Life as I know it is one of dependance on other people's time. Most jobs don't rely wholeheartedly on schedules of only a few- but in medicine, it's all about the attending. For those who don't know this, the atteding is the top of the pyramid. Yes, there's the CEO, the chair, the chief- but most of us don't see them on the wards with any regulariy. We see the attending. And when we see the attending is one of the most interesting components of hopital life.
Even since I graduated from medical school in 2005, lots has changed. The 80 hour/week mandated work rules were put into place which were supposed to create a safer working environment for doctors and patients. Stories of car crashes following 40 hour shifts and accidents (most notoriously the case of Libby Zion- beautifully summarized here http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html) led to these changes. Hence us young trainees actually leaving the hospital at decent hours and having a semblance of a life outside of medicine kicked off officially one year prior to my starting training as a medicine resident. This was seen by most young docs, at the time, as a terrific move. The post-call intern was relieved of duty, on most days, at a reasonable hour. Calls were never more than 24 hours long except in the ICU where they lasted up to 36 hours. Night float residents were assigned to cover all admissions after 8:30pm until 7am, allowing interns to go home and sleep a bit. (We never got out at 8:30- more like 1am).
But here I sit, less than one year graduated from my residency- and I am beginning to wonder if those reduced hours helped me or hurt. And this leads back to the attending. The truth is- with all of those hours NOT being worked by the interns and residents, someone had to step in and work harder. That someone was the attending. I have informally been polling my attending physicians on a multitude of services for 3 years and have universally found the same response to my inquiry about whether or not the work hours have affected their lives: BIG TIME. Doctors already average >60 hour work weeks once they are attendings. Those in the teaching hospitals where I have worked for my post-med school career average >80 hours. The increased hours are due to a bunch of factors. Doctors in academic settings are under extreme pressure to bring in money for the hospital. This can be in the form of grants or in clinic time. Some specialties, like gastroenterology and cardiology are procedure oriented and thus have lots of billable services. Others, like nephrology, endocrinology, neurology- are solely office visit based and are "supported" by their money making counterparts. Whichever division an attending works in, he or she has a packed schedule- and one which requires lots of hours for a combination of grant writing, lab research, clinical research, teaching duties, clinic time, and now more and more committee obligations. The attendings bring home the bacon- and the attendings work for it.
So how does this affect me? Why do I care (other than the fact that one day not too long from now I'll be "attending" myself?) Well, last week I got home at 8:45pm 3 times and at 7pm 2 other times. This was because my attending couldn't round with the team until 5:30pm due to her responsibilities in the endoscopy suite, and when she did, rounds were interrupted by phone calls from her patients, and her secretary. Rounds were interrupted by her co-grant writer calling just before a deadline. And when she taught- we looked at the clock. We didn't want to- but we are spoiled now on 80 hour weeks. We are spoiled by 15 minutes with our kids before they go to sleep, and spoiled by the ability to eat a 9pm dinner. We want out at the end of a 14 hour day. And while 10 years ago out wasn't an option- we new-generation doctors know that out is as important as in the hospital.
And all of this isn't only due to the 80 hour work rule- soon to be amended to 56 hours of maximum work a week per resident- but someone has to do that work, and no one is feeling sorry for attendings. After all, they bring in the bacon.
Thursday, September 25, 2008
Sunday, September 14, 2008
Consider This
To anyone who has been awaiting this entry- my apologies for my absence. I had to think through my goals for this blog a bit and also figure out a few technical issues which are now resolved. Welcome back!
I met the most amazing woman this afternoon in the hospital. She is 67 and looks 45. She is beautiful in spirit and in person. Her husband was kind and concerned (appropriately) about the pain in her abdomen. She has been bleeding with every bowel movement for 3 weeks. She has lost 15 pounds since this began. She is in crampy pain and she is uncomfortable. She can hardly walk due to the pain and she is weak and her blood counts are low from the bleeding. She has ulcerative colitis. We have started steroids and she will improve- but not before the steroids make her jittery, and sleepless, and not hungry, and if she’s unlucky, even psychotic. But despite all of that- she is very much herself and wishes to go home as soon as possible so she can see her daughter and help her buy a crib for her first grandchild. She was a teacher until she retired. And she has a glow about her that radiates something warm, kind, knowing. The truth is, this is not her first flare. She takes all of her medications. She may or may not respond to the pills and IV streroids and she may need an operation which would cure her- but leave her without a colon and instead with a permanent ileostomy (a bag for her feces) either temporarily or permanently.
