I slept really badly last night- I think it has something to do with the upcoming MSFC conference. I don’t know why I’m nervous about it (should be a lot of fun… meet some new people, hear some stats, get a free trip to LA) but I am. I’ve never been to a conference before.

You know, the other thing is that someone out there has decided that I’m worth spending $200 on. They gave me enough to buy a plane ticket and rent a car, because somehow me going to this conference is something they see as valuable.

Crazy, eh?

I really have meant to write about Friday and Saturday, but time flies when you’re having fun.

Friday we saw several neurology patients with different diseases. The first woman had ALS (Lou Gehrig’s disease)… I never realized how horrible it actually is. ALS slowly paralyzes your muscles, inexorably over the course of several years. Patients start tripping first, then begin falling. They need a cane, then a wheelchair, then are bedridden. Eventually they start needing respirators to sleep at night, since the muscles that help them breathe start to fail. Finally swallowing muscles and voiding muscles go, so they need a GI tube and colostomy bag. The only muscles that don’t die off are the eye muscles- so eventually the patient becomes confined to a bed, completely unable to move, and only capable of looking in the direction that
their head is facing.

The awful thing is that there is essentially no degeneration of the mind. I suppose that’s a good thing in some ways- it’s not a descent into dementia like many other neurological diseases- but at the same time, that means that you become a shell. Your entire body shuts down around you and you watch, knowing full well exactly what is happening. The neurologist put it very delicately. “Patients can be kept alive using ventilators, GI tubes, and colostomy bags- but when all you can do is look straight ahead, day in and day out… most of our patients… reject that life”.

I guess I can’t even imagine what it would be like to have to decide to take yourself off a ventilator and die, knowing full well what you are doing. It’s not even that you’re in pain all day, or near the end with terminal cancer, or anything. You just can’t move.

—

Saturday I had my first patient EVER! I volunteered at a clinic and screened a few people for glaucoma. It was a slow day, but since it was my first one I didn’t mind- gave the medical students time to practice all our tests on each other (like putting eyedrops in and such). Anyhow, his name was Frank, he was 75, and turned out to be totally fine. His vision was awesome for his age (no cataracts), and he was a really nice guy. I don’t really know what else to say about him… I only saw him for about 15 minutes, tested his visual acuity and peripheral vision, took his blood pressure and intraocular pressure (which is one of the hallmarks of glaucoma), and checked out his eyes with my sweet opthalmoscope.

I think it made an impression on me specifically because he was the very first person I ever took care of myself. I presented his case to the doctor working with us, who then made the diagnosis, but basically, Frank was MY patient. I gave him medical care… and while it wasn’t much, and was pretty basic, it was still what I’m here for. I had a great rest of the day . I can’t wait to sign up for more clinics… it really puts into perspective what we’re learning here, and why.

Today was huge… I doubt I’ll touch on even half of what we went through.

First, we went over child abuse in our social/behavioral sciences class. It was a difficult session- lots of pictures that you wish you hadn’t seen (some of the worst, actually, were just the X-rays of kids that had “fallen from a couch”, with multiple broken bones, healing ribs, head fractures, and hematomas- blatant, ongoing physical abuse). Amazing, too, the gamut that “abuse” runs. Physical abuse, mental abuse, emotional abuse, sexual abuse. The number of things that we humans can do to our offspring is so varied, and being presented with a quick and dirty litany of awful stuff was pretty emotional at times.

Funny, too, that I started to look somewhat dispassionately at it. Not because I didn’t care, but because I realized that if I were the physician taking care of this child, the most important thing I could do would to get the child help- and help probably means CPS, and that means that a forensics examiner needs to talk to the kid. If you’re talking to a little boy about how his daddy hits him all the time, you can’t say “well, that’s TERRIBLE” and get totally upset. If you do, when the forensics examiner asks him, he won’t say what happened, because you judged him on it- so, as the doctor with the first-pass exam, you have to be totally unemotional. That’s not to say that you can’t be boiling with rage inside… and some of the stuff we saw and heard today was just vile. You just have to be able to outwardly be dispassionate. Turn it on, turn it off, with the flick of a switch. Interesting, as I keep finding out the implications of this career that I’ve chosen. There’s a lot of nasty stuff in this world that I’ll be dealing
with.

Then we had our bioethics conference. The one gaping flaw with U of A’s curriculum is that they don’t give us much ethics- and there are a LOT of ethics in medicine. The current solution is that one of the student groups organized this bioethics conference, which was really incredible. It was a 5-hour thing, and was extremely well run and VERY thought provoking. I wasn’t bored for a minute.

The first issue we talked about was very similar to My Sister’s Keeper. The watered down version of our case is that a 5 year old girl needs a blood transfusion. Her mother is pregnant, and the baby has a 25% chance of being a match for the transfusion (and if it is, the transfusion would be much more likely to succeed than from someone else). The test, though, is dangerous to the fetus- so what do you do? Endanger the fetus’ life for the sister’s? Go for the unmatched donor and hope for the best?

Worst case scenario, mind you, is that the fetus dies from the testing, and the sister dies when the transfusion fails. Then the patient is left with no children. As the physician you have to discuss all of this… and then you walk the road with the patient. You’re the one who has to tell the mother that her daughter’s transfusion didn’t work and she’s dying (much like I did yesterday). You’re the one who has to tell her that the testing caused a miscarraige. So, you can’t sit on the sidelines and wait for someone else to take charge.

