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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.

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MICU to Heme/Onc — What a Change

After a month of intensity on the MICU, I have switched to the Hematology and Oncology service.

I won’t lie. The first few days after Switch Day I realized that I missed the intensity and the severity we had on an hourly basis with critically ill patients. It was like coming off of an adrenaline rush.

There are few Heme/Onc emergencies that require a response from the team immediately. I have explained to teams requesting a consult that their request was placed quite late in the day after we have completed rounds, and since it is not an urgent matter, we will see the patient in the morning.

I have been consulted on masses found incidentally or not-so-incidentally on imaging. Masses that are highly suspicious for malignancy. After seeing the patients, I write my recommendations: Please obtain a tissue biopsy. If stable for discharge, patient can follow up in Heme/Onc clinic as an outpatient. (Of course, there are frequently other specific tests I might ask for.)

Sayonara. See you later. Thanks for your question.

I don’t mean to sound or appear callous about patient’s with cancer. I appreciate the gravity of the subject matter. I know it often sounds like a death sentence when the diagnosis falls upon a patient’s ears for the first time. And the second. And sometimes, even the third. I know how it affects the family of the patient. I know they are scrambling for news, grasping for hope. I know how it feels because I was one of those family members when my mom was diagnosed with cancer while I was in college. So don’t misunderstand me. I don’t downplay the significance or the weight of what I deal with now that I am on the Hematology and Oncology service.

I just mean that the energy required of me is a lot less.

The intensity of the critical care unit takes it’s toll emotionally, psychologcially and physically.

I sleep a bit more now. I have time to read more now. And yesterday, I even had time to go discuss a research project with an attending.

It’s a good thing that residency affords these highs and lows. I don’t think I would survive 100% of either level.

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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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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.