Most people look forward to vacations and breaks. But not like interns. Man, we literally live for them. They are the ONLY thing that keeps you going. As interns we work 80+ hours a week. Get only 4 days of a month and only 3 weeks off in the year. So when we go on vacation it's a big damn deal. I got all my vacation at the beginning of the year. And that is not ideal because it means no more than 2 days off in a row for the rest of the year. (Our year starts with June 24th and ends with the 23rd on the following June.)
So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.
Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.
No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.
I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.
10/18/10
Not another one
I was on call last night. I spent the day dealing with a patient who had either a ruptured abdominal aortic aneurysm or a small bowel obstruction. Clinically this man looked great. I really wasn't worried about him. My main concern was the nursing staff that just would not be helpful. I was sabotaged every step of the way. I wanted abdominal xrays they wanted me to order them at bedside (not useful). I ordered labs, they cancelled them.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
10/16/10
List management
Census, rounding sheet, list, rounds report, these are all names we have for the list that we print out every morning with all of our patients on it. Each hospital and each service within a hospital has a different way of managing that list. Some hospitals list nothing but room number, patient name and diagnosis. Others are much more extensive. My hospital prides itself on our list. We like to think of ourselves as pioneers in this one bit of data recording. Our list contains not just the basics, but what meds they are on, their vitals, ins and outs and diet for the last 24 hours auto populates every time you print a new list. Additionally you can add in any procedures they have had or that are planned for. You can type up a plan, put in notes for the cross-cover intern. You can stick in random details about the patient that you don't want forgotten.
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
10/10/10
Dr. Give-A-Crap
I'm on vascular surgery this month which brings with it a whole new patient set. These patients aren't adorable kids like in the world of peds surg and they aren't misfortunate like the burn patients. Well, sometimes the burn patients are a little stupid. I mean, really what kind of person burns trash with gasoline? Gasoline doesn't burn, it explodes. But, I digress. The vascular patients are a whole new breed.
For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.
Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.
And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.
I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.
Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.
So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.
There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.
And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?
It takes a toll on you.
As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.
I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.
For those of you that aren't a hundred percent sure what vascular surgery is allow me to explain before I delve into the patients. It will make things a little easier. According to wikipedia, vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The long and short of it is that we make blood go where it no longer wants to go.
Well that's weird, you say. Why does the blood not want to go there? Well, if you were to spend your entire life scarfing down cheeseburgers and smoking, not to mention mismanaging your diabetes and ignoring your hypertension, your blood vessels are going to give up. And, can you blame them? I mean, I'm not going to pretend like I'm the picture of health or anything. But, I make some attempt to prevent what is definitely a preventable disease. Atherosclerosis, diabetic neuropathy, gangrene are not diseases which just strike down the undeserving. You have to actively work to have these things happen to you.
And, the end result of most of these diseases are amputations. And if you're a good vascular surgeon you won't just take the leg. You'll be as sparing as you can each time you operate. You'll take the big toe, and the the others, then you'll take the rest of the longs bones in the foot, then you'll go below the knee, then above the knee and then finally you'll take the nub that's left and disconnect it from the hip. This is a process that takes years. And it's depressing to watch. It's even more depressing for the patient.
I want to feel bad for them. I try and feel bad for them. But most of them make it so hard. And it's not because they are bitter and angry. I get that, hell I would be too. But because they don't change their ways. Fine, you lived life hard for the first 40 or so years. But then your toe falls off. Shouldn't that be enough of a wake up call to quit smoking? To take your anti-hypertensives? To put down the remote and go for a walk? How about simply measuring your blood glucose? But, for some reason they don't. And that is what frustrates me.
Of course there are vascular patient who did not bring it on themselves. We get patients with rare genetic disorders whose blood clots when it shouldn't. We get people who for some unknown reason have an aneurysm in their aorta you could drive an 18-wheeler through. But, the majority of them aren't just simply unlucky. They are people who never bothered to take care of themselves. And when you decide to go into a profession the respects life above all else people who don't respect their own make you angry.
