” Too many “too’s.” Too late. Too old. Too much.

I said goodbye to Helen. She would be discharged the next day and I was going to be off. I wished her the best. I reminded her to follow up with Oncology in a week. Little did I know, I would be seeing her again too soon.

To be continued…

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Geriatrics and Palliative Care Medicine

That’s what this month has been all about.

Ok, so I did get a week of vacation at the beginning of the month, but after that I have been dealing with senior citizen patients, quite a few of whom are hospice care patients.

It has been strange — the palliative care side of things, that is. I feel like I have spent the last few years preparing for a career in which I do everything I can in order to help someone get better. And on occasion, we must get out of nature’s way and allow death to happen. However, this month I feel like that model of medicine has been flipped upside down — that my role has now shifted.

I feel like so many of the patients I see are desperate for help. They crave to die with dignity and with peace. And for that, they look to us.

It is different when the family members of patients come looking to you, not for hope in a recovery, but for hope in a peaceful passing.

I have a great deal of respect for physicians who choose to go into palliative medicine. I used to look at the specialty of Oncology/Hematology as the “saddest” of specialties. Yet it seems the field of Palliative Care is grimmer still.

Perhaps I am just not used to it.

But maybe I don’t want to get used to it.