So think about this: One day you get sick. Not a flu- or a cold- but painful, bloody diarrhea. You go so many times to the bathroom in a day that you have to move your desk closer to the bathroom. You are afraid to tell anyone except your husband. Six months later you gather the courage to seek medical help. You undergo a colonoscopy and no one tells you that the prep the night before is much worse than the study. Weeks later you get a call that you have colitis. A year later, after the drugs that several doctors have tried for those 12 months don't work you are given a choice: Be sick with a chance of rupturing your bowels at some point, losing weight, an increased cancer risk, infection risk, risk of pain, etc. or have a surgery that leaves you with a bag that many patients find humiliating- but most learn to live with. After all, that bag fits snugly under a shirt- and many of you have passed someone with an ileostomy on the street today without knowing it.
These are the choices we present to patients every day. And I marvel at the braveness by which people make their choices. It's no easy task, being a patient. It may be the hardest job in the world. Doctors struggle to define who does it well. To some of my peers, the "good" patient is "compliant" and "listens." I find those doctors arrogant. For me, the best patient is one who chooses to be informed (when that is possible) about their choices- and then makes a choice for themselves based on what they believe is best. People are too different to lump into "good" and "bad" and sometimes doctors need to remember that someone who doesn't agree with THE PLAN may still be right. This is part of the confusing relationship that is doctor/patient. We are there to inform you and serve your body best. Your job is to trust us- but not blindly- and to use the information as best you can. In so many ways this relationship can go awry- and I struggle every day with various patients to make certain I am doing right by them despite how they may act, what they may say, (or do).
Tomorrow I am going to recommend surgery to my new patient. From our early discussions it sounds like she will agree that this is best for her based on her support structure, religious beliefs, views on health care and her body, access to ongoing care, desire to be better, ability to tolerate a surgery, and other factors that she and I will weigh together when discussing the matter. And no matter what she chooses, I will honor her wishes, and support her. After all, honor is exactly what doctors should be striving to uphold.
I met the most amazing woman this afternoon in the hospital. She is 67 and looks 45. She is beautiful in spirit and in person. Her husband was kind and concerned (appropriately) about the pain in her abdomen. She has been bleeding with every bowel movement for 3 weeks. She has lost 15 pounds since this began. She is in crampy pain and she is uncomfortable. She can hardly walk due to the pain and she is weak and her blood counts are low from the bleeding. She has ulcerative colitis. We have started steroids and she will improve- but not before the steroids make her jittery, and sleepless, and not hungry, and if she’s unlucky, even psychotic. But despite all of that- she is very much herself and wishes to go home as soon as possible so she can see her daughter and help her buy a crib for her first grandchild. She was a teacher until she retired. And she has a glow about her that radiates something warm, kind, knowing. The truth is, this is not her first flare. She takes all of her medications. She may or may not respond to the pills and IV streroids and she may need an operation which would cure her- but leave her without a colon and instead with a permanent ileostomy (a bag for her feces) either temporarily or permanently.
So think about this: One day you get sick. Not a flu- or a cold- but painful, bloody diarrhea. You go so many times to the bathroom in a day that you have to move your desk closer to the bathroom. You are afraid to tell anyone except your husband. Six months later you gather the courage to seek medical help. You undergo a colonoscopy and no one tells you that the prep the night before is much worse than the study. Weeks later you get a call that you have colitis. A year later, after the drugs that several doctors have tried for those 12 months don't work you are given a choice: Be sick with a chance of rupturing your bowels at some point, losing weight, an increased cancer risk, infection risk, risk of pain, etc. or have a surgery that leaves you with a bag that many patients find humiliating- but most learn to live with. After all, that bag fits snugly under a shirt- and many of you have passed someone with an ileostomy on the street today without knowing it.
