It's a cold, quiet night, and my current rotation has me on clinic, so I'm not anxiously awaiting the pager. So naturally I'm reflecting. The last nine years have changed me, as I related here, and I've achieved at least one dream in being a cardiology fellow. But tonight, I came across a poem by Sassoon that brought me back to my third year as a medical student, watching a patient die for the first time. The poem, which you should read (assuming I still have any readers, and you care) is called The Death Bed. The part that got to me is this:
Light many lamps and gather round his bed.
Lend him your eyes, warm blood, and will to live.
Speak to him; rouse him; you may save him yet.
He’s young; he hated War; how should he die
When cruel old campaigners win safe through?
But death replied: ‘I choose him.’ So he went,
And there was silence in the summer night;
Silence and safety; and the veils of sleep.
Then, far away, the thudding of the guns.
It is perhaps an open secret that I did several of my medical school rotations in military hospitals, and the perspective I have on war is perhaps more visceral than that of most who haven't been in one. I've never been shot at, but seven years ago, I watched someone who had go through the lines above. It seemed pointless. I probably tried to write the poignancy of the scene, which happened literally minutes after the news station (filming a special on the soldier and his pregnant wife, carrying a baby he would never see) turned off the cameras and walked away. But I am not the writer he deserved. Sasson was.
I wonder what he accomplished. What he saw as the great purpose of his nearly two and a half decades of life. I realize that, as a modestly terrified med student on surgery, I knew far, far more about his vital signs than whatever it was that made him truly vital, truly human. But I wanted to lend him my will to live, nonetheless. I still do.
My last few posts talked about moving away from the direct experience of patients and more into management. I now know that process is what friends warned me against when saying "don't let them change you" as I shuffled off to yet another school that summer in 2003. The change creeps up without the changed noticing how great it is. But sometimes the realization breaks through and a refreshing of humanity comes back.
So it is good tonight to sit in silence, far away, and weep for a soldier.
Monday, November 28, 2011
Saturday, July 03, 2010
Fellow
I've begun my cardiology fellowship. Though my efforts here may not reach their former level, in many ways, this is a beginning anew of the residency process. I am again at the base of a long totem pole, with vast amounts of learning to acquire. Hence, I feel the need to write again.
The first day wasn't terrible. However I did send one patient to the ICU, made two big mistakes while running a treadmill test, and received instruction in no uncertain terms regarding my deficiency there.
Just like being an intern.
The first day wasn't terrible. However I did send one patient to the ICU, made two big mistakes while running a treadmill test, and received instruction in no uncertain terms regarding my deficiency there.
Just like being an intern.
Saturday, December 20, 2008
Resident
The bildungsroman that is this blog has been quiet, and perhaps dead, for sometime now. I'm not certain why this has happened, but I think the reason is at least three fold.
First, as I've progressed into second year, I've found that I depersonalize my patients more. This sounds horrible, so let me explain. As an intern, I was responsible for anywhere between six and ten patients at a time, and my one job was to talk to them, find out what was going on, and report it. So I spent a lot of time talking to them. Now, as a resident, I have anywhere from two to three interns below me on the totem pole, and hence I'm less able to spend time with the patients, because I'm listening to the intern's reports, and then formulating plans and managing people. Managing people isn't touching, usually, and it makes for poor stories. So I haven't told them.
Second, and maybe most importantly, I've run out of time. My workload keeps getting heavier, and I haven't got the time to work, sleep, play, and write the blog.
Lastly, I think the journey this chronicles is complete. I am not a finished person, by any means, but I have made the transition from medical student to physician, and for the same reason there's never a story beyond "happily ever after" I've run out of stories.
Which isn't to say I won't be back. The conflicts and triumphs of the future may well be worth setting down, but for now, I've run out of steam. Thanks to all who encouraged me on my way, I will miss hearing from you.
Pax vobiscum.
