A first death

Closing in on the end of the residency year, most of the interns have earned their first death. Some took their time. Some didn’t have to wait too long at all. All in all, I find that the reactions that they have to death are quite different and sometimes offer a unique insight.

The experience of death is a little different for each of them. Getting called by the nurse at 4 AM and being told that Mrs. R expired is quite different from being the person pumping on Mrs. R’s chest, and even this is more insulated than being the person having to tell Mrs. R’s family that there’s nothing more that we can do. And all of this is easy compared to being the person who forgot to write for an antibiotic for Mrs. R’s positive blood culture.

When a patient dies, some of the interns are relieved. The patient is no longer going to torture the intern with really hard decisions and clinical questions, many of which are life or death types of choices. It’s all over now. No more stress. Maybe the intern can get some sleep now.

Some are utterly devastated. There was so much emotional involvement, and now, no outlet. It feels like gas in your stomach, and you can’t belch it out. And it hurts in a deep way that can’t be easily resolved. You can’t talk yourself out of it. Some people drink themselves out of it.

And sometimes, every now and then, you’ll meet someone who just doesn’t care. They take the news of their patient’s death with the same attitude that someone from Nebraska would have about the Mets losing the NLCS.

I thought for sure that I would be the destroyed person when I had my first death. I thought it would empty me out and hurt me in ways that I couldn’t even comprehend. But surprisingly, I found myself in the ‘don’t care’ column. A nurse called me to pronounce on a patient that was DNR. I went to bedside, pronounced the patient, and then went back to bed.

Since then, I’ve had a lot of other death experiences, and they’ve run the gamut of relief to devastation. But I’ve always felt a little guilty about Mrs. R. Not that I did anything wrong per se but her death was so forgettable to me, and that my reaction was not one of sadness, but of relief.

I’ve since had some surprisingly hard deaths, deaths where I was so angry and so disappointed with myself that I threw things and slammed doors. I punched a door so hard that I thought I broke my hand. And I remember one death where I went balls to the wall in treatment, I talked the family out of a DNR, and after 8 hours of very aggressive treatment, the patient had a systolic pressure of 50/20. I talked to the family and we went to comfort care, and I threw things and cursed and was so angry. I did everything right, and even then, I failed.

Each death is a little different, and in the end, I find that it helps to insulate yourself a little. Each death hurts, and rather than pouring yourself out each time, it helps to ration out your compassion a bit. I know it sounds cold, but the human soul can only bear so much suffering.

The last day of ICU

Today was my last day of the ICU rotation. I have to say that I actually learned very little on my rotation. I learned how to write an ICU note. That was something. I learned that despite what everyone says, common things occur commonly.

Today was a very... stupid day. I caught five or six things today that were just silly. One patient had two H2 blockers. Another patient was on heparin and actively bleeding. Another patient had meds that the pharmacy didn't send up. One patient was NPO and getting scheduled insulin. It was just a string of stupidity today.

I greatly confused a nurse today. She needed a boost, but she walked right past me. If you've never met me, I'm a pretty big guy. So I stopped her and we boosted her patient, and that was that, but I think it's sort of... a sign of the times, y'know? I think that a lot of docs and students think they're too good for this sort of stuff.

It's like we were putting in a Cordis, and I can assist someone in a sterile field just as well as a nurse. It takes all of one hour to learn how to maintain a sterile field. And the nurse was surprised at me.

Maybe it's because my mom is a nurse, but whenever I work with nurses, I'm always on my best behavior. I realized one day that nursing is a really tough job, and I should try to be helpful if I can. I mean, why does some nurse need to waste time helping another nurse boost a patient when I can help? Why does a nurse need to stand around at a simple procedure when I can do the same thing?

I thought I was the only person that did this, but I discovered that M was also guilty of doing this stuff, and in fact did much more of it than I did. I think that's why I liked working on rotations with M. We both were eager to do things that had absolutely no teaching value, but were things that were... good-natured.

I thought about it a long time, and I used to think that a lot of my attendings liked me because I was a hard worker, but I discovered that this is not really the case. It's the willingness to do something that really has no value to me whatsoever. It's that I would talk to families of patients on my own. It's that I would stick around late and help out. It's that I wouldn't leave until I'd done what I said I would do. It's that I actually cared. It's that I'm still sad for the wife of a patient I saw who blamed herself for her husband's death. It's that I'm still angry about an aggressive workup on a brain dead patient.

I was thinking today about how devastating oncology was for my mental wellbeing. I was thinking that I'd said that I could never do it. I was thinking today that it's not only a field I could do, but one that I should consider. It's got a healthy amount of intellectual stimulation, but moreover, it and general medicine are two fields where your relationship with your patient can be more valuable than any treatment you have to offer. Y'know the truth of the matter is that I think I could be a decent oncologist. It's simply a matter of whether my heart could stand it.

Zebra hunting

One of my patients died. I was very... angry about it. Well, not angry. It was just that... we did a ton of workup and treatment on a guy that was toast. Y'know, it's very frustrating to be in a setting where we almost don't know when to stop. To me, my patient died at 6AM. The death certificate I'm sure will read sometime in the evening. The family was all torn up about it, and I guess I can understand. I'm torn up about it too.

Y'know, the one thing that I learned in medicine about life is that I'd like to die with a little dignity. I've seen too many people die too messy a death in the hospital. When I go out, I'd like it to be a little less nuts. Y'know, we spend our entire careers in medicine battling the inevitable.

Still, I went down to the coffee cart to try to get an espresso after work, to take the edge off the horrible taste in my mouth from knowing that my patient was alive yesterday and is dead today. I'm not sure if you've never been in medicine that you can really appreciate what it's like to know that someone in your care has done exceptionally badly, and is now dead. You detach yourself. You harp on little things.

