Privileged #7 - comfort

In medicine, we are allowed to be involved in people's lives in a way that few other professions are. And sometimes, that can hurt. I had a former patient who was a lovable and gregarious gentleman with many unhealthy habits, so it was no surprise to me when I got the notice that he'd been admitted to the hospital. I checked the hospital records, and his room was listed as in the ICU. That's not super unusual. Sometimes, the hospital fills up and it's the only available bed, but I had a bad feeling, and so I checked his chart. He'd had a cardiac arrest and was currently on a ventilator.

I don't always visit my patients, but when someone is actively dying, I make the effort. I wanted to see him, see if I could help, and maybe assuage some of the guilt I was feeling. So after clinic, I headed over to the hospital, but I had a couple errands to run. I stopped by the cleaners to pick up my shirts, and I grabbed a few groceries for dinner. By the time I arrived at the ICU, things were fairly quiet. I made my way to his room and noticed that the lights were off and the monitors off. Before I could go in, the ICU nurse stopped me. She was one of my favorite ICU RN's, from an older generation of nursing when the job was brutal but humanizing. We'd shared many a dark moment in the unit, and this would be one more. 

My patient had coded about 60 minutes ago and died. They had only just finished getting him cleaned up for family to visit with him, pulling off all the wires and tubes and needles and tags. She was just finishing up her charting, since she was the code nurse for the event. 

I was devastated. I had just missed him. If I hadn't run those errands, I would've been there, but I wasn't there and for the dumbest reason. I couldn't have changed the outcome, and I wasn't the ICU doctor anyway, but he was still my patient. I should have been there, and I wasn't, because I needed to pick up my shirts before the cleaners closed. 

While I was standing there thunderstruck, the nurse pointed to the door behind me. The family was gathered in there. I hadn't seen any of them because they were waiting until the nurses finished cleaning him up. "You should go in," she said. So I screwed up my nerve and walked in to find twenty people jammed into a space meant for ten. There were sons and daughters and grandchildren and siblings, and at the head of the conference table was my patient's wife. I walked up to her and started to apologize profusely, but she didn't let me finish. 

"Oh doctor, I'm so glad you're here. Thank you so much for coming. It would've meant so much to him that you came." She then introduced me to her children and her grandchildren. I had expected wailing and sobbing, but they all had such a bittersweet expression, like they understood that this was the end of a beautiful moment, like the ending credits of a movie. They shared stories of his life with me, the life that I had never seen, the one that didn't involve A1c's or blood pressures or cholesterol levels. They laughed and cried. 

"Do you want to see him?" she asked me. Yes, of course. She let me go, while the family returned to reminiscing of better times. I left the conference room and went back to his ICU room. I held his cold hand and said my goodbyes. The family let me have my time, and I felt almost greedy that I should be the first to say my farewells. 

I came to the hospital expecting to provide support and comfort, and instead, I was the one who was comforted by this family who adopted me for one brief moment. I understood then that I was not a stranger in his life. I had been a part, however small it may have been, and was welcomed into the intimacy of his life. Since then, I've had other patients die, and I've grieved with spouses. I have several patients who've lost spouses who were under my care. They still come to see me, a testament to their faith in me, and when I see them, we share a little memory and a moment, and I can't help but feel so lucky that I am welcomed into their lives, and so honored that I should receive such trust.

Privileged #6 - Enough

The first time that I pronounced someone dead was a very mild experience. I was an intern, and one of our patients was under comfort care measures only, and was due to expire sometime that night. I was on the floor to sign some orders, and one of the nurses grabbed me. "You need to pronounce Mr. S in 422."

I had no idea how to pronounce someone dead. Was there a procedure? Did I need to do an exam? How sure did I have to be? I wasn't going to take any chances. I felt for breath and for pulse. I did painful stimuli. I listened for heartbeat and respiration. I even printed a telemetry strip. He'd expired before the nurses could unhook his leads.

When I looked at the strip, I went back into the room. There was activity on the strip. There were occasional ventricular contractions. I needed to be sure. The nurse was a little impatient. She had a look at the strip too.

