After a shift the other night, a few of us emergency residents went to go grab a beer.  We’ve gotten much less interesting lately; last year we would have elaborate dinner parties, hiking trips out to the local mountains, you name it.  Nowadays we try to muster the energy to pour back a cold one before we pass out in our beds.  The news was playing in the bar.

“… multicar pileup on the freeway today,” intoned the news announcer, “all 12 injured taken to the local trauma center where we anxiously await news of their health.”

I turned to one of the other residents, who was watching the newscast with vague interest in between sips of his drink.

“Anybody hurt?” I asked.

“One broken humerus and some whiplash, is all,” he said.

“That’s good,” I nodded, “Trauma ICU’s already pretty full.”

“Yep.”

We sat, news blaring, and took another sip of beer in silence.

He was a guy my age, in his mid-twenties, and his friend was driving drunk.  When they hit the tree at 50mph he was ejected out of the car, slamming his head into the tree on his way to the ground several meters away.  Initially he was walking and talking – a good prognostic sign for the severity of his underlying brain injury – but quickly decompensated when EMS arrived on scene.

By the time he came to me in the Trauma ICU he was comatose, intubated, and on very shaky ground.  The bleed in his brain was severe, and I wasn’t sure if he was going to make it.  A petite asian girl sat in the corner of his room while I did my initial evaluation.  She didn’t say anything, just sat there looking at the floor.  After my examination I went over and introduced myself.

“I’m Dr. Zac,” I said, “How are the two of you related?”

She didn’t look to be more than 23 years old, about his age, and she slowly looked up, a puzzled look on her face.  She looked like she was in shock.  It took her a moment to speak, but when she did, what she said knocked the wind right out of me.

“I’m Jen.  I’m… his wife.  We got married yesterday,” she said simply, “I love him.”

She twisted the ring on her finger as though it was unnatural, unfamiliar.  Her gaze was empty.  A single tear coursed down her cheek.

I don’t normally get attached to patients, especially in the ICU.  I care for them deeply or else I wouldn’t be in this job, but getting emotionally invested is dangerous.  I learned that early on.  Your responsibility as a physician is to all your patients, and decompensating from a bad outcome can have devastating consequences for everyone else.

But sometimes emotions take over no matter our intentions.  I didn’t know what to say at first, and then it all came tumbling out.

“I’m… I’m so sorry.  I can’t imagine what this is like for you.  You have my word that I will do everything within my power to save his life.  I will not sleep tonight.”

That night, everything fell into place.  Everything that could go right, did.  I gave countless boluses of mannitol and hypertonic saline to drive his intracranial pressures down.  I drained fluid off his ventricles.  I sedated him into a medical coma and made him hypothermic to decrease brain metabolism, and paralyzed his body to decrease shivering.

For all my efforts, in the middle of the night I realized I was going to lose him. Intracranial pressures spiked, his heart rate dropped, and I had maximized every available option.  I went in and stood, arms crossed, watching the monitors.  Helpless. Just him and the universe, now.

Jen saw the look on my face.  I think she knew there was nothing left I could do.  She slowly walked over and took his hand in hers, kissed him gently on the forehead, and then whispered “I love you” in his ear.

And I watched, astonished, as his heart rate slowly picked up.  His intracranial pressure dropped to normal levels.  She sat next to his bed, a vigil for the rest of the night, but the turning point had been reached.   My treatments became less frequent and more effective.  By the morning his vital signs were as stable as a rock.

It’ll be a long recovery, but he should be completely normal in a few months.  More than anything, I’m happy that I’ve been trained well enough to help him in his time of need.  It’s a good feeling.

It was the best wedding present I could think of on short notice, Jen.  Congratulations, and many happy returns.

3AM, and the all-too-familiar beeping starts.  I awake to the dull amber glow of my pager.  Call the nurse for bed 29, please.

“Zac… we have a patient who is scaring us and we need you to come see him.”  I rub the sand out of my eyes and stumble out of bed.

It’s quiet in the hospital, but there is an ominous tone hanging over the night.  Wind whips past windows and the rain has been coming in bursts.  The nursing station is silent except for the gentle beeping of the monitors.  The lights are dimmed in the ICU, except for Robert’s room, bed 29.  He’s a psych patient who landed himself here by driving full-bore into a concrete median.  He’s been in and out of consciousness since day one.

I walk down the darkened hallway and towards his room. Eerie noises emanate as I get closer; a mixture of wails and shrieks.  It’s Robert.

