Monday, October 31, 2011

Respect for Death

In a way, it's apt that I'm writing this post on Halloween, even though this event transpired about 4 days ago.

I had been following this one patient ever since we admitted him to the hospital from the clinic towards the beginning of October. He came to us after seeing many other doctors, all of whom had failed to solve his problem and relieve his pain. We promised him that we'd try, that perhaps we could finally release him from his suffering.

I had checked in on him every morning before the team, at the crack of . . . well, evening (since it was well before dawn). I saw the misery he was in every day. After the first week, we had identified the problem - an infected bypass graft in his leg. We operated and removed the graft. As a complication, a clot was "thrown" down to his foot causing his foot to become ischemic (lack blood flow) and die. We operated and amputated his toes. Every morning I changed his dressings when I rounded with the team.

We assured him that we had fixed his problem, but he was still miserable. Every day we prayed that he would get better. He wasn't getting worse, but he wasn't progressing either - just stayed in that limbo where he wore a pained mask. Last Thursday, my resident remarked, "He isn't getting worse but he's also not progressing. If he doesn't get out of here, he will die here." I changed his dressings as he waited patiently to watch The Price Is Right on TV. To me he had looked better than he had that entire week.

That afternoon I got the call that he had coded. He had a seizure or a stroke or a heart attack, no one was really sure. The resident did CPR on him for 20 minutes before the surgeon found a pulse. He was wheeled off to the SICU (surgical intensive care unit). One thing was for sure, he was in bad shape. Later he was found to be in PEA (pulseless electrical activity). He quickly approached the threshold beyond which treatment would be futile. After discussion with the surgeon, his daughter made the decision to withdraw care and at around 8:30pm, he died.

The following morning, the other med student and I stalked his chart to figure out why he had died. When he had read that his daughter made the decision to withdraw care, he said out loud, "What?! She withdrew care? His family killed him!" That infuriated me. He was in that zone where we could keep him technically alive but without any quality of life. To me, his daughter had saved her father from a week of agony in a state of painful limbo - neither truly alive nor dead. That afternoon as we briefly discussed about him, the surgeon agreed that the daughter had done the right thing. She had saved him from a miserable pseudo-existence, a kind of hell on earth.

One of the most important things to learn is when not treating is the correct treatment, and when we should respect death rather than fight it. This goes against almost everything we've been taught and trained to do. We must always keep in the back of our minds whether or not aggressive treatment is worth it, especially in absence of a cure. The figures don't lie: we spend most of our health care spending in the last 6 months of life. Why? Because for one reason or another, we just can't let go when we really should.

Thursday, October 20, 2011

Reclaiming Humanity

When does a person become a patient become an organ or a thing - a gallbladder, an amputation, a diverticulitis? The onset was so insidious that I never even noticed the progression, especially on surgery where everyone becomes that which we operate on. When did I stop noticing the person and, to some degree, stop caring? This was not what I came to med school for.

I recently observed a family meeting with the patient, his wife, and their oldest son. The patient was terminal, his death is only a matter of time; the only surgical intervention left would mean certain death. For the first time in weeks I saw not the blank yet pained gaze through lidded eyes still heavy with sleep at 5:30am, but emotion: sadness, contemplation, and reflection. I saw not a patient who we monitored through labs, changed wound dressings on daily, and examined with the repetitive motions of a machine; I saw a father and a grandfather who, though saddened by the inevitability of his end, is without regret for living his life.

His wife asked with tears obscuring her eyes, "Can you give us a time estimate of how long?" We had no answer - it could be hours, days, weeks, months. With diagnosing complete and treatment deferred, true healing can now begin. As for me, I can start caring again and do what I came here to do.

Sunday, October 16, 2011

More Weddings!

Wow. I've been so consumed by rotations that I had completely forgotten to post about 2 very important events that happened over these last 3 months! As much as I want to bitch, whine, and moan about surgery, this post is dedicated strictly to non-medical things. So here we go!
July - Best Friend's Wedding

In early July, I drove 4 hours to my best friend's wedding. He's a recurrent character on this blog, though I forgot what name I gave him. His original "code name" was JW-M, so I'll stick to that, lol. This wedding was actually referenced months ago in this post. Over the years I had come to admire his intellect, his wit, his calm mind, and above all his inner child. He's one of perhaps five people who knows exactly what to say to put me in a great mood. Only a handful of things (death being one of them) could have prevented me from attending his wedding.

The lovely chapel.

Their wedding was short and sweet, perfectly suited to the newlyweds. Several of our mutual friends were invited to the wedding (or were part of it), and it had been so long since I'd seen all of them in one spot. The reception was quite nice as well and their cake was delicious (I expected nothing less from the dessert palate of my friend, lol). At the end of the evening they had a cookie bar. :-)

This cake is no lie! So yummy!!

The married couple cutting the cake. Showing the back to protect their anonymity.

The following day, several of us drove to the lake to hang out. Since I had gone separately from most people, I headed over to the lake about 3 hours ahead of everyone else. Though it was in the 90s, it still felt nice oddly enough.

Lovely beach area. :-)


Pirate ship on the lake!

