January 28, 2014

May Die Tonight

Her room is at the beginning of the hallway into the hospital ward.  You might think this is a noisy place to be, but it is actually the opposite.  A long expanse of administrative offices provide a sound break between the elevators and the rest of the rooms beyond hers.  Further into the ward is the nurses' station, which is full of bustle and paperwork and ringing phones and vacuum-tubed medications at all hours of the night.  But the beginning of the hallway is calm and quiet.  It is the best place for her to be.  The small, square magnet on her door frame has a blue background and a white tree, a subtle sign to anyone who enters that the patient inside is dying.

I helped admit her when she first came in, with septic shock from an infection, but especially ill because she had metastatic cancer that had immobilized her gut, altered her urinary tract, and prevented her from eating.  She was in pain and clearly uncomfortable.  Her mother was a dominant force in the room, giving us the history and settling her in.  It soon became clear that the patient and her family were devoutly religious, and hoped she would be healed in a miracle.  She was only on our floor for a few hours before we transferred her to the ICU.

We followed her course from afar, knowing that if she survived long enough to leave the ICU she would return to our service.  We read about how she broke a bone just by repositioning herself on an x-ray table, because the cancer had riddled every part of her body.  We read the notes of the music-thanatologist (someone who studies death), a harpist who played bedside music in vigils that provided comfort for the patient and her family.

When she came back to us, she was in worse shape but the focus had shifted from treatment to providing comfort and pain control.  After a week or so with us on the floor, she began to weaken, as we had predicted would happen.  The cancer was too voracious; every day became a waiting game.

Each night, when our team would "sign out" our patients to the overnight doctors (give them a brief overview of each patient, with instructions in case of any overnight issues), we wrote at the bottom of her note: May Die Tonight.  We added it when her breathing had become labored, with pauses; however, we had underestimated her strength.  Each day, the footnote remained the same.  It was intended as a warning, a small heads-up for the covering team that they might want to be certain of how to pronounce someone dead, of which forms to fill out, of what kind of documentation would be required.

As the days went by, however, it became clear that "May Die Tonight" was more of an aspiration than a warning.  I found myself dreading and yet needing to visit her room each day, wanting to be available for her mother and family but uncomfortable at the way her death reflected my own mortality back at me.  I dreaded the daily toll of being frank in the face of her mother's continued (but diminishing) optimism -- or was it purely denial by now? -- that a miracle would occur.  I dreaded the strong memories of my grandmother's death a few years ago, a tableau of home hospice that prepared me for the stages of death as this patient progressed toward the end of her life.

Each night before bed, I would check the computer one last time to see if she was still living.  Part of me wanted to know so that I wouldn't be surprised in the morning; part of me was hoping each night that tonight would be the night, that soon my patient's pain and suffering would end and she would slip away to be with the Lord, just as she and her family believed.

It is a strange feeling to hope that your patient will die.

January 22, 2014

Chess and Butterflies

Everyone at my school is required to take two sub-internships (or "acting internships," as they're known elsewhere): one in a surgical field, one in a medical field.  For surgery, students pick all sorts of specialties or subspecialties; for medicine, we can pick from pediatrics, internal medicine, or family medicine.  All year, I had been dreading this month on the medicine ward team.  To me (and to anyone going into a surgical specialty), the endless rounds and notes and complicated admissions and calculations of fluid requirements, renal and liver function, and acid-base calculations are great ways to torture students and residents into submission.  Add to this the fact that there would be four months of vacation, boards studying, and an anatomy elective since the last time I had put hands on a (living) patient and I was pretty sure that January was going to be a hellish month.  

Much to my surprise, it has been great so far.  Part of this is due to my team: my senior resident is full of boundless energy and good humor (she reminds me of one of my best friends, so much so that sometimes I forget that she's evaluating me), the interns on the team are super nice and easy to work with, and both of the attending physicians have been fair to work for and great teachers to boot.  I've been learning a lot about how to handle patients independently, and the workload hasn't even been as much as I expected.

What I've really come to appreciate, however, is the actual intricacies of the work of internal medicine.  Much of the cerebral exercise of medicine--exactly what makes it so frustrating to someone like me, who prefers action and pragmatic, instant solutions to the long-term waiting of medicine and diagnostics--the cerebral exercise of medicine is exactly what draws internists to their field.  I found myself thinking about how I learned to play chess.  I read through a set of rules in the chess box, played a few games against my father and uncles, and taught my brother how to play.  I quickly tired of the game, though.  The only way to be a true chess master is to have the ability to think thoroughly about consequences: one must be capable of anticipating how the move now will impact the board six turns later.  In the same way, internal medicine is the chess of the medical field.  By adding up the signs and symptoms and lab values that a patient has, the internist comes to a conclusion about what disease process is going on.  She then makes a plan that not only addresses immediate concerns but anticipates problems down the road.

For example: a patient comes in from home with a pneumonia.  The patient is ill enough to be hospitalized but not ill enough to require a ventilator or significant interventions.  The internist makes sure to put the patient on appropriate antibiotic coverage, ensures that physical therapy is seeing the patient once it's clear that the patient is getting better, and when discharging the patient makes sure that he leaves with prescriptions for the right antibiotic as well as follow-up appointments with his regular doctor.  She might also send him with a prescription for a probiotic supplement (to ward off C. difficile diarrhea, a condition for which one is more at risk after having taken antibiotics) or with instructions to have a lab drawn to check on his kidney function if the antibiotics given during the hospital stay are harmful to the kidneys.  In all ways, the goal is not just to fix the immediate problem, but to look ahead and anticipate the next problem before it starts.

To put it another way, internal medicine seems to be the art of looking at butterflies and trying to see which ones will cause hurricanes and which ones will simply fly off to the next flower.

I suppose I've never been good at chess, though.  I always wanted to be the kind of smart that can look six steps ahead and know what the best moves are as well as the most likely moves of my opponent; however, even when I was playing chess or Risk or other strategy games, I grew tired and frustrated with them quickly.  I prefer the Zen approach of the surgeon: living in the present, dealing with what is in front of them, and approaching a problem with a concrete solution rather than a hypothetical or invisible one.  I do not think this is a superior approach; it is simply a different one.  

Some in medicine live in the present; they are the surgeons.  Some live in the future; they are the internists, pediatricians, and family physicians.  And some live in the past; they are perhaps the pathologists.  They delve into what has already happened, students of the body's history in order to explain the body's present.