These are the choices we present to patients every day. And I marvel at the braveness by which people make their choices. It's no easy task, being a patient. It may be the hardest job in the world. Doctors struggle to define who does it well. To some of my peers, the "good" patient is "compliant" and "listens." I find those doctors arrogant. For me, the best patient is one who chooses to be informed (when that is possible) about their choices- and then makes a choice for themselves based on what they believe is best. People are too different to lump into "good" and "bad" and sometimes doctors need to remember that someone who doesn't agree with THE PLAN may still be right. This is part of the confusing relationship that is doctor/patient. We are there to inform you and serve your body best. Your job is to trust us- but not blindly- and to use the information as best you can. In so many ways this relationship can go awry- and I struggle every day with various patients to make certain I am doing right by them despite how they may act, what they may say, (or do).
Tomorrow I am going to recommend surgery to my new patient. From our early discussions it sounds like she will agree that this is best for her based on her support structure, religious beliefs, views on health care and her body, access to ongoing care, desire to be better, ability to tolerate a surgery, and other factors that she and I will weigh together when discussing the matter. And no matter what she chooses, I will honor her wishes, and support her. After all, honor is exactly what doctors should be striving to uphold.
From the air
Today I’m writing from a plane. I tend to get a lot of good thinking done on flights. This one is from Chicago where I spent the weekend at an advanced endoscopy training. I spent much of yesterday placing endoscopes into pig stomachs and practicing on tools that deliver staples, sutures, rubber bands, and other goodies to bleeding vessels, or polyps, or tumors. We doctors need to practice- and trust me, better on a pig than on you. Still, most of what we do for the first time is with real patients. Many people still believe that one should avoid the hospital altogether in July since those of us practicing are so new. But this has been disproven in the literature which is summed up in this article: http://www.newsweek.com/id/144227/page/1. In some ways, I found in residency that July may be the safest time of year to come in since the amount of supervision is high. I assumed nothing in July during my Junior and Senior years- I double checked all of the interns’ work. Every resident does this- and in that way, July patients get very careful workups, lab checks, etc. that they should be getting all year round, but may not in later months, when assumptions are made, for better or for worse, about the level of knowledge gained by an intern by, say, February. The intersection of earning independence and others taking for granted that you don’t know everything yet is the toughest one to cross in residency- and most of my friends and I struggled with that as we bridged from intern year to managing the team as Juniors.
It is at these moments of quiet, abord this plane admiring my view of the clouds and the remains of hurricaine Ike (which has unfortunately destroyed the homes and uprooted the lives of many Texans this week), that I reflect on my life from the 30,000 foot view. Everyone needs moments like that- where you simply stop the madness of the busy days, and tasks, and stress- and ponder. I don’t think we do enough of that. When patients and I discuss difficult things- the death of a family member, a new illness, a lost job- sometimes my urge is to fill the void of those moments with encouragement, with words. But I am learning, as I get slightly further along in my career, that silence is the most powerful tool at times. It doesn’t always take a plane ride to find that moment. Luckily for me- I have found one now and I find myself thinking of how I got here and I will share a bit of that.
My career in medicine probably began before I knew it. At five, my favorite book was an old set of Encyclopedia Britannicas my parents kept in the living room. Chapters on how to make soap sculptures were fun for Sunday afternoons- but even better were the diagrams of anatomy. I remember well tracing the brain over and over with tracing paper- and somehow feeling proud that I could copy it so that it looked real. In elementary school I loved my science classes. I begged my parents for just about every pet I could have and I spent days with my fish tank, measuring the pH of the water. I guess I was pretty nerdy in my private time- but outwardly I played soccer and hung out with friends and was very much an active boy.
