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.

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.

I haven’t posted much lately because honestly, I’ve gotten into a routine. Not a particularly good one, but a routine nonetheless. Usually it involves waking up just before a shift, seeing a ton of patients and burning out halfway through my workday, and then slinking back home, too tired to even think about doing anything social. It’s boring and it’s a far cry from the “fun” that I was having earlier in residency.

I think it’s simply a function of working too damn hard. 80 hours a week is TOUGH – especially hours spent in the Emergency Department. I know there are people out there who work harder, and others that would kill for my job, but it doesn’t change the fact that I’m exhausted.

Rolling into the ED today (a “big boy” shift, as I affectionately call it… our Level I Major Trauma / Major Resuscitation unit) I was tired. And hungry. And caffeine-deprived. Dreading 10 hours of nonstop traumas and dying patients.

And the most amazing thing happened. One of the nurses had an extra cup of coffee. Another resident had a leftover PB&J sandwich. To top it off, not a single patient came in to the ED for 20 minutes, so I had several delicious moments of pure, unabated downtime. The traumas started rolling in. And I was on my game.

I saved 3 lives today. Me, personally. I intubated 2 people who couldn’t protect their airways, and saw another patient who was rapidly becoming hypoxic from a huge fluid buildup around her lungs. She was heading very quickly towards intubation, but instead I stuck a needle through her back, drained off 1.5 liters of fluid off her lung, and got her back to breathing normally.

I left work today with a smile. Little ‘ol me, saving the world one life at a time. I’m excited to go back tomorrow.

A gem from a recent dictation on a patient of mine:

[The patient] initially denied recent substance abuse, but, when confronted with a positive urine drug screen, says she “had sex with a man who uses drugs” and then finally admitted to smoking crack cocaine last night. She says her use is mainly confined to “weekends”, though, of course, last night was a Tuesday.

Seeing the horrible stuff my patients go through makes me appreciate what I have even more.

Right now I’m sitting at my breakfast table, fresh brewed kona coffee steaming in my favorite mug, eating a feta and shredded chicken omelette I made for myself. Music blares through my speakers, all my windows are open and the weather is perfect.

Can’t ask for more than this.