"Oh fuck, I forgot the magnet!" She ran out of the room and came back quickly with a round magnet and placed it on his chest. There was no more activity. Mr. S's pacemaker was off now.

I saved the telemetry strip from Mr. S and look at it every now and then. It helps to remind me of the amazing technological achievement in medicine, and that despite all of this achievement, sometimes a person has to say that enough is enough.

Privileged #5 - Reconciliation

One of my most memorable patients from residency was a very pleasant lady in her 50's that I met for a total of 10 minutes. I was called down to the ER to admit her to the ICU, and when I arrived in her room, she was sitting in the bed, smiling pleasantly, with a pO2 of 30. She had been in the ER for several hours, and they were as shocked as I was when the ABG came back. Once we realized her situation, she of course turned blue and coded.

Once we got her into the ICU, it became clear to me what was happening: she was in neutropenic sepsis. She had just finished a round of chemotherapy and did not have a single white blood cell in her blood stream. Without an immune response, she had looked quite decent in the ER, until she suddenly and rapidly decompensated.

Her vitals plummeted. The ICU staff looked to me with that classic look meaning, 'How long as you going to torture this woman? When will you let her go?' so I told the staff up front: "We will keep going until her family arrives." And we did. For a couple hours, we got everything the ICU had: fluids, colloids, antibiotics, pressors... any and everything. We managed to keep her alive, but just barely so.

Finally, family arrived. Her sister was the first one to come. She went immediately to the bedside and started weeping. Gently, we described the situation to the sister: this lady would most certainly die. Then, we let her sit with her sister and ponder that horrible news.

Next came the patient's boyfriend. The nurse didn't think anything about ushering him into the room, but as soon as he walked in, an argument ensued. The sister barred him from the ICU room, and asked for security to escort him off the premises. Sadly, family squabbles make their way into the ICU all too frequently.

We brought the boyfriend to the break room while security was called, and I asked the sister to step out to the nursing station. We sat over some coffee. With all 27 years of my life experience, I tried to give the sister, who was easily double my age, some perspective.

"Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. She is going to die.

"Now, you have the exceptional duty to carry out her wishes, since she can no longer speak for herself. No one asks for this job, but it's fallen to you, and I'm sorry for that. But please, whatever you may think of this man, whatever your beef with him, please remember that you are speaking for your sister. Please think, what would your sister want?"

The task of a health care proxy (DPOA-HC) is never easy. It looks simple based on the paperwork. It sounds simple to say that you'll speak up for a loved one when needed. But proxies are only ever asked to make decisions in the worst circumstances, at the worst times, when the choices are between horrifying and terrifying. And when you most want to have someone to talk to, a loved one to help guide you, that person is lying in a hospital bed, dying.

The sister flinched, and turned it over in her mind. She eventually relented, and let the boyfriend into the ICU room. They sat together in silence as we turned off the medications and the ventilator. They both wept openly as I came in and finally pronounced the patient dead. They took turns grieving, and finally stepped out of the room, hugging each other tightly, desperately clinging for support.

Before she left the ICU, the sister stopped at the nursing station. She thanked me, the man whom she will forever remember as the person who let her sister die. She thanked me because when most important, love will always be more powerful than hate, and love will always win.

This was the exact moment when I learned that being a physician often has nothing to do with any medical test or treatment.

Privileged #4 - Thankful

On ICU call, sometimes it can get pretty awful, and this night was terrible. It was 3 AM, and I had just finished admitting a patient to the ICU who has gone into respiratory failure, when a code was called overhead. It was a bad scene. The patient was roughly 300 lbs, lying face down on the floor. He had apparently tried to go to the bathroom and never made it. Usually the nurses would be in the midst of CPR by the time I arrived, but they couldn't even roll him over because of his size.

It took 4 guys to muscle the patient onto his back so we could finally check for a rhythm. Of course: pulseless electrical activity. PEA is a really painful code, not because it is difficult or complicated, but because it is so frustrating. Everything on the monitor looks right, except that your patient is dead.

We ran the code on the floor, since we didn't have the strength to get him to a bed. After 20 minutes of futility, I called the code and paged the patient's attending. As I waited for the call back, one of the floor nurses grabbed me. The patient's wife was here.