In high school I started to see that my appreciation for science could one day lead to a career. I didn’t really work that hard and I certainly should have gotten an earlier jump then- since now, in my 30s, I wish desperately every day that I could be done training and actually making money and making decisions for myself. But I credit my high school biology teacher, Mr. Howard, for his constant enthusiasm. It was in him that I started to see that science wasn’t just a fun hobby- it was a way of thinking- and in many ways I thought scientifically. Still, musical interests, sports, girlfriends- all sort of distracted me from diving in head-first and I was not the quintessential pre-med student in college. For one, I majored in English. This was a terrific decision. Young doctors-to-be, you will spend the rest of your studying medicine- take a few years in college to branch out a bit. I wrote poetry and short stories in college, and a thesis on Raymond Carver’s (who permanently changed how I see the world). And I had fun. Maybe too much fun- as I realized that I was not the top of my class, and that medical school would be a challenge to get into. I didn’t apply when I graduated from Cornell in 1995. I waited for life experience- for the right moment.
What I did not know is that the moment wouldn’t be for six more years. Looking back I partially blame this on my own insecurities in my ability. Partly, though, I think circumstances- my parent’s divorce at 23, an accident that year that left me completely dependent on others for 3 months, jobs in research that excited me- all delayed the inevitable. But after 5 years of waiting, I took my entrance exam for medical school in 2000 and applied that year. I remember the day I interviewed at Thomas Jefferson Medical School, In Philadelphia- with a woman my uncle (a gynecologist) had worked with for years. She is an incredible doctor- a neurologist named Dr. Madhu Khalia who became my good friend a few years prior when she on sabbatical in Boston where I lived. It was she whose encouragement at that time motivated me to go for it- and she who I still credit for understanding that sometimes, those of us who chose this long path, need some help to find it.
I’ll save medical school and residency for other entries- as I know, throughout this blogging experience, I’ll cover the whole story. What I can say now, with authority, as we approach our destination, fasten seatbelts, follow the relentless rules of the less and less friendly skies- (which happen to cost more and more)- is that I am happy to be a doctor, and that all of this hard work is worth it: even a weekend far away, one of my only weekends off in a while spent not with my wife and daughter, but with pig stomachs. Oh, and before I stop writing this, I do wish to share that time with my family is the most important thing to me, by far, and that which I get to enjoy the least. That is the single biggest sacrifice of being a doctor so far- time. More on this tomorrow.
It is at these moments of quiet, abord this plane admiring my view of the clouds and the remains of hurricaine Ike (which has unfortunately destroyed the homes and uprooted the lives of many Texans this week), that I reflect on my life from the 30,000 foot view. Everyone needs moments like that- where you simply stop the madness of the busy days, and tasks, and stress- and ponder. I don’t think we do enough of that. When patients and I discuss difficult things- the death of a family member, a new illness, a lost job- sometimes my urge is to fill the void of those moments with encouragement, with words. But I am learning, as I get slightly further along in my career, that silence is the most powerful tool at times. It doesn’t always take a plane ride to find that moment. Luckily for me- I have found one now and I find myself thinking of how I got here and I will share a bit of that.
My career in medicine probably began before I knew it. At five, my favorite book was an old set of Encyclopedia Britannicas my parents kept in the living room. Chapters on how to make soap sculptures were fun for Sunday afternoons- but even better were the diagrams of anatomy. I remember well tracing the brain over and over with tracing paper- and somehow feeling proud that I could copy it so that it looked real. In elementary school I loved my science classes. I begged my parents for just about every pet I could have and I spent days with my fish tank, measuring the pH of the water. I guess I was pretty nerdy in my private time- but outwardly I played soccer and hung out with friends and was very much an active boy.