So, this past week has been hard for me. And when people ask me why I look so run down I can't give this long and convoluted answer. It makes me sound so judgmental. So, instead I talk about the long hours, how sick the patients are, how tedious the surgeries are, how long our census is. But, deep down it's because I can not feel bad for my patients. I don't not feel sympathy for them. Empathy, yes, but not sympathy. And, for me, that makes my job feel nearly impossible.
There are a lot of trite and cliched reasons that people give for wanting to become a doctor. I sometimes wonder what the real reason is. I've bullshitted my way through answering that question so many times I'm no longer certain. And looking back to the girl that made this choice in grade school I know she had no idea what she was getting herself into. And it's not the long nights, the endless hours, the unfortunate tragedies that I was naive to. It's the helplessness that you feel when you realize that no matter what you do this person is not going to change and they are going to lose their leg.
And this isn't just with vascular surgery. Yes, it's more apparent here. But what about the frequent flyer in the trauma bay? The guy you see two or three times a year for getting drunk and crashing into something? Every time you patch him up, set his leg, transfuse him, sew up his holes. And each time you send him out you know it's only a matter of time before he is back there. Or the smoker with COPD? You know that no matter how bad it gets she's going to keep smoking. And how about the 400 pound guy who comes in for a gastric bypass, which fails because he literally ate till his stomach exploded. What do you with these patients?
It takes a toll on you.
As I was writing this I kept thinking about a myriad of scrubs episodes in which Dr. Cox expresses these same emotions. The link to one of these rants is embedded in the title of this blog. He says that he knows he's supposed to be "Dr. Give-A-Crap" but that he can't be in certain situations. That's how I feel. I feel badly that a patient is losing their leg, I do. But, a part of me is angry at them for bringing it on themselves.
I don't know if I'm ever going to reconcile these emotions within myself. But for right now I'm glad that I'm angry at these patients because it means I'm not yet so jaded that I've actually lost the ability to give a crap. And that is not the kind of doctor I want to be.
10/3/10
It's not a pager, it's a leash.
My last few posts have been kind off depressing. I don't want all of you out there (you know, the 2 people that read this thing) to think that my job is just one depressing event to the next. And, I don't want to dwell on just the sad stuff either. I see older residents who are angry and bitter because they can't get past the sad. When something good happens they can't enjoy it because they are so jaded. I don't want to become that kind of doctor and I don't want you all thinking that that's the way it is either.
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
Sometimes being a doctor is ridiculous, sometime it's surreal, sometimes it's downright hilarious. I think one of the things that is a constant source of amusement/frustration are the pages we get from nurses. Some of these I got, some my co-interns got, but they are all hilarious.
1. "Pt smoking in underwear. Please advise."
2. "What rate do you want me to give the bolus at?"
3. "I would like to give enema. Pt refusing. Can you talk with him?"
4. "Pt has not peed for last 6 hours but has been sleeping. I think it's ok"
5. "FYI: Pt not w/ fever. Feels very warm. Removed Xtra blankets. Will reassess in hr"
6. "Pt on regular diet. Can he have jello?"
7. "Pt has restless leg syndrome . . . of his penis"
8. "Pt is crying, please evaluate."
9. "Pt had nightmare, was being chased by clowns. Call psych?"
10. "Pt now with erection, please evaluate."
11. "Pt ejaculated during bath. Urology consult please?"
12. "Pt's child keeps screaming. Please assess"
13. "Pt stole ace wrap from supply and has bandaged his hand."
14. "Pt refusing vitamins for last 2 days. Now requesting. Can I give?"
15. "Pt wants morphine. Doesn't look in pain. Poss drug seeking?"
16. "Pt is naked and screaming. I called security. Please come now."
