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Night Three

It’s now night 3 of 6. Six straight days — er, nights — covering the ICU patients here at one of the local county hospitals. Night 1 was great. Occasional calls here and there from nurses for little things that did not require much brain power. I am also working with an intern. He is covering the non-ICU patients. Night 1 went well for him too. I think I saw him watching tv shows on his iPad during the down time.

Night 2 was definitely busier for the both of us. For me, there was one patient who pretty much required my attention the entire night. And when I finally failed at placing a functional arterial line, I had to go call Anesthesia to help me place it. And then while they were at bedside, I asked if they could also intubate my patient as well. Later, as the early morning hours rolled around, I was about to place a central line. I had collected the consent and all the necessary materials. I had the ultrasound machine ready. However, the patient was still moving around so I asked that the sedation be turned up and I would return shortly.

I never did return. Because while I was waiting for increased sedation, I got another call for a patient on the other side of the ICU. Apparently they were having non-convulsive seizures through much of the night and the EEG tech was notifying us. Six in the morning. The patient had already been well loaded with dilantin, a type of anti-seizure medication the night before. However, despite the dilantin, the seizures continued. I considered adding another medication at a constant infusion via IV. The caveat, though, is that a constant infusion of versed (the medication I was considering) requires a patient to be intubated because it can depress the respiratory function.

I did not want to make that decision alone, though. So I paged the on-call neurologist. Unable to get a response, I finally paged the neurologist who would come on call at 8 AM. She advised against the versed infusion and suggested a different regimen. By the time this was sorted out, the day teams had already began showing up and I signed out the events of the night to them.

Tonight I am writing this on night 3. The call team admitted at least one very sick, ICU patient. At this point we have come up with a plan and we will continue to see how the patient does over the course of the night.

While I generally dislike working nights, there are some things that are nice.

I just have to focus on those niceties for another 3 nights.

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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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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.

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Medicine & Death

I just found this quote by Dr. Atul Gawande and I wanted to share it:

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.

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Dreams

Just woke up from a strange dream. It was a pretty convoluted “storyline” that started off with me running away from the “authorities” in some old-time setting. And by old-time setting I mean a couple hundred years ago. At least that’s how it felt because the people who were chasing me were doing so with swords.

Anyhow, the dream ended in a modern day setting where I was at a party. There were movie stars and I was some new person to the “scene.” My manager was worried about me and the press coverage.

Suddenly one of the ladies at the party started flying. But we knew she was on some sort of harness and it was all part of the entertainment. Something went wrong, though, and she slammed into a wall and dropped like a rag doll. I rushed to her side and started assessing the situation.

We didn’t want to mover her.

I believe I managed to intubate her.

It was a blur, and a flurry of action because along the way some good-natured person slipped her a pill while she was unconscious in hopes of helping her. I’m not sure when this happened but it must’ve been while I was otherwise occupied. This pill was causing her airway to close up and the reason I had to intubate her.

I just had to write this up because it seems like dream-me is progressing through my medical education faster than real-me. Which is alright, I suppose. Because at least real-me doesn’t have to run away with armed guards equipped from swords.

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Change The World

I’m not in the habit of adding music to my blog posts. So this is a special occasion — or just an opportunity for me to hunt down and try out a new plugin for my blog.

Yesterday I drove back to Loma Linda (from San Fernando) to get my H1N1 vaccine and to pick up some other things. This vaccine was the main reason. I received an email a couple weeks back saying that all students at Loma Linda University would be required to have the vaccination in order to register for Spring quarter. Last week (during exams), I received an email from one of my deans stating that I had not yet received mine and they wanted to know why and when I would get one. So, taking advantage of Christmas break (a time when the I’ve-got-to-study-every-minute-I-can feeling is slightly diminished), I decided to get my shot.

On the drive back I selected shuffle on my iPod and placed Apple in charge of my driving music. I frequently download music, add it to my library, and never listen to it. So there are plenty of songs that have a zero play count. But eventually I do get to hear some of the songs when my iPod shuffles to it.

Somewhere around Pasadena this song started playing (lyrics below). I think it was the first time I’d ever listened to it.

As the chorus played I thought about medicine — about the practice of it. I thought about the current healthcare reform debate. I thought about the seeming futility of trying to make a difference. I thought of all the practicing doctors who started out hoping to change the world but who have since become filled with cynicism. And I thought about Loma Linda University’s motto: “…to Make Man Whole.”

Can we make a difference on a grand scale? I don’t know. Through the optimistic lenses of my medical student glasses I’d like to hope that we can. I want to believe it’s possible.

But at the very least, we can start on the path towards changing the world by making a difference in the lives of one patient at a time.

Hope everyone has a wonderful Christmas.

If you’re a medical student, or any other student, I hope you get well-rested, refreshed, and ready to attack a new quarter come January.

If you’re out of school and working, I hope the office Christmas parties will have made you smile at least a little — even if it was to laugh at the foolishness around you.

And if you are a bum, I hope the chaos of the season will not be too overwhelming for you.

Change
Performed by Carrie Underwood
Album: Play On

What’cha gonna do with the 36 cents
Sticky with Coke on your floorboard
When a woman on the street is huddled in the cold
On a sidewalk vent trying to keep warm
Do you call her over hand her the change
Ask her a story ask her her name
Or do you tell yourself

You’re just a fool
Just a fool
You believe you can change the world
You’re just a fool
Just a fool
You believe you can change the world

What’cha gonna do when you’re watching t.v.
And an ad comes on
Yeah you know the kind
Flashin’ up pictures of a child in need
For a dime a day you can save a life
Do you call the number reach out a hand
Or do you change the channel call it a scam
Or do you tell yourself

You’re just a fool
Just a fool
You believe you can change the world
Don’t you listen to them when they say
You’re just a fool
Just a fool
You believe you can change the world
Oh the smallest thing can make all the difference
Love is alive
Don’t listen to them when they say
You’re just a fool
Just a fool
You believe you can change the world

The worlds so big it could break your heart
And you just wanna help
But not sure where to start
so you close your eyes
Send up a prayer into the dark

You’re just a fool
Just a fool
You believe you can change the world
Don’t listen to them when they say
Youre just a fool
Just a fool you believe
You can change the world
Oh the smallest thing can all the difference
Love is alive
Don’t listen to them when they say
You’re just a fool
Just a fool
You believe you can change the world