In high school I started to see that my appreciation for science could one day lead to a career. I didn’t really work that hard and I certainly should have gotten an earlier jump then- since now, in my 30s, I wish desperately every day that I could be done training and actually making money and making decisions for myself. But I credit my high school biology teacher, Mr. Howard, for his constant enthusiasm. It was in him that I started to see that science wasn’t just a fun hobby- it was a way of thinking- and in many ways I thought scientifically. Still, musical interests, sports, girlfriends- all sort of distracted me from diving in head-first and I was not the quintessential pre-med student in college. For one, I majored in English. This was a terrific decision. Young doctors-to-be, you will spend the rest of your studying medicine- take a few years in college to branch out a bit. I wrote poetry and short stories in college, and a thesis on Raymond Carver’s (who permanently changed how I see the world). And I had fun. Maybe too much fun- as I realized that I was not the top of my class, and that medical school would be a challenge to get into. I didn’t apply when I graduated from Cornell in 1995. I waited for life experience- for the right moment.
What I did not know is that the moment wouldn’t be for six more years. Looking back I partially blame this on my own insecurities in my ability. Partly, though, I think circumstances- my parent’s divorce at 23, an accident that year that left me completely dependent on others for 3 months, jobs in research that excited me- all delayed the inevitable. But after 5 years of waiting, I took my entrance exam for medical school in 2000 and applied that year. I remember the day I interviewed at Thomas Jefferson Medical School, In Philadelphia- with a woman my uncle (a gynecologist) had worked with for years. She is an incredible doctor- a neurologist named Dr. Madhu Khalia who became my good friend a few years prior when she on sabbatical in Boston where I lived. It was she whose encouragement at that time motivated me to go for it- and she who I still credit for understanding that sometimes, those of us who chose this long path, need some help to find it.
I’ll save medical school and residency for other entries- as I know, throughout this blogging experience, I’ll cover the whole story. What I can say now, with authority, as we approach our destination, fasten seatbelts, follow the relentless rules of the less and less friendly skies- (which happen to cost more and more)- is that I am happy to be a doctor, and that all of this hard work is worth it: even a weekend far away, one of my only weekends off in a while spent not with my wife and daughter, but with pig stomachs. Oh, and before I stop writing this, I do wish to share that time with my family is the most important thing to me, by far, and that which I get to enjoy the least. That is the single biggest sacrifice of being a doctor so far- time. More on this tomorrow.
Thursday, September 11, 2008
All In a Day's Work
36 hours awake now- and still writing. Well, I actually snuck in a nap around 2am (19 hours ago) when my ICU patient was as tucked as we could get him for the night (or morning- they tend to blend together these days). But don't worry, this isn't a woe-is-me opportunity to elicit sympathy from non doctors and "been there" from those in medicine. In fact I'm enjoying the quiet.
Hospitals are not quiet places. In fact, I am bombarded by more pagers, beeps, buzzers, alarms, overhead alerts, ambulance sounds (if I step outside for one second), elevator door dings and other noises than I ever expected. This is among the things one doesn't know when they sign up for the life of a doctor: The noises are always present and reliably annoying. Once, a few years ago, I was senior resident on a medical team and we were all in an elevator and I blurted out "Do you hear that?" And everyone listened intently- until I added, "that's the rare sound of silence," which was met with knowing smiles. The med student asked, "Do you guys get headaches a lot around here?" I had never really thought about it. I had indeed had a slew of headaches since medical school, maybe one or two a month which was new for me- and then I started to realize that almost every nurse I knew carried Tylenol in their bag, and that almost every colleague of mine was asking for Tylenol from a nurse at some point. I had never drawn the conclusion that all of those noises took off from their respective machine, only to make a turbulent landing somewhere between my inner ear and the part of my brain that is supposed to make sense of such sounds- and the result was not pretty. In fact, by the end of a shift, doctors, nurses, techs and other who work the halls of the hospital aren't in the best shape. We have bloodshot eyes, and we are often irritable. It is commonplace for folks to lose the most basic communication skills and small arguments between nurses and docs, docs and docs, nurses and nurses, anyone and a complaining patient are not uncommon, especially as the day wears on. This article is interesting and skims the surface of what has now been widely recognized: Hospitals are WAY behind on creating a business environment in which people respect some basic rules of working together (oh, and I happily disclose that I have no affiliation with the company):
http://www.lftinc.com/content/about-our-company/newsletter/detail.jsp/q/id/15
And this MSNBC article, while a tad sensational for my taste, is really interesting and touches on what is happening to change the hospital environment:
http://www.msnbc.msn.com/id/25594124/
In all fairness to myself and my overworked, underpaid colleagues (I'll touch on trainee payment and how much debt I'm in another day), hospitals are also stressful places. Where else, in a day, do you come across the sick and dying on almost every floor. Commonplace are sights that are frightening- tubes coming out of places that shouldn't have tubes, blood, people the color of Big Bird, or Oscar The Grouch, as yellow and green as yellow and green get. I always wonder, when I see people bring their children to the hospital, what nightmares they might have from an afternoon in those halls where I have spent every day for years. This is not a place for people unprepared for the truth about the human body: It breaks down. It is as frail as a leaf. It isn't built to last forever.