Nurses stand back against the cabinets, and I see Robert lying in his bed, ripping and tearing at his restraints.  A thin line of spittle hangs down his mouth and a small trickle of blood trails from where he has chafed at the wrist cuffs.  He’s hurting himself.  He moans like a caged animal.

“Robert, it’s the doctor, just coming to check on you…” I stammer, but his eyes are wild and rolled in the back of his head.  The rain starts to pick up outside of the room, first brisk and then torrential. I don’t want to be in the room alone with him, but the nurses file out now that I’m here.

He mumbles something, eyes darting around the room.

“I can’t hear you, Robert, please speak up.”  He meets my eyes for one brief moment, lucid, and motions me over.  Slowly, I advance.  I’m keenly aware of the darkened hallway behind me.  This feels like something out of a horror movie and I have the distinct sensation that something is there.   I glance over my back.  I’m being silly, it’s nobody.  The hairs on the back of my neck crawl anyway.

Nervous, I lean in. “Robert, I can’t understand you.  You’re speaking nonsense.”  He grunts some more.  I edge closer.

Suddenly, he sits bolt upright, his face inches from mine.  I jump back, startled. Panting, sweat beading off his brow, his arms are cords of muscle  as he fights the restraints.

Robert’s head starts turning, slowly, staring straight forward, breath fetid.   A slow, terrifying grin spreads across his face as he fixes his gaze to mine, his cracked yellowing teeth in a rictus of madness.  Slowly, his head tilts, his bloodshot eyes boring into me.  The patter of rain is the only sound in the room.  And then he speaks, his voice deep, hoarse, and gutteral.

“Look… out… the WINDOW!”

Panicked, I spin around as a single bolt of lightning illuminates the room.  A shadow flits across the glass – no, it must be my imagination – but my heart is pounding.  The rain traces lazy rivulets down the window.  I turn back quickly, but Robert, spent, is lying back in bed, breathing softly, eyes closed.  The room is silent again except for the rain.

We’ve got a medical student rotating on service with us, and I have grown to hate him.

Now, I don’t dislike very many people.  In fact, I would argue that I’m a pretty friendly guy all around.  But this one, he has pushed all of my buttons.

I’m on Surgical/Trauma ICU this month, and as an emergency resident, I don’t have quite the pull that the surgical residents do.  Chest tubes, intubations, and other procedures somehow seem to fall in their laps a bit more often than in mine.  I’m also not expected to know as much – both a relief and insulting at the same time – and my plans for patient care are often ignored on rounds, the attending turning away to flirt with the nurses while I’m talking.  This is pretty frustrating, as I’m training at one of the most elite emergency medicine programs in the country, and it took a lot of percentiles to get here.

Medical Student has recognized this power dichotomy, and as such, has shown me his true colors.  Unlike the surgeons that he’s trying to impress, he doesn’t bother to hide from me that he’s incompetent, unpleasant, and lazy.  He figures I’m not evaluating him at the end of his rotation.  He is quite mistaken.

“Honestly, man, I can’t say I’m thrilled to see patients this morning.”

“You want to teach me about heart failure?  Why on earth would I ever want to know about that?  I’m going to be a surgeon, not a hospitalist.”

“Well, you emergency guys just admit all sorts of crap anyway…”

As such, I have found a vast, previously unknown wellspring of pure malice lurking deep within my person.  They say power corrupts.  I never really understood until I wasn’t at the bottom of the hierarchy.

Now, I don’t stoop so low as to scut him out to fetch me coffee (like my surgical residents did to me as a medical student), but I have started to call him on his bullshit.  When he bitched about being asked to learn something for rounds, my response turned decidedly nasty this morning.

“Maybe if you already knew it, you wouldn’t need to look it up in the first place,” I sneered, “but of course, it’s not like ventilator management is important for your education, now is it?  You’re going to be a Surgeon, right?  ’Course, you need to actually match into a surgery program first…”

I’m not a mean person, but I must admit I get a perverse sense of pleasure from watching him squirm on rounds.  I usually pantomime answers to medical students on rounds to make them look good in front of the attending.  Instead, I just smirk when he roasts on the spit under the rapidfire questions.

A big part of this is being immersed in the surgical culture.  The same mean streak emerged last year when I was a general surgery intern.  Being surrounded by so much poison makes it next to impossible to maintain a good attitude.  I simply do not fit in with this culture of harsh, trust-nobody, work until you drop self loathing.  But being submerged in it for a month, it takes its toll.  It’ll be a few weeks before I detox all the Surgeon out of my system and go back to being a fun, good-natured emergency doc.