Back wandering in town.

I was glad that I went. JW-M told me that I was one of the few close friends he had made in undergrad.
September - Old Friend's Wedding

About 3 weeks ago I flew home for my old friend's wedding (I'll call him TR-M here as I think I had before). We had known each other since kindergarten and we were next-door neighbors for almost a decade. We stayed friends even after I moved to the other side of town. Like my best friend's wedding, this was one I couldn't miss.

I love stained glass windows.

The ring-bearers. They were SO ADORABLE!! Especially the younger patting the older one on the back in reassurance.

There were many people at the wedding that I hadn't seen since high school! It was a very nostalgic feeling to see them and what's happened since we all graduated high school. Aside from the wedding train, we all sat at the same table . . . at the very back of the reception hall next to the bar. Though we were annoyed at being seated so far away from the head table, we had fun anyhow. The most interesting thing about the reception was the distinct lack of a wedding cake. Instead, the newlyweds had an assortment of desserts that came around quite frequently. It was differently delicious!!

Table 16/20 at the end.

This is what I had instead of cake: hazelnut creme brulee.
All these pictures don't do justice to the events. But of course there are many more pics that I took that I will refrain from including. I'm glad that I was able to make it to both these weddings. This makes the 3rd wedding I've been to this year! Wow.

Remember the hot gay intern I met at the one meet and greet a few weeks back? Probably not, but that's okay. I randomly came across him on Grindr. Alas it says that he's partnered. :-( Sigh, such is my luck ALWAYS.

Saturday, October 8, 2011

Imagine . . .

. . . that you've been in love with someone for 2 years. Recently you are engaged to him; you couldn't be happier, life couldn't be more perfect.

Then out of the blue, he suddenly gets intense chest pain and belly pain. You take him to a nearby hospital. The medicine doctors spend 2 days trying to figure out what's wrong, meanwhile he gets worse and worse. Then they finally discover that he has an aortic dissection, and the worst possible kind at that! His aorta, the main artery that brings blood to the body, has split open from where it leaves the heart all the way down to his groin.

Your fiance is immediately transferred to a larger hospital in town, because leaving him where he is means certain death. The cardiothoracic surgeons manage to (miraculous) fix the aortic dissection in a grueling marathon of a surgery. Afterwards, the doctors notice that his legs start to hurt, swell, and turn dark. Immediately the vascular surgeons open up his legs to relieve the pressure and restore blood flow to his legs, hoping that they made it in time. Unfortunately, it was too late.

His legs are dying. They are causing him more and more pain each day, so much so in fact that it causes him to become delirious - he does not know where he is, he does not know what year it is, he does not know what's going on. He can no longer make medical decisions for himself. They turn to you, as his power of attorney, to ask if you would give them permission to cut off his feet. What do you do? What can you say? Cut off his feet in order to save his life (and his sanity)?

You agree. Days later, they come back and tell you that things are worse than they appear. More of his legs have died than they initially thought. They have to cut more off. They ask you to give permission to cut off his legs above the knees. What kind of decision is this? Your fiance will never walk again. But you agree to save his life.

And for the next several weeks, you get phone calls and every time you visit your fiance in the hospital, the surgeons find you and ask for permission over and over again to cut more of his legs off, because more has died and they can't predict or control it. What can you say? This is the person you love. This is the person you were going to marry! He no longer looks anything like his former self. But you love him . . . and you want him to live . . .
This is the kind of story that I'm seeing more and more of on rotations. Being part of the care team detaches me emotionally from the situation. All we can focus on is doing what's best for the patient to help him live and move on with his life. But in the process, patients sometimes lose so much of themselves (literally) and family members have to make hard choices.

If you were the one making the decisions above for a loved one, how would you react? What would you do? Would you be strong enough to endure it?

Sunday, October 2, 2011

Introspection & Privilege

This weekend is a "golden weekend," so called because we have both Saturday and Sunday off. This is a golden weekend because we're now halfway between our surgery rotation here, and we're all switching hospital sites. Starting tomorrow I'll be at a different hospital for surgery. So this weekend is a temporary respite.

I'm glad that the first month is over. There are days that I was seriously doubting if I could make it to the end. On average in September, I was in the hospital about 60 hours/week. It could've been much worse . . . though I'd rather not think about it. However, a moment of retrospection brings me to my final patient on surgery at the first site.

Patient: "I admire you all and what you do. I really do. You do so much to take care of us."
Me: "Thanks. That's our job. We wouldn't be here if we didn't want to help take care of people like you. We chose this."
Patient: "Yeah, but thanks anyway. I wish you the best."

I'm not sure if I can adequately describe in words the profoundness of that brief moment. No matter how I or others may whine, bitch, and complain, it remains truly a privilege to take care of patients and do what (little) you can for them. It is a privilege to have others trust you with their health. As one of my friends said (in a jokingly serious manner): "What other profession do you get to cut people open and touch them in such ways without getting jailed? In fact, they're paying you to do just what you're doing."

Anyway, I think it's worth a moment of introspection for us to appreciate that which society allows us to do, and understand the responsibilities that society expects us to bear (justified or not).