So I suppose this is all sort of somber (OK, downright depressing) this evening. And in order to remind myself, and you, why anyone would do this, I will leave you with this:
A mother of a mentally retarded man sat on his bed with me yesterday and asked me if I would mind explaining to him what he was doing in the hospital and where he was heading next (a rehabilitation center). I began to speak with him (which I had done daily in her presence) and he nodded as I spoke about his condition and his treatment and that he was improving and would return to his mother's home soon and play checkers again and play with his dog again and watch Baywatch DVDs and live happily. As I reminded him of the things that he loved in life- all of which he shared with me in these past weeks, all of which peppered the walls of his room in the photos that his mother brought and posted- he smiled broadly. When I was done there was silence. The mother dried a tear from her eye. This has been a terrible week for her. She has been living in a hotel next to the hospital since their home is hours away. She has come every day and kept a log of what we say and had to meet well over 50 doctors caring for him in these weeks and seen team after team press on his belly and seen the looks of kindness and compassion and sometimes awkwardness on the faces of his caretakers who want to connect with him but somehow can't. She dried that tear and probably hoped that for an instant he might forget this terrible month-long admission and remember fresh air and sky and fun. She hoped. And in that silence and his smile I knew that he had made this connection. And he pointed to the wall and said "My dog!! I'm gonna see my dog!"
Hospitals are not quiet places. In fact, I am bombarded by more pagers, beeps, buzzers, alarms, overhead alerts, ambulance sounds (if I step outside for one second), elevator door dings and other noises than I ever expected. This is among the things one doesn't know when they sign up for the life of a doctor: The noises are always present and reliably annoying. Once, a few years ago, I was senior resident on a medical team and we were all in an elevator and I blurted out "Do you hear that?" And everyone listened intently- until I added, "that's the rare sound of silence," which was met with knowing smiles. The med student asked, "Do you guys get headaches a lot around here?" I had never really thought about it. I had indeed had a slew of headaches since medical school, maybe one or two a month which was new for me- and then I started to realize that almost every nurse I knew carried Tylenol in their bag, and that almost every colleague of mine was asking for Tylenol from a nurse at some point. I had never drawn the conclusion that all of those noises took off from their respective machine, only to make a turbulent landing somewhere between my inner ear and the part of my brain that is supposed to make sense of such sounds- and the result was not pretty. In fact, by the end of a shift, doctors, nurses, techs and other who work the halls of the hospital aren't in the best shape. We have bloodshot eyes, and we are often irritable. It is commonplace for folks to lose the most basic communication skills and small arguments between nurses and docs, docs and docs, nurses and nurses, anyone and a complaining patient are not uncommon, especially as the day wears on. This article is interesting and skims the surface of what has now been widely recognized: Hospitals are WAY behind on creating a business environment in which people respect some basic rules of working together (oh, and I happily disclose that I have no affiliation with the company):
http://www.lftinc.com/content/about-our-company/newsletter/detail.jsp/q/id/15
And this MSNBC article, while a tad sensational for my taste, is really interesting and touches on what is happening to change the hospital environment:
http://www.msnbc.msn.com/id/25594124/
In all fairness to myself and my overworked, underpaid colleagues (I'll touch on trainee payment and how much debt I'm in another day), hospitals are also stressful places. Where else, in a day, do you come across the sick and dying on almost every floor. Commonplace are sights that are frightening- tubes coming out of places that shouldn't have tubes, blood, people the color of Big Bird, or Oscar The Grouch, as yellow and green as yellow and green get. I always wonder, when I see people bring their children to the hospital, what nightmares they might have from an afternoon in those halls where I have spent every day for years. This is not a place for people unprepared for the truth about the human body: It breaks down. It is as frail as a leaf. It isn't built to last forever.
