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Explain this... - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
Explain this...
A is a very nice woman. Everyone who keeps admitting her for me on Staff Medicine while I am signed out tells me this. On Staff Medicine, "nice" is a death knell. I have had nice patients suffer acute strokes, die of pulmonary emboli, get diagnosed with end-stage cancer and be discharged to Hospice, and get diagnosed with end-stage cancer and die in the hospital. It is the way of things.
So examining the chart of this very nice woman with heart failure, kidney failure, abnormal liver tests and two liters of fluid in her right lung, I had a Very Bad Feeling. We chased diagnoses all over the place; the specialists at $major_city_hospital had been treating her problems for a year or two without success. We found an enlarged lymph node and got a biopsy.
A has systemic AL-type amyloidosis. It's a horrible disease in which a particular line of cells in the bone marrow is overproduced, yielding an excess of a particular protein, which then simply silts out into the spaces between cells. The only good thing about this disease is that when you stain amyloid with Congo Red and light it up with a polarized microscope, it glows a bright shade of green and looks very pretty. The prognosis is poor, the progression is relentless, and most people who have it die within the year.

A is in her forties.

I got the pathology report from the pathologist. I called her nephrologist, in desperation. "What do I do?" Send her to Heme-Onc, it's their field. And I called and I got her an appointment and now she's on the autologous stem cell transplant list for the next few weeks at $major_research-center even though Mayo Clinic criteria exclude her from transplant candidacy. They're doing it because it is the only chance she has.

I saw her in the office the other day. She smiled and hugged me and thanked me for everything I did for her. I told her, as I have every time, that all I was doing was trying to keep things coordinated. It's no easy task. She has wildly swinging potassium and renal function, she has atrial fibrillation, and she keeps reaccumulating her fluid in her right lung. We've drained over 6 liters in four separate taps now. All of this involves me making phone calls and referrals and admitting her to the hospital over and over again.
She's a nice woman. Very nice. That makes me afraid.

I am going to enroll Miriam in swimming lessons. The Y has a "water babies" program for infants 6 months and older; we could go on weekends. She turns six months old on Tuesday.

This decision was prompted by the twelve-year-old boy who came into the PICU on my last night of Peds call. He was out at a family event with an uncle when someone noticed something at the bottom of the pool. They dove in to check it out and pulled W out of the bottom, unresponsive. Bystander CPR (learn it, folks - you never know) was initially successful - he began breathing and coughing up water on his own. By the time he got to the ER he was answering questions and knew his parents. GCS of fifteen.
Our ER docs never ever treat a near-drowning as a routine matter; they got the obligatory lab data and called the peds ICU. And it was a good thing.

His arterial pH came back at 6.9. Now - in a normal person with good respiratory status, pH should be about 7.4. In a critically ill person, pH is less than 7.2 or so. This is a logarithmic scale - those little decimal points mean a lot. The decision was made for elective intubation in anticipation of precisely what happened.
What happened was ARDS - acute respiratory distress syndrome. W's lungs, with all of the surfactant that normally holds them open now washed away, irritated by the chlorine of pool water and responding as lungs do, went from functioning well to not at all. His chest X-ray, initially fairly clear, filled with a diffuse haziness that radiologists insist on calling "ground-glass" despite the fact that it looks more like "sandblasted" to me, progressing to opacity on both sides. He became progressively more and more difficult to ventilate. They went to high-frequency ventilation, which is little puffs more often, and then to the oscillator, which gives breaths at some 100-200 per minute.

And then W, twelve years old and talking to his parents in the ER, coded and died from complete lung failure, on my colleague's cross-cover pediatric night, while she was taking call as a favor to another resident. And that's it. Just like that.
I heard about it the next morning, in clinic, in the way that M has of conveying these things. "That kid, the near drowning, he died. Sucks." He told me the story in simple terms, indulged my need for gory detail, and ambled off. I wonder what he was thinking.

We're a funny lot, residents. One minute sarcastic and harsh, the next wounded. One is a tough guy who talks big but fed black bean soup to my baby so I could eat my salad. One hates everything but melts when you ask about her two-pound puppy. Even in this enlightened culture of 80-hour work week limits and ten-hour sleep shifts, something happens inside, in the psyche. It's different for each of us.