At the nurses station sat a willowy, elderly lady. She was wearing an overcoat, a light blue lace nightgown, and pink house slippers. The nurses gave her a cup of that terrible coffee ubiquitous to every hospital unit, but she could barely hold onto it. It was singularly the most pathetic sight I had ever seen in the hospital to that point in my life.

I took her to the conference room and sat her with a couple nurses. They held her hand while I explained what happened. Her husband got up in the middle of the night and had a sudden heart attack, likely (hopefully) dying instantly. We made every effort to bring him back, using shocks and chemicals and CPR, but nothing worked, and we declared him dead (As an aside, when you tell someone that their loved one is dead, you must be tragically blunt sometimes. Denial is a powerful thing).

Tears were already pouring down her face. I told her the nurses were getting her husband cleaned up, and she could visit with him shortly. She had no questions, no accusations, just tears. I sat with her for a few minutes, and then excused myself to leave. The nurses had her well in hand, offering tissues and hugs. Before I could leave, she stopped me to say one thing: "Dr. Ifinding, I know that you didn't know my husband at all, but I just wanted to thank you for doing all that you could to save him. He's a good man and would've appreciated it."

I stopped by later that night to finish some charting. She was still there, weeping at her husband's bedside, holding his cold hand, whispering softly to him.

This code hurt for so long. It hurt because I had failed this patient and failed his wife, and then to have her thank me, it was salt on a wound. As a resident, the sight of her sitting next to his body was painfully seared into my mind. But when I think back on this now, I am so touched by this whole event. It must've taken so much courage for her to thank me, when she had so little to be thankful for. And it was such a beautiful thing to see, a wife crying over her dead husband. It was a display of love that far outshone the most joyous wedding. Words cannot convey how utterly heartbreaking a sight this was, but at the same time, how grateful I am to have seen it.

Privileged #3 - kindness

In my resident clinic, I had a patient who was an asshole. 100% asshole. He was mean and rude to doctors and staff. He had a hard life, harder than most, and suffered severe disabilities from his medical condition. He had bounced around the medical system, and found his way to my clinic.

I picked him up because one of the other residents unceremoniously dumped him on me. The other resident knew him and had him in the hospital, but feigned total ignorance when he bounced back to the hospital, and so I took his case. I realized a week later that this was a dump, and was I ever pissed off. But I took the patient into my resident clinic, because I will never turn down honest work.

In clinic, he was instantly trouble. He was rude and mean to the staff and other physicians. He complained bitterly about everyone. My attending advocated dismissing him from the clinic. I picked an alternate plan: I would be nice.

And so he would come in every 8 weeks or so and I was nice. He was rude and abrasive to me, and I returned kindness. He cursed and scowled, and I reassured. He was hateful and self-loathing, and I was empathetic. He railed and complained, and I listened.

And for three years this dance continued until my resident clinic ended. At his last appointment, he was quiet and thoughtful. He shook my hand and thanked me for helping him. He left, saying good bye to the staff by name, and thanking them for helping him recently with a prescription issue. One of the staff came up to me afterward and said, 'I can't believe that's the same Mr M! When he started here, he was such an asshole!'

For me, it was such a special moment to see the power of kindness, and that it is possible to do good in this world. I did nothing special for him except show him kindness and compassion, and that was all it took. You can do good in this world too, if only you can remember that in order to do good, you must be good.

"Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that." -Martin Luther King, Jr.

Privileged #2 - Happy birthday

In the ICU, it is sometimes easy to forget that we are dealing with people. There are tubes and machines and alarms, and somewhere in all of this is a human who can't talk, can't move, and can't proclaim to us their humanity.

I had a patient during my residency who was in such a predicament. She was without any family or friends. She had no visitors. She was in severe septic shock from pneumonia, unconscious and barely clinging to life. Her legal guardian told us, "If there is any chance of recovery, you should proceed. If it is futile, then stop."

