It gets easier... right?

I had the chance to talk to a budding medical student last week, and it's strange to see the medical student perspective again. When I was going to medical school, I had a very self-centered experience. That is to say, I did not notice a lot of what was going on around me because I was so focused on what I needed and wanted.

Now that I'm done with the medical education process, I find I have remarkably little sympathy for the plight of the medical student. Everything seemed so dramatic at the time, but the thing about medical education is that every subsequent year is worse. MS2 is worse than MS1. MS3 is worse than MS2. MS4, while easier from the education side, is far worse with interviews and rank lists and the Match. PGY1 is pure hell. Subsequent PGY's are painful for new and horrible reasons. Being an attending is a whole new basket of terrible issues.

So it's hard to be sympathetic when medical students complain about med school. It's like complaining to a major league baseball player that a 70 MPH fastball is hard to hit. Yes, it is, but if you want to go forward, it doesn't get any easier. In fact, it only gets worse.

Caution if hepatic impairment

I was editing and reposting old entries from the old server, and ran across a post that reminded me of something I'd tried to forget. I had a patient in the ICU, barely holding on to life, with diffusely metastatic cancer, suffering not only from all the complications of the cancer, but all the side effects of the chemotherapy, with cardiomyopathy, neutropenia, anemia, and a host of other terrible side effects.

Even with inotropes [drugs that make the heart beat stronger] and pressors [drugs to increase blood pressure], her systolic pressure was a laughable 60 mmHg. She was having end organ ischemia, and her liver was failing. Her AST and ALT were in the 1000-1500 range. Her renal function was non-existent.

And as a result, we stopped all meds that were toxic to the kidneys and liver. That included her prozac. And every morning that she was conscious, she begged me for her prozac, and I had to tell her that her liver couldn't take it. Her organs weren't working. But she would beg me to give it to her.

Eventually, my attending started the prozac again, despite the miserable state of her liver. 'Ifinding, why not give her the prozac? With everything else going wrong, why not let her have this?' And I felt real guilt. I had been trying to protect this patient from the possible toxic buildup of the drug, but I had taken away the only thing that had made her life bearable. I was worse than the chemo.

And I learned then that the compassionate choice is not always the most medically appropriate, but far easier on the soul.