So I suppose this is all sort of somber (OK, downright depressing) this evening. And in order to remind myself, and you, why anyone would do this, I will leave you with this:
A mother of a mentally retarded man sat on his bed with me yesterday and asked me if I would mind explaining to him what he was doing in the hospital and where he was heading next (a rehabilitation center). I began to speak with him (which I had done daily in her presence) and he nodded as I spoke about his condition and his treatment and that he was improving and would return to his mother's home soon and play checkers again and play with his dog again and watch Baywatch DVDs and live happily. As I reminded him of the things that he loved in life- all of which he shared with me in these past weeks, all of which peppered the walls of his room in the photos that his mother brought and posted- he smiled broadly. When I was done there was silence. The mother dried a tear from her eye. This has been a terrible week for her. She has been living in a hotel next to the hospital since their home is hours away. She has come every day and kept a log of what we say and had to meet well over 50 doctors caring for him in these weeks and seen team after team press on his belly and seen the looks of kindness and compassion and sometimes awkwardness on the faces of his caretakers who want to connect with him but somehow can't. She dried that tear and probably hoped that for an instant he might forget this terrible month-long admission and remember fresh air and sky and fun. She hoped. And in that silence and his smile I knew that he had made this connection. And he pointed to the wall and said "My dog!! I'm gonna see my dog!"
Wednesday, September 10, 2008
Day 1
Welcome to my blog- which is really a brief daily journal of my life as a young doctor in training. I am a fellow in a Boston academic teaching hospital. I am in my 12th year of training including college (4 years), medical school (4 years), residency (3 years) and now fellowship. I make less money than most of my friends. I have very little time for my family or friends- but I love what I do, and I care about my patients and learning as much as I can in order to be a well-trained physician. (More on this another day). For now, let me give you a flavor of what to expect from this blog:
So tonight I was called to see a consult on a man in the intensive care unit (ICU). He has chronic pancreatitis from alcohol use and frequently comes in and out of the hospital when he decides to drink himself into a stupor. But this admission was different. He presented with his usual nausea and vomiting, which the medicine team treated with various medications- but on the second day of the hospitalization he felt weak, fainted while walking down the hall, and quickly deteriorated into a cardiac arrhythmia (heart was beating very irregularly) and subsequent cardiac arrest (Code Blue). He was stabilized by a rapid response team and placed on a ventillator. (Yes, the stuff we see on TV does actually happen every day in hospitals.)
I was called to see him in the ICU to help the many teams caring for him decide what was next. But soon after I arrived it became clear to me that everyone was watching him through tunnelled glasses. The pulmonologists were busy deciding whether or not he had aspirated his blood and vomit during the cardiac arrest. The kidney doctors were worrying about the state of his kidneys and his ability to clear toxins from his blood in the form of urine. The cardiologists were worried about the state of his heart. The surgeons were concerned about blood surrounding his pancreas. But all I saw was a dying man. Only 42, this guy- but certainly dying. Doctors were scurrying about- charts in hand. Some were arguing quietly outside the room. A med student was pushing gently on his stomach. Tubes and lines dangled from him like tangled fishing lines. I was there to push and pull and write my note and take part in this giant random production, and I did so reluctantly. But all the while I was mindful of the inevitable truth to this alcoholic man: he would be dead by tomorrow, and there was nothing we could do to stop that. No medication. No surgery. No hail mary pass. Nothing.