Futile? Who's to say what is futile? Is futile a 5% chance of survival? Is it 1%? Is it 10% but with permanent, neurologic damage? We settled on some criteria and proceeded. If she showed any improvement, we would continue aggressive measures.

She only worsened. Each day I came to the hospital hoping for some sign, but every day was worse than before. Finally, the day came where we all agreed her care was futile. That day happened to be her birthday.

There was no one there to celebrate or wish her well, no cards or decorations. The nurses got some cake from the cafeteria, and we sang happy birthday. Then I wrote the orders, the nurses turned off the vent and pressors, and I closed her eyes and declared her dead.

That afternoon spent with the nurses was such a special moment. Without friends of family or anyone to mourn, we took a minute to celebrate her life, even as it ended. Because being a doctor means never forgetting that life is beautiful, and although no one else treasured this life, we did.

Privileged #1 - How are you?

One of my most memorable patients was a wonderful lady with floridly metastatic, unresponsive to treatment, triple negative breast cancer who developed subsequent cardiomyopathy from chemotherapy. She had an EF of <10% and during the course of her hospitalization underwent multi-organ system failure from end organ ischemia. To translate this into normal speak: she had the worst possible breast cancer, with the worst possible response to treatment, and the worst possible side effects.

I was only an intern but I had to give 'the talk.' I sat her family in a conference room, went through the facts of her case slowly, and gave my assessment: she had two terminal conditions, both of which we could not fix. The family cried, and the oncologist piped up about radiation, or another round of chemo if we could get her heart back, or something ridiculous. I ignored him completely. I sat there for five painful minutes while they cried and asked me "Why?!" Once you have done this a few times, you realize that as much as a family wants the answer, you do not have it. Bad luck? Fate? God's will? There is no right answer to this question, only tissues and holding a hand.

The family consented to weaning off vasopressors (medications to elevate blood pressure), and with her loved ones at her bedside, we turned off all the supportive measures. I declared her dead about 30 minutes later. As memorable a moment as this was, it was not the most memorable.

The privileged moment came one day earlier. The oncology attending had just met with the family and discussed keeping their hopes up as well as future chemo options. It was a pep rally, to be sure. I was eating lunch at the time. My senior resident asked me to check on the labs, so I headed back to the ICU, and ran into the patient's sister in the hallway. I said, "Hi! How are you?" with a little wave.

She looked at me, and managed say, "I'm fine, tha-" before bursting into tears. She collapsed to her knees in the hallway, and I had to help her into a chair. I got her some tissues and sat with her for 15 minutes. We joked a little about some funny things her sister had said. After regaining her composure, she looked at me directly, and asked, "Dr ifinding, is she going to die?" I told her that we should get her family together and talk about this, leading to the family meeting the next day.

I am still amazed that this small, chance event of saying hello could be so profound. It was the opening she sought, the chance to ask the question everyone had avoided. She just needed a chance to ask. And it made me realize that even the smallest interactions can have big impacts.

I also felt very honored by the trust placed in me by this family. I was the wet-behind-the-ears intern, but they saw me every morning doing my job, and that was enough for them, because being a good doctor means that you are someone worthy of trust.

Privileged

In today's world of medicine, I think that people forget that being a physician is a privilege. There are plenty of things in life that you earn with hard work and skill, and medicine requires those things too, but it is a unique privilege to be a physician. We are asked to do things to people that are painful, we are told things in confidence, we are asked to make life or death decisions. We are the ones who have to tell the family that their loved one is now dead.

I have had a lot of fun writing the "Don't be a doctor" series, but I think it might be nice to write something a little more inspirational, and so I am going to embark on another series of posts, about moments I was privileged to witness in my medical career.

You'll have to excuse me for repeating some post content. I have undoubtedly blogged about some of these events before.

(1) How are you?
Even the smallest interactions can have big impacts.

(2) Happy birthday
We took a minute to celebrate her life, even as it ended.

(3) Kindness
It is possible to do good in this world.

(4) Thankful
She had so little to be thankful for.

(5) Reconciliation
Love will always be more powerful than hate.

(6) Enough
Sometimes a person has to say enough is enough.

(7) Comfort
I was not a stranger in his life. I had been a part.