Then there were a whole other host of issues. What if the parents test the fetus, find out that it isn’t compatible, and decide to abort and then get pregnant again in the hopes of getting a match? I mean, I’m very pro-choice and I’m still reviled by the idea of trading one life for another so flippantly. Obviously a lot would go into that decision- maybe flippant is the wrong word- but still. The idea that these issues are constantly going to be popping up throughout my life is pretty awesome.

It was good to sit around and talk about these things. There were two other things we did (one was somewhat related to the Schiavo case) and it was fascinating to hear what some people had to say. Even people that I would have figured to be completely set in their opinions seemed to have their foundations rocked when there was no clear right answer. I suppose this is what hospital ethics boards are for- letting doctors pass difficult decisions by a group of people who will mull it around for hours.

Also interesting is the fact that though it was emphasized several times that there were “no right answers” to these questions… but in the end, a choice will still be made. “I don’t know what I’d do” is no longer a viable answer. Chew on that for a while .

God I love medical school. This is what it feels like when you know you’ve made the right decision.

Well, apologies for not having written for a week, but we’ve been pretty much back at the grind.

Turns out that the “delivering bad news” class wasn’t a week ago (that was a standard high-risk interview. Mine went pretty well, though the initial 5 questions still seem pretty stunted and difficult to ask for me- name, age, hometown, doctor, sex), it was yesterday. And man, was it intense.

I figured I’d go first out of our group of 6, because I was so nervous I just wanted to get it over with. In terms of scenarios to get, I got pretty lucky- I had to tell a woman her cancer biopsy came back positive. She was in denial about it (they teach us a bunch of standard defense mechanisms… one being “I can’t have cancer, I’ve lived a healthy and fulfilling life up until this point! I eat well! I exercise readily! Check the test again! I want a different doctor!”), so I had to tell her that we were extremely careful and it was, in fact, cancer, and we’d have to start a treatment regimen. It certainly wasn’t fun, but it wasn’t that bad.

The next person got the woman whose chemotherapy had stopped working, and she had less than a year to live. The woman started sobbing. She didn’t know what her family would do without her, wasn’t ready to die, was too young to die… I mean, it was ROUGH. The next guy got the patient whose spouse had died on the operating table… and he definitely got yelled at. “YOU DIDNT DO ENOUGH! YOU AREN’T SORRY, I’M THE ONE THAT’S SORRY, I HAVE TO LIVE WITHOUT HIM FOR THE REST OF MY LIFE”.

So, anyway. Fun times. We got to deal with all the nasty stuff that happens when medicine goes wrong in a concentrated hour and a half. My stomach was a bit knotty after the whole thing, really. Not so sure that oncology is going to be my bread and butter after that. Oh, by the way… these were standardized patients, not real ones. Still, its very realistic… the woman who was sobbing was actually crying, and the one screaming was yelling and cursing at the top of her lungs.

Interesting, though, playing the role of arbiter of truth. They had to tell us that we can’t really sugar coat stuff any more. If someone has a year to live, you don’t tell them they have 5. If someone gets diagnosed with HIV, has never done IV drugs, and has only ever been with their highschool sweetheart… you’d better believe that the highschool sweetheart has been doing more than sitting at home watching soap operas.

2 weeks until the MSFC conference! I’m heading out to LA to learn more about contraception and women’s health- should be fun. A couple other students have already been to conferences (Universal Healthcare, College of Surgery) and they’ve had a pretty great time so far. It’s pretty sweet to have someone else pay for your traveling, just because they think it’s important that you learn something.

So I’m a bit nervous about tomorrow. Not only do we go back to the grind (week of vacation, how I loved you), but I have to deliver bad news. Yep, that’s right, I get to “learn” how to tell someone that their wife died, or they have cancer, or whatever. Fun times, I know. I suppose you have to do it sometime.

What’s scary is rumor has it that 1 of the 6 students gets the violent patient. Not physically violent (they leave that for the wards) but screaming, yelling, “I CANT BELIEVE YOU’D DO THAT, THIS ISN’T HAPPENING TO ME” sort of craziness. Not so much that I’m worried it’s going to be me… 1 in 6 aren’t great odds. It’s more that they keep throwing these things on us (remember the high-risk behavior entry from before?) and it just keeps escalating. This time I get to tell someone that they are going to die. We’re going to get instructions beforehand, of course- the calculated, empathetic touch, the words of condolence….

I guess I still have to figure out what level of personal emotion there should be. I mean, I’m nowhere near the wards yet, haven’t actually done any care on my own, so in part this is all idle speculation until I do (I’m volunteering for a glaucoma clinic 2 weeks from now). Some people say that the doc is there to give information, and needs to be a rock that the patient can depend on for information. Others hate that idea, and think you should cry WITH the patient.

I have no idea. I haven’t been through enough of this to be able do to more than throw out the worries that I have. Person? Deliverer of facts? Caregiver? Somewhere in between? There are a lot of things you’ve got to start to ask yourself when you deal with people’s lives on a daily basis.

I suppose I could also sidestep the whole issue, go and be a pathologist, or a radiologist; someone who ends up doing the patient-less work. I know that’s not why I wanted to go into medicine, though.

Still and all, it’s hard to wrap your head around the realization that at some point, you could be desensitized to death. Obviously it depends on your profession (a high-risk cancer doc is going to have to counsel a lot more dying patients than, say, a family practitioner), so maybe this is all idle speculation. Maybe you don’t lose that, no matter how much you go through it. I’d like to think so. I’ve heard too many people say otherwise.

Call me up in 5 years, ask me where I am. That’s the real question, I suppose. Who will I be after all of this?