In the meantime, I’m carefully crafting my end of the month evaluation for Medical Student… the bus, my friend.  You’re about to be thrown under it.

And like that, it’s finished.  No fanfare, no awards.  Walk out of the hospital one day an intern, return the next a resident.

My parents called to ask if it felt any different.  To my surprise, I answered, “yes… it kind of does.”

Countless books have been written about intern year.  Every physician gets a bit misty-eyed when thinking back to the nascent, formative moments of their career.  Medical students peer forward, trying to pierce that impenetrable veil of transition from student to doctor.

The difference between an intern and a fourth year medical student is simply the M.D. behind their name.  But, of course, that’s everything.  Someone has accredited an intern to make decisions about patient care.  An order for a CT scan will result in the same scan, no matter whether an intern, resident, or attending authorized it, but no medical student can give that order.

Exactly one year ago, on my first night on call as an intern, I got a call from a nurse for the simplest of things.  ”Doctor,” she said, “your patient in bed six has a fever of 102.4, and there is no Tylenol ordered.  Can I give him some?”

I panicked. Tylenol is the oldest of drugs.  Parents give it to their kids like candy.  There are elixer, flavor, chew tab, and extra strength variants.   It has countless brand names across the world.  I was a doctor now, and I should know the answer.  Just a simple Tylenol order.  And yet.

In a patient with liver failure, Tylenol can be lethal.  The primary team didn’t think there were going to be any problems with this patient overnight, and suddenly I was presented with a fever.  Fevers in the hospital setting are often the harbinger of massive bacterial infections, lethal blood clots, wound infections, sepsis from urinary tract infections, and so on.  A simple order for Tylenol… well, it’s not so simple.

I sprung out of bed, hair mussed, wild eyed, heart racing.  The patient was sleeping, but I woke him up and grilled him for 10 minutes to make sure he felt alright.  Gruffly he responded, “well, I was doing just fine until you woke me up!”  I pored over the chart, trying to comprehend his care, his underlying pathology.  He was postoperative from an appendectomy.  Nervously, I reasoned that his fevers were from atelectasis, a common and benign cause of postop fevers, and ordered the tylenol.

What if I was wrong?  What if it was infection?  What if lying in the bed had caused clots to form in his legs, rocketing off and wedging themselves in his lungs?  I went back to my call room and laid awake for hours, exhausted, the dim blue glow of the computer suffusing the room with bits of the electronic medical record.

In the morning, I called the primary team to let them know I had given tylenol to their patient overnight.  ”Cool, man, thanks, he probably just had atelectasis,” said the resident.  In a single moment, a night of agony validated and dismissed.

I soon learned that with experience, confidence builds.  With every mistake identified, every correct decision confirmed, I grew as a physician.  4,000 hours spent in the hospital, 80 hours a week, 50 weeks a year.  Bathed in the milieu of medicine day in, day out.

And at the end of it, one step up the ladder.  One layer of supervision, peeled away.  One more level of scrubs asking me the questions. One year of training down.

I saw a new intern walking into the hospital on her first day as a doctor this morning, uncomfortable in her starched new white coat, the hospital logo emblazoned proudly on her sleeve.  She kept grabbing at the pockets, adjusting her stethoscope, buttoning and unbuttoning, checking her pens.  Nervous, but deathly afraid to show it.  I remember that feeling well.

“Morning!” I greeted her, cheerfully, “You excited?”

“Yeah…” she allowed.

“It’s going to be a fantastic year, ” I assured her.  ”Come find me if you have any questions.”

Walking out of the MICU today, I had an overwhelming sense of accomplishment.  In the last couple days I’ve placed 5 central venous catheters and intubated 2 people – one of whom looked to be a few minutes away from dying when I walked in the room.  I’ve started to really hit my stride.

I swung by Trader Joe’s after work in my scrub bottoms and t-shirt. I used to keep an extra pair of clothes in the car so I didn’t have to walk around in scrubs, but at some point I got too tired to make the effort.  I figure taking off the scrub top is a good compromise.

As I was checking out, the cashier struck up a conversation.

“Just going on, or coming off?” she asked, brightly, “You look a bit tired, so I’m assuming coming off.”

I smiled, “What gave me away?”

“Well, the scrubs, for starters.  You haven’t shaved in about 4 days.  And you’ve just got that… look about you.”

“What look?”  I asked.