Yes, these are funny. And, most of the time you call the nurse back and try your hardest not to make them feel stupid. Other times you get paged like this at 3:30 in the morning, just when you found ten minutes to lie down and all you want to do is scream.
Because we cross cover majority of the patients that we get called about when we are on call are not ours. We've never met them before. We are there to put out fires. So, that adds to the absurdity of these pages. Take the patient who stole the ace wrap. I had to call that back because he was a trauma pt, maybe he did have an injury to his hand that went overlooked. But, when I called back I found out that this man keeps stealing things from supply and pretending to have issues because he doesn't want to go back to jail. Well, if this is normal why page me at 10 pm?
Oh, and all the "please assess/please evaluate" pages are the worst! I am not going to check on a screaming child. It is not my job to take away cigarettes and make people wear clothes. And why did you call security before you called me? Because what someone who is having a psychotic break really needs is security guards surrounding her. That's not going to make matters worse at all.
Anyways, these pages might drive us all insane when we get them. But we save them to our pagers so that we can show our fellow interns and residents because they make for one hell of story. And, if it weren't for the great stories why would we keep doing this?
9/27/10
Time of death
I watch a lot of movies and a lot of television. One of my favorite shows is M*A*S*H. I can't remember when I started watching M*A*S*H. It must have been on Nick at Nite. But, I eventually bought the box set and I've watched every episode a dozen times. I can quote it, I can give the blow-by-blow of most episodes. But, there are some episodes that stick with me more than others. One in particular is a Christmas episode where an injured soldier is flown into the unit during a party on Christmas Day. Colonel Potter, BJ, Hawkeye and Hot Lips keep everyone else in the dark while they try and save this man. Eventually they realize that he can't be saved and they instead settle for keeping him alive just long enough so that his kids don't find out that their father died on Christmas. Unfortunately the soldier dies just before midnight. They bluff the death certificate anyways. It's a good episode. One of many good episodes. But, like I said it always stuck with me.
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.
He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.
Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.
This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.
He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.
So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.
I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.
I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.
Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.
As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?
I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.
When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."
9/20/10
Proud owner of a used heart
On occasion my chiefs will tell us lowly interns about what it was like when they were first years. Sometimes it will be just to tell us how easy we have it, or how they were better than us. But every now and then you'll get a little nugget of truth out of one of them. A few weeks ago one of my chiefs told us how he used to go home and curl up in the fetal position while listening to Megadeath. He said it soothed him.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
Now, I've heard the music he listens to cause he has one of those fancy ipods with built in speakers so the Megadeath doesn't surprise me. But the admission that he got upset during his intern year was surprisingly gratifying. Because this Chief of mine is pretty good at his job. He definitely puts me to shame on a regular basis.
I know that intern year is hard, I know that everyone goes through it and handles it in their own way but it's always nice knowing that you aren't the only one who feels incompetent and bad at their job. Of course, he is generally the one that makes me feel that way. But, every time I screw up I work ten times harder to prevent the next one. So, that's the positive side.
Anyways, I walked out of the hospital today feeling pretty medium about life. I'd screwed up on a number of things and I'd beat myself up pretty good about all of them. But, I'll fix those mistakes and make a whole new set tomorrow. What's really got me feeling iffy is the outcome of my trauma victim from last week. Her heart went to save the life of another little girl who just turned 1 a week and a half ago. She's spent her whole life in this hospital. When she outgrew her NICU crib she moved down to the PICU and now she has a heart that works and will finally be able to see a world outside of the hospital.
That story should give me the warm and fuzzies. Except, I know where that heart came from. I was in the room with the donor when we were trying to save her life. I saw the book that the nurses put together for the grieving parents. It has the little girl's hand and foot prints stamped in it. A nurse and a bereavement counselor sat with the parents and filled in her first words, favorite foods and all her hopes and dreams. And that is all that is left of her. Because even though her heart is beating in another little girl's chest she is still gone.
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