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Death Is Hard

February 9, 2012 By Leave a Comment

In the past I have found it easy to say that it is harder to see a sick, hospitalized child than a sick, hosptitalized elderly patient. It is easy to reason that the senior citizen has lived a full life while the child has his future ahead of him. But I think this position ignores the viewpoint of the patient’s family. Sure, sometimes a family is prepared for the death of a daying grandfather who has lived a long life and is going out on good terms. But few are ever prepared for a tragic death that comes on suddenly — no matter what age it happens.

Recently I saw a patient who I shall refer to as Mrs. B. We were not the primary team. I saw her as a consult after she had been in the hospital for a rather extended period of time. At the time the consult came in the team was pressed for time so we split up the duties. I would go and talk to the patient while my colleague would put together a consul note summarizing the hospital course and patient’s past medical history using the patient record as a source.

Without reading anything about the patient I went off to find Mrs. B. All I knew about her was that she had been hospitalized for quite some time and that she was fighting an infection that had spread to the blood. As I walked up to her bed she lie silently with her eyes open. I asked her how she was doing but couldn’t make out what she was saying. I tried to ask her in Spanish but she only responded with a more excited mumbling sound.

I realized that I wouldn’t be able to take a history from her. That sort of thing is difficult in non-communcating patients. So I proceeded to perform a quick physical exam. I noticed scleral icterus (jaundiced, yellow eyes) and a few skin wounds. But nothing else really jumped out at me. I left, but not before looking over her chart and collecting her vital signs for the last 24 hours.

When we began rounding our attending began writing out Mrs. B’s information across the large white board that hung in the workroom. Everything we had been able to find from the review of the patient record went on the board. We dissected and discussed the details and the big picture. And, after almost two hours, our attending decided it was time to go and see the patient.

We paused at Mrs. B’s door to pull out some gowns. A nurse ran up to us and whispered, “She just died. The family is inside.” And, while looking at the nearest clock she added, “She died about an hour ago.”

I was shocked. I didn’t know what to think. I had just seen her and touched her just over two hours ago. And now she was gone. At the time I saw her, I had no idea how sick she was. And my physical exam didn’t tell me she was so close to death. During our discussion, though, our attending noted how bad her labs looked and that she would probably benefit from palliative care.

I don’t know how the family took her death. I didn’t go inside the room. I didn’t come back later. To me her death was sudden. I was not expected it so soon. But death, it seems, waits for no one. When it’s time, it’s time.

It is hard to care for sick children in the hospital. But I think it can also be hard to care for sick adults who face tragic endings as well.

Death is hard. Period.

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Tears

February 5, 2012 By Leave a Comment

I used to say that I am immune to tears. I grew up with a baby sister. I saw many tears. And admittedly, some were caused by me.

But I have realized that I am not as immune to them as I thought.

I am only immune to some of them. The kind that are manipulative. You know the kind. The kind that flows like a never-ending river when a child is not getting his or her way. The ones that go along with the sad, puppy-dog eyes that beg for you to give in. These kinds of tears I can handle. I can laugh at them because I will not be manipulated like that. I refuse.

But then there are the other kinds of tears. The tears that flow due to deep, heart-breaking pain. I realized this for the first time when I stood in a patient’s room. The patient lay in the bed, sedated by medications. The attending stood in front of me, trying to explain the circumstances to the family members.

I remember seeing the tears. I also remember hearing the guttural, almost-primal screams of agony and despair. The words they cried out weren’t even in English. But pain needs to translating. Theirs was a pain borne from unexpected outcome. The patient had been discharged home just days before. That night I had worked on the admission and, with the help a translator, been able to communicate with the patient. But over the course of 10 hours the patient had deteriorated and pain and anguish was what was left in the room.

I physically removed myself from the room. I had seen sad situations many times before but this one got to me. I could feel my eyes start to water. My throat got tight. The air was thick and heavy. I needed to take a few breaths.

I used to say that I am immune to tears. I cannot anymore.

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Veterinarians and Pediatricians (and Pediatric ER Physicians too)

December 4, 2011 By 1 Comment

I’ve always thought that veterinarians have it tough. They see patients who cannot communicate. Their patients don’t speak or complain of symptoms. So veterinarians have to go by what owners have observed and by the physical exam for most of their data.

It’s kind of like a pediatrician or even a Pediatric ER physician. Little kids might not be able to complain. And when they do, they may be very vague, unable to give a good description of what they are feeling.