“You look like a tightly coiled spring.  Calm at the surface but ready to act in a heartbeat.  I’ll bet you know exactly where the AED is in the store.”

I chuckled.  I had noticed the AED.  Back corner, newer model.  It’s become unconscious, that quick assessment.  It has served me well in the ICU and the ER so far.  A year ago I doubt I would have been able to make that snap decision to intubate just by looking at someone.

I finished bagging my groceries and thanked the cashier.  As I walked out an elderly gentleman walked in, breathing hard and barrel chested, nicotine stains on his fingers.  ”COPD,” I thought to myself, as I strode to my car.

Like a tightly coiled spring.

I apologize for the number of times I’ve talked about death recently.  It’s not so much morbid fascination or curiosity, but simply a reflection of the rotation that I’m on.  In the Medical ICU our team’s mortality is approaching 60%, and since we round on these patients – and consequentially, their caring families – every day, it’s hard not to find meaning in death.

Last night a very young gentleman died, but the cause of his fulminant liver failure remains unclear.  We suspect he may have had a rare condition that is nearly impossible to diagnose, but until the autopsy comes back we won’t know.

As I walked by his room, the arterial line monitoring his blood pressure caught my eye.  In the Emergency Department we only measure blood pressures every 5 minutes or so with an external cuff; in the ICU an “art line” lets us watch the blood pressure in real time from a catheter placed directly in the arterial system.  I watched, a sick feeling in the pit of my stomach as his systolic blood pressure lazily swung down from 80… to 79… to 76…

My attending was at that moment talking to the family, explaining to them the futility of his care.  We were trying to convince them to change his code status from FULL CODE to DNR, so that we would not need to start CPR on his already frail body when he died.  He was actively dying; no matter how badly we wanted to, we could never cure him.

He was on the maximum doses of 3 different pressors – medications that keep blood pressure artificially elevated – and we knew that instantaneously on stopping them, he would die.  Unfortunately at that moment, as I was watching his systolic blood pressure hit 63… 58… I knew we had no time left for long discussions.  If he flatlined before the family agreed to his DNR status, I would be obligated to start the code.  That was a violation of his body I did not want to perform.

Nervously, I waited.  54… 49…  43…

And then my attending rounded the corner, his arm around the mother’s shoulder, her head low, gait unsteady, sobbing.  He nodded to me as they walked in the room; crisis averted.  It is a small accomplishment every time we allow a death to occur naturally in the ICU.  I sincerely believe it’s the right way to let people with end-stage conditions go, but it can be exceptionally hard to explain this to families.

I sat at the nurses’ station, watching the remote monitor.  With every heartbeat, a soft *bing!*

*bing*  *bing*  *bing*

And then a pause.  One more halfhearted *bing*, and it stopped forever.  A wail from his room, first quiet, then louder and torrential; a mother’s love, devastated.  I watched the EKG tracing for quite a while, the fine, flat line devoid of life.  What once was and now is not.  Dust to dust.

Life is short.  Live it while you can.

A few weeks back, I had a 450 pound woman lumber into one of the back rooms of the Emergency Department.  To be honest, I’m not quite sure how she got around on a daily basis, but kudos to her for not caving to the electric scooter craze.

Before I went in the room, I looked up her records.  Multiple UTI’s – in fact, 7 in the past 6 months – with every antibiotic under the sun thrown at her.  Chronic diarrhea, probably secondary to the antibiotics.  Diabetes with extreme insulin resistance.  Hypertension resistant to treatment.  The list goes on.

She was an overwhelmingly nice woman, and said that for the past 6 months it “burned down there” on and off whenever she peed.  7 different courses of antibiotics, no cure yet.  Multiple workups for gonorrhea, chlamydia, trichomonas… all negative.

Lo and behold, she had another UTI.  Bacteria were swarming all over her urine sample.  I sat there, scratching my head; all my antibiotic tricks had already been used with no cure.

And then I thought to myself:  I wonder if this was a clean specimen?

I did a pelvic exam.  It took myself and 3 other people to physically lift her pannus to the point where I could get a clean, catheterized specimen.  It was actually the most physically taxing thing I did all week.  We were all sweating by the time we finished, but I finally, successfully, got a clean urine sample directly from her bladder.  Along the way, I noticed that she had a wicked yeast infection.

Lo and behold, her urine came back crystal clear.  Not a single bacteria.  The special KOH slide I tested, on the other hand, showed copious amounts of yeast.