It's impossible for me to concentrate, so I spent tonight playing America's Army. It's better than thinking about the whole situation and my aggravation with it. Y'know, the guy is dead, and we're still hunting zebras on him. And everyone feels comfortable with that, and that's the part that bothers me the most.

Y'know, I've greatly disliked my month in the ICU, because it has single-handedly gone against everything I've ever thought about medicine. We order million dollar workups on everyone that comes through the door. We order so many tests that tracking them all down is next to impossible. We order tests that take days to come back for questions on acute management. Everything in the ICU is a zebra. We spend no time with the patients. I've actually written a note on a patient, and only realized after rounds that I had not done a physical exam. We treat numbers almost exclusively.

I wish I was back on my sub-internship. I liked seeing my patients. I liked taking care of them. My ICU patients, a good number of them got better, but I certainly don't feel any better about it. And maybe that's because I really can't say for sure that we actually did anything to help them. I'm willing to bet that aside from the vent, they did it all themselves.

My resident couldn't believe I wanted to do general medicine, but the thought of doing critical care for a living makes me nauseous. Y'know, people talk about lifestyle and pay and all that stuff, but in the end, you have to do a job that at the end of the day, you can go home and sleep at night. I think about the ICU, and it makes me ill.

I have so many criticisms of my ICU experience that I wouldn't know where to start, but I guess in the end, my biggest problem with it is that you would think that the ICU is where you get the absolute best care in the hospital, and the truth of the matter is that if not for the nurses, I'd never admit anyone to the unit.

RRC in the ICU

The other student I'm with seems to be enjoying this rotation. I on the other hand am dying. It reminds me so much of my time on vascular surgery, the rotation that convinced me that I wanted nothing to do with surgery. It's criminal what we do to people. I can think of no greater humiliation than dying with a foley and a rectal tube, a decubitus sacral ulcer, and some med student breaking my ribs doing compressions while the intern warms up the defibrillator.

The ICU is not the real world. That is what bothers me the most about it. Everything that happens in the ICU is like medicine practiced on crystal meth. It's the last 30 seconds of a basketball game played for the whole game. It's a hockey game that's 60 minutes of power play. I can't get into it. I can't appreciate it.

I did the math and for an ICU rotation, the residents are actually doing pretty okay. It's not q3 overnight call. There's more than one intern covering a service. Caps are enforced. So when residents complain, I'm just not sympathetic anymore. Medicine isn't supposed to be easy. It's hard. And ICU is the hardest. At some point, you've got to say that there's a limit.

A lot of people in my class are going into radiology and emergency and other fields that are basically shift work, and it depresses me. Medicine should not be a job. It's a profession. Mechanic is a job. Electrician is a job. Plumber is a job. Medicine is a profession, and that means something. It's ridiculous to ask someone to work 80 hours a week, but life can be pretty ridiculous.

You do what you have to do. I've never left the building without updating my patients on the list. That's simply being responsible. Today, my senior told me to go home, and an hour later, I was still there. I could've just left, but I refuse to leave the hospital without doing what I was supposed to do. It's my responsibility, and if I expect to be taken seriously, I have to act serious.

My senior has been sending the interns home early recently, and while I'm sure I'd be thankful if I was an intern, I'd also resent it somewhat. When you're on a team, you work as a team. That's the way teams work. You don't see a pitcher in baseball happy to be taken out of the game.

It's tough to put into words what I'm trying to say, so I'll stop here, and note that I had a successful radial stick for ABG today. Nice.

Medicine treats disease. We do not 'help' anyone.

The ICU is not for me. I know that now. There's something so... unsatisfying about taking care of a patient for only a few days, and then turfing that patient to another service. One of my patients made it out of the ICU, despite our best efforts, and I can't help but wonder what will come of him. It's like another patient I have from last month. He's still in house, and I keep meaning to visit him, but I don't have the time. I wish I could see him. I feel like I should. And that's how I know I'm meant for primary care. Because the thought that I'm not going to follow a patient is sad.

On the slacking front, it's become next to impossible to slack. I'm trying to slack, but there is just so much work to do. I'm only following two patients, but it adds up with other patients. Find this lab. Write this order. Do this. It's making the interns' lives a little easier to have another set of eyes and ears to catch the little stuff that slips through, but this rotation is one of the busiest I've ever done.

And I know you're saying to yourself, it's the ICU, man, what did you expect? Well, honestly, I expected that I'd get to be a medical student again. Instead, this rotation is far more like a subinternship than my actual subinternship.

I keep seeing attendings that I've worked with before. Uniformly, I get the comment that I'll make an excellent resident and that they hope I stay. Y'know, everyone tells me that I'll be a great resident, but I know me. The aspect of medicine that I excel at is just the work. I work hard. That's all. I think I know less than most. I just try to keep at it. I try to move things along.

We had a lecture about goal-oriented care, and I thought it was pretty stupid, because it's something I think about every day. We do all these things to patients, and half the time, I question who we're really treating: the patient or ourselves. In the end, I applied to medical school thinking that I'd get to help people, but most of the time, we don't help too much. It's mostly trying to hold back the tide. And the only rewarding part of that is knowing that at least you tried.

I had a patient who was put into Hospice care, and I was glad. Glad that we avoided putting in a PEG tube, putting in a trach, and doing all those things that make me hate medicine every day. I had always thought that the role of medicine was to help people. It's only now that I understand that the role of medicine is not to help people but to treat disease, and that is not the same, not by a longshot.