I wonder what it's doing to me. I don't write like I used to - feverishly, as if the glut of words in my mind will overwhelm me in flood tide. I don't write much poetry. I don't write enough prose. I am tired, weary inside sometimes, and there is nothing that I want to do but not-think and not-be.
And I miss, sometimes, the broken and fragile creature that I was, with the wellspring of creativity that stemmed from sourceless pain. I wonder, sometimes, who and what I have become.

Current Location: $ER
now feeling:: blank blank

9 whispers echo . o O ( ... ) O o . whisper a word
buggrit_1979 From: buggrit_1979 Date: July 21st, 2007 02:50 pm (UTC) (etched in stone)
*hugs tight* Wow.. this broke my heart. Not just for A and W... but for N, who I love dearly and miss very much.

I'm excited to hear you have a baby now! Could you send me pictures? My email addy is buggrit 1979 at yahoo dot com.

Give M my love too.

clipdude From: clipdude Date: July 21st, 2007 07:03 pm (UTC) (etched in stone)
It's been over four years since I've had CPR training, but this post makes me want to go get re-certified.
turnberryknkn From: turnberryknkn Date: July 21st, 2007 07:20 pm (UTC) (etched in stone)
I wonder, sometimes, who and what I have become.

I wonder that of myself sometimes, too.

I know this process will -- is -- shaping us into what we must be for our patients. Forging us, like steel between hammer and anvil, between forge flame and ice quench. Giving us the sharpness and strength and edge we need to fight for our patients. I know this process will make us into the physicians our patients need. I just wonder, sometimes, what will be left of us when the forging is done.


I'm sorry to hear about your patients.

I guess I'm confused about W, tho -- there wasn't time to put him on ECMO?
ayradyss From: ayradyss Date: July 21st, 2007 07:32 pm (UTC) (etched in stone)
You know, I knew they'd been talking about it and then I think he crashed too fast. We don't do ECMO - it would have to be a transport.
mdrnprometheus From: mdrnprometheus Date: July 21st, 2007 08:25 pm (UTC) (etched in stone)
Giving us the sharpness and strength and edge we need to fight for our patients. I know this process will make us into the physicians our patients need.

They tell us this. I am not at all sure it is true. I am especially unsure of this when I stop, take a step back and think about how many *more* lives could be saved with the money spent on a single ICU patient. Yes, this patient is someone's spouse/sibling/child/etc... but so are many, many others who are not getting even basic medical care because it's been priced out of their reach.

Is our fighting for our patients truly helping them?
coanteen From: coanteen Date: July 21st, 2007 08:31 pm (UTC) (etched in stone)
Meh, the "you" you were before the seemingly endless grind of residency will come back once residency's over. You mostly become sane once more.
turnberryknkn From: turnberryknkn Date: July 22nd, 2007 12:35 am (UTC) (etched in stone)
I agree with you entirely. We as physicians can't just limit our focus to our own wards, our individual patients, and ignore the bigger questions and the bigger picture. We have to be not just aware of the bigger picture in which our own individual decisions are made, but be out there *shaping* the bigger picture. We have to be out there fighting for our patients -- and our profession -- in the places where the future is being shaped by policy and law. And that if we fail to take up that challenge -- if we fail to take up that battle -- we ultimately fail our patients. And I agree our schools and our programs don't do as good a job as they could preparing us for that reality, for that responsibility.

The wards aren't the only place we as physicians must fight for our patients; they might not even be the most important place, in terms of numbers of lives changed. We gotta be sharp, we gotta be strong, and most of all, we gotta get into the game.

Which, now that I'm free of my MD/PhD imposed term limits, I am free to get back into. And am beginning to move forward in doing. :-)

From: dr_bobbie Date: July 23rd, 2007 01:54 am (UTC) (etched in stone)
You and me both. ::hugs::

I'm alive, Lanie turns three in less than two months, her sister arrives (as yet nameless) in a little over two months...AND I'M DOCUMENTING NONE OF THIS.

ayradyss From: ayradyss Date: July 23rd, 2007 01:54 am (UTC) (etched in stone)
Are you going to KC again?
9 whispers echo . o O ( ... ) O o . whisper a word