I went in and talked with her for quite a while afterwards.  ”You don’t have a urinary tract infection,” I explained, “and probably never did.  All the antibiotics you were given predisposed you to your diarrhea and this yeast infection.  You need to know – and this isn’t an easy thing to hear – the reason you’ve been diagnosed with UTI’s so many times is that you are physically unable to give a clean urine specimen because of your morbid obesity.”

“I know it’s causing me problems,” she said, “but I sure didn’t know it could do that.  Thank you for your kindness.  I know I need to lose weight, maybe this will be the reason.”

I hope she does, but statistically she is mandated to undergo gastric bypass; the incidence of complications from the surgery is actually less than that of simply being so obese.  I wonder… should we add frequently misdiagnosed UTI’s to the known complications of morbid obesity?

I need to get the poison out.

I went into medicine for all the right reasons.  I wanted to cure people, to help them, to smooth their journeys through life.  And in the best of times, that’s exactly what happens.  I love my job.  I love taking care of people.

And yet, residency is a huge toll.  I’m a low-maintenance person, but each of my vacation requests have been denied.  With the exception of 4 days off in October and a few days where I attended a national lecture series, I have been working straight since residency started.  80 hours a week is hard.   80 hours a week is harder when you realize that you haven’t had a single Saturday/Sunday off for months and months.

The last straw was our lecture today.  Two lawyers came in to explain a recent malpractice case; it was a case where the doctors did everything right, and the plaintiff still died.  Just by virtue of there being a bad outcome, all the docs got sued.  I deal with death every single day, and my whole purpose is to try to stave it off.  But the idea that not only do I work my ass off to help people, but that I have a greater than 100% chance of being sued just because of my profession... well, that was just about enough for me.

I’ve been depressed all day.

Why, exactly, should I slave away, devoting the best 7 years of my life learning how to help people… giving up nights, weekends, vacation, free time… if in the end I’m going to be sued for the one time I make a mistake?  My friends from college right now are planning reunions I will never be able to attend.

It’s too much.  I want just one day truly off, where I don’t feel guilty for not obsessively reading about the correct treatment for strep throat, or the appropriate management of septic shock.

I need a break.

This month I’m rotating through the Medical ICU, which means that I deal with a lot of death. I suppose over the last few years I’ve learned – had to learn – to be comfortable with the dead and dying. I find this extends as well to families. I’d like to think I’ve learned a few things about how to be caring and compassionate.

I had a phenomenal conversation with a very loving family today. Their son suffered an absolutely devastating brain injury after a cardiac arrest, and has not recovered. Despite everything we could do – and we tried everything – he continues to be completely nonresponsive. It’s been a very difficult series of conversations, mostly because they are simply not ready to let him go. Most importantly, he remained a FULL CODE until today, which means a brutalizing, dehumanizing round of CPR, intubation, and caustic medications in a last-ditch effort to restart the heart when, inevitably, he tries to die.

I decided it was time to ask them to come to terms with his injury. I went in to the room and simply closed the door, shut off all the beeping alarms, and the 5 of us sat down together. I asked them to explain to me their expectations, hopes, and fears. I’m not an expert at end-of-life counseling by any stretch, but I do think that having everyone sit and talk takes the edge off.

As I’ve experienced many times now, with enough talking, the underlying theme arises: they don’t want him to suffer. They don’t like the tubes, the beeping, and the IVs; but they somehow think that it is necessary. This is just how it is done, and doctors know best. I think it’s one of the biggest failures we as doctors perpetrate on our patients. That somehow, against all odds, against complete and utter medical futility, we can save everyone.

So, once they were done talking, I began to explain. None of these tubes are necessary. None of them will change anything. Some of them will make him feel better, so with their permission I’d like to keep those in. Some of them, like the tube shoved down his nose to force-feed his stomach, should go.

And then, the most delicate moment. “There is a lot of misunderstanding about DNR/DNI,” I quietly explained, “that somehow it means we aren’t fully taking care of your son. What it really means is that when it is time for him to die, we allow him to do so peacefully and on his own terms. The alternative, and what his FULL CODE status currently means, is that when his heart stops beating, we will perform CPR on him for about 20 minutes, possibly breaking ribs in the process, try to establish huge IVs in his groin and neck to push medications, and shove a tube down his throat to force breaths into his lungs. If he were my brother, I would never ask for this to be done to him.”

The family was quiet for a moment.

“He would never have wanted that. Please don’t do that to him.”

They hugged, and shed a few tears. I bid a quiet farewell. I think they’ll be more at peace with his passing now.