I recently worked a Pediatric ER shift where I saw a 4 year old patient who was transferred from another facility. The other hospital wanted us to rule out appendicitis because the patient had abdominal pain and a CT scan that was equivocal.

I went in to see this little patient who appeared to be lying comfortably in the gurney watching the TV hanging on the wall. The patient, who I’ll call Joe, didn’t seem to be in pain. So I asked his parents what the problem was. It turns out that Joe had been vomiting — up to 10 times over night — and that was why he was brought in to the ED. I asked if Joe was communicative at home. His parents told me he was.

Was Joe a child who would normally complain of pain like a stomach ache? Yes, they told me. Did Joe ever complain that his stomach was hurting? No, he didn’t.

At this point appendicitis was getting knocked down lower on my differential (list of possible diagnoses). I proceeded to sit down next to Joe and say hello. He stared back at me. I told him I was going to just take a look at his stomach and started to pull back the hospital sheet that was covering his belly.

Almost immediately he pulled it back. Apparently, this kid liked his stomach covered up. I pulled back a little and pressed on his stomach. He started crying. I tried to observe how he was crying — to see if he was just being fussy or if it was really painful. I started pressing on the left side and worked my way to the right lower area of his abdomen (where appendicitis typically presents with pain) and tried to see if his crying intensified as I neared that spot.

I finally gave up and let him cover up his stomach. But I tried one more time. This time, I pressed on his stomach through the sheet. This time Joe did not cry. I was able to press fairly deep all over his stomach without eliciting any cries of pain.

That pretty much did it for me. And, after more discussion with the parents about Joe’s symptoms at home prior to coming in to the hospital, I concluded that appendicitis was not likely in this little patient.

In the adult world, most patients are able to communicate. Sure, I’ve had adults who were unable to communicate with me, but the proportion of patients who can’t communicate is much, much less. I don’t plan on going into pediatrics or emergency medicine. But I can appreciate how difficult it can be at times. And I am thankful that there are people who choose to do it.

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That swell feeling…

September 27, 2011 By Leave a Comment

Today.. for the first time since I have been seeing patients… I felt like tears were possible; I felt that if I allowed it, MY tears would flow. Or at least trickle out. Not because I was being an idiot and getting berated by an attending. But because of the pain in the family members standing inside a dying patient’s room.

For a moment I felt the tears begin to swell. And I turned away, took a second, and kept my composure.

I have been in sad situations before. But this was the first time it (almost) got to me.

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My Weekend Rant

September 17, 2011 By 5 Comments

As I walked through the hallway of the Emergency Department, my eyes fell upon one particular gurney that was parked against a wall. It was a typical night in the ED. People were flowing through the doors and patients were being “roomed” in the hallways. As I looked at this gurney’s occupant, I cringed. The pale face with wrinkled skin and sunken eyes was all I could see. The body was covered up with a blanket. But that face was unmistakable. I knew the face — or at least I thought I did. I didn’t want to take the risk of being recognized so I quickly walked passed. I cringed, knowing that I’d have to walk back this way on the return trip.

When I passed the gurney for the second time I realized that the patient was asleep. This time I paused at the bedside. I noticed her wrist was exposed. And on that wrist was her identification badge. The name confirmed my fears. This was the very patient our team had discharged one week earlier and showed up in the ED the very next day with discharge papers still in hand. This was the patient whose medical record would reveal multiple visits to the ED for the purpose of obtaining meds.

If you’ve read this far and are wondering why I was so fearful, it’s because I feared that the patient would be a “bounce-back.” A patient becomes a bounce-back when they return to the hospital within the same calendar month after their discharge. When this happens, should the patient need an admission, they go back to the team that originally took care of them. The theory is that it provides continuity of care as the team is already familiar with the patient and his or her issues.

As I continued on with my work, I knew I didn’t want this bounce-back. I didn’t want the patient back on our team. She had been hard to work with in the first place. She had terrorized the nursing staff. She had frustrated her sitter. She had tried our patience. She had refused treatments. She was a difficult patient.

Like I wrote earlier, she was a frequent flier. I am not sure her repeated admissions helped her. Sure, she had physical ailments. And we could help the occasional exacerbation. But they were chronic conditions that we wouldn’t cure. To me, it seemed that the most pressing issue was her mental health. I suspect, and I’m no psychiatrist, that much of her behavior would improve with more attention to her mental health. But sadly, the system we are in affords little help to who need it, and even less to those who don’t think they have a problem.