The secret of medicine is that when you step back from the room, and look at the big picture, you see amazing things. Everyone is often working separately- but together there is a symphony of ideas. Everyone had the same goal today- fix this man. But no one can do more than their part. It's like the 5 minutes before a show- when each instrument is tuning up- and the cacophony of sounds that fill the air are somehow exciting and make sense even though the notes are random and out of sync. So rarely, however, does anyone step back. That moment, in American Beauty- when Kevin Spacey lies dead at his kitchen table and Wes Bentley's character (Ricky Fitts) stares into his reflection in a perfect pool of still blood- that is the moment we need to capture more of. There is, I have no doubt any more, beauty to be found in death. There is a natural, inevitable, silent awe that overtakes you. The first time a patient died before me I was terrified. Eventually I realized that it is the one absolute guarantee in life, and the one moment that is unique in every way to each person. The day I made that realization I stopped fearing death altogether.
So my patient will not live through the night- but I gained something valuable from meeting him- in the saddest of circumstances, and for that, I will forever be grateful. Now off to sleep- I worked many hours past the rules this week (they say 80 hours is appropriate- but get mad at us if we clock 81) and I'm tired.
Ask me questions- send me thoughts- I'd love to hear from whomever is out there.
'Night
So tonight I was called to see a consult on a man in the intensive care unit (ICU). He has chronic pancreatitis from alcohol use and frequently comes in and out of the hospital when he decides to drink himself into a stupor. But this admission was different. He presented with his usual nausea and vomiting, which the medicine team treated with various medications- but on the second day of the hospitalization he felt weak, fainted while walking down the hall, and quickly deteriorated into a cardiac arrhythmia (heart was beating very irregularly) and subsequent cardiac arrest (Code Blue). He was stabilized by a rapid response team and placed on a ventillator. (Yes, the stuff we see on TV does actually happen every day in hospitals.)
I was called to see him in the ICU to help the many teams caring for him decide what was next. But soon after I arrived it became clear to me that everyone was watching him through tunnelled glasses. The pulmonologists were busy deciding whether or not he had aspirated his blood and vomit during the cardiac arrest. The kidney doctors were worrying about the state of his kidneys and his ability to clear toxins from his blood in the form of urine. The cardiologists were worried about the state of his heart. The surgeons were concerned about blood surrounding his pancreas. But all I saw was a dying man. Only 42, this guy- but certainly dying. Doctors were scurrying about- charts in hand. Some were arguing quietly outside the room. A med student was pushing gently on his stomach. Tubes and lines dangled from him like tangled fishing lines. I was there to push and pull and write my note and take part in this giant random production, and I did so reluctantly. But all the while I was mindful of the inevitable truth to this alcoholic man: he would be dead by tomorrow, and there was nothing we could do to stop that. No medication. No surgery. No hail mary pass. Nothing.
The secret of medicine is that when you step back from the room, and look at the big picture, you see amazing things. Everyone is often working separately- but together there is a symphony of ideas. Everyone had the same goal today- fix this man. But no one can do more than their part. It's like the 5 minutes before a show- when each instrument is tuning up- and the cacophony of sounds that fill the air are somehow exciting and make sense even though the notes are random and out of sync. So rarely, however, does anyone step back. That moment, in American Beauty- when Kevin Spacey lies dead at his kitchen table and Wes Bentley's character (Ricky Fitts) stares into his reflection in a perfect pool of still blood- that is the moment we need to capture more of. There is, I have no doubt any more, beauty to be found in death. There is a natural, inevitable, silent awe that overtakes you. The first time a patient died before me I was terrified. Eventually I realized that it is the one absolute guarantee in life, and the one moment that is unique in every way to each person. The day I made that realization I stopped fearing death altogether.
So my patient will not live through the night- but I gained something valuable from meeting him- in the saddest of circumstances, and for that, I will forever be grateful. Now off to sleep- I worked many hours past the rules this week (they say 80 hours is appropriate- but get mad at us if we clock 81) and I'm tired.
Ask me questions- send me thoughts- I'd love to hear from whomever is out there.
'Night
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