Agraphia Medical Tragicomedy

A Tightly Coiled Spring

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.

Dust To Dust

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.

The Unintended Side Effect Of Morbid Obesity

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?

The Breaking Point

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.

It’s OK To Die

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.