As I begin to wrap up this post, I admit I am struggling. I don’t know where I am going. I suppose it is borne out of a frustration that is without an avenue of release. There’s nothing that I can do to help patients like the one above. And as I go into Internal Medicine, I am sure I will encounter many more people who, though suffering from significant medical and mental illnesses, will try the patience of those taking care of them.

Perhaps, this is just my weekend, off-day rant.

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Can We Really Understand Our Patients?

July 11, 2011 By 2 Comments

The following post originally appeared on Medscape’s The Differential on January 12, 2011.

*****

Knowing I had recently completed a rotation in OB/GYN, a friend asked me how they (medical schools) make male medical students understand what their pregnant patients feel like. It was an interesting question. And it got me thinking about understanding what our patients go through – no matter their age, or sex, or condition.

As medical students, there is not much discussion about how our patients feel. Sure, there are classes about human suffering. But these classes deal with generalities. Each patient experiences their condition in their own unique way. To draw upon the obstetrical cases, telling a woman that she is pregnant can be met with a variety of responses that range from fear and dread to joy and elation.

I once heard Dr. Wil Alexander say, “The moment a symptom occurs, a story begins.” Those words seemed so profound at the time that I wrote the idea down and saved it. Each patient who walks through the hospital doors is more than a symptom. They are more than a diagnosis. They are more than a disease. They are human beings who have a story – a story that is just waiting to be told.

The question that my friend raised, regarding how male medical students are made to understand the experiences of their pregnant patients, made me realize that there is little done to help us understand our patients’ experiences. But I am okay with that. Because each experience is too individual to explain away with a blanket statement. It is impossible for anyone to know exactly how another feels.

The important thing, in my opinion, is for us to connect with our patients and convey that we acknowledge that they are going through a difficult or trying situation and to offer ourselves as they cope with it. It can be something as simple as giving them permission to be candid about their raw emotions – the frustrations and fears that build up – in a safe environment where no one will betray their trust or judge them or treat them any differently because of it.

It would probably be a good thing if we could understand exactly what our patients were experiencing. It would probably help many of us with our empathy. But without that ability to understand perfectly the experiences of our patients, we are left with the ability to accept perfectly the experiences of our patients. And I suspect that for most of them, this much is enough.

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“You’d be surprised.”

June 17, 2011 By Leave a Comment

Not long ago a classmate and I were told that there was a patient who needed his chest tube removed. The intern said one of us would do it. Initially I was going to do the pulling. But it really didn’t matter. Neither of us had ever done it.

Before we reached the patient’s room, our intern verbally walked us through the steps we needed to do in order to safely remove the chest tube. After all, you don’t want to be giving instructions at the bedside while the patient is awake and afraid.

It turned out the patient was very afraid. He had just experienced having a chest tube removed a few days ago. For reasons I was not familiar with (as I had never met him before and never looked at his chart), he had required a second chest tube. Now, though, it was time for the second one to come out.

As I bent over the bed cutting off the sutures the patient continued to express his fear. It had been very painful the last time it was done. He also wanted to make sure that we waited long enough for the pain medication to kick in (he had received some IV pain medication from the nurse right before we came in).

I finished cutting the sutures and the patient looked at me and asked if I had ever done this before. For a split second my mind froze. I didn’t want to say no. But it is bad form to lie to a patient. After gathering myself, my answer came out: “You’d be surprised. This is actually fairly common in the hospital.” At this point my classmate chimed in that chest tubes were fairly common and it was pretty routine for them to be taken out.

It worked. The patient seemed to find comfort in the fact that his procedure was simple — and in the process he appeared to move away from the question he initially posed of whether or not the two medical students in his room had ever done the procedure before.

My classmate ended up pulling the chest tube. The patient was actually quite happy about the whole ordeal; it hurt a lot less than the previous one. He even said that he wanted us doing his chest tubes next time he needed one pulled.

The way I answered my patient when he asked if I had ever pulled a chest tube was not something I came up with alone. I actually heard of it from a pediatrics attending physician. She recounted a similar incident that occurred to her while she was in residency. She told us that the patient looked at her and asked her if she had ever done a procedure before. And her answer was, “You’d be surprised how many of these I’ve done.”

By the very nature of medical education, there will always be a patient who is our “first.” Our first intubation, our first blood draw, our first whatever. Sometimes, we have to, as my attending told us, “fake it” until we make it. That’s the only way we can learn.

And for those readers who are not familiar with medical education, this may sound terrifying. But the intern, who had pulled many chest tubes, was by the bed when the time came for the pull. Should something have gone wrong, we were being supervised.

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