First, as I've progressed into second year, I've found that I depersonalize my patients more. This sounds horrible, so let me explain. As an intern, I was responsible for anywhere between six and ten patients at a time, and my one job was to talk to them, find out what was going on, and report it. So I spent a lot of time talking to them. Now, as a resident, I have anywhere from two to three interns below me on the totem pole, and hence I'm less able to spend time with the patients, because I'm listening to the intern's reports, and then formulating plans and managing people. Managing people isn't touching, usually, and it makes for poor stories. So I haven't told them.
Second, and maybe most importantly, I've run out of time. My workload keeps getting heavier, and I haven't got the time to work, sleep, play, and write the blog.
Lastly, I think the journey this chronicles is complete. I am not a finished person, by any means, but I have made the transition from medical student to physician, and for the same reason there's never a story beyond "happily ever after" I've run out of stories.
Which isn't to say I won't be back. The conflicts and triumphs of the future may well be worth setting down, but for now, I've run out of steam. Thanks to all who encouraged me on my way, I will miss hearing from you.
Pax vobiscum.
Monday, July 28, 2008
Hope
"My one question is, can I have this at home?"
Those were almost the last words he said before we put the endotracheal tube down his throat and started breathing for him. Mr. Baker was an old, old man with lungs that had pretty much given up on him. Thanks to the miracle of modern medicine, he now has at least a few weeks of drug-induced sleep ahead of him before he can rest eternally.
I've not been able to get those words out of my head, or the next ones, a muffled repetition of "stop, you're hurting me" to the anaesthesia resident who was clamping a bag mask over the man's face prior to intubation.
I like the guy, a lot. It had been a while since I had liked a patient, since I've spent the last month or so in the ICU, dealing with the surprising tide of alcoholics, drug abusers, and the merely testosterone poisoned who wind up, along with the occasional patient rescued from the clutches of the surgeons, on the MICU team.
The work itself is exciting. It's been amazing to see what is possible, and at the same time, I'm now the resident, responsible for supervising the interns, which is more work than I expected.
I wanted to write about that. About how I've been following orders for so long, I hadn't realized I knew anything. About how I've come to realize how much I have learned, and about how much there is left to learn. But "stop it, you're hurting me" was the first thing that really seemed important enough to write.
A lot of this month has been hellish. I've realized that, no matter how good they are with knives, a lot (I'm tempted to say most, but I do have a limited perspective here) surgeons are absolutely clueless where complicated medical problems are concerned. Most than one patient I've managed this month had their conditioned worsened by a surgery resident, and in at least one case, the surgery team managed to induce both diabetic ketoacidosis and a myocardial infarction in the same patient. I've realized that seemingly competent medicine interns still have to watched like a hawk by their medicine residents. And I've learned that even I can make mistakes.
I've changed. The show-cynicism of internship is now mostly heartfelt, as I start to see the same cases of self harm, sometimes even the same patients, and I feel the helplessness than undergirds all of what we do.
This was in even sharper perspective somehow the month before, on the heme/onc service, where I realized that all we are offering people with medicine is time. No one cures anyone. We treat and postpone, but rarely cure. Even when we do, for instance saving the third Tylenol overdose of the month with some well timed N-acetyl cystine, I know the fourth is right around the corner. And who knows, this one may come back with more success in her strivings at a later date.
I treated him, God healed him
In the last analysis, that's really all anyone is doing, even outside of medicine. The gas station attendant, the bus driver, and the coffee shop owner are all united with the physician in that all we are doing is allowing others to continue their lives. Some lucky individuals may even help improve them.
Which is of course the point, and it's what keeps the cynicism at 3am while admitting the fourth intubated overdose patient of the night from becoming full blown despair. We're all here to help people, to love our neighbor as ourselves, in the manner we're most fitted to do it. And if I can maybe relieve a little of the pain I see, and maybe give these people and their families a little more time, I will have succeeded.
I hope, or I could not live.
Those were almost the last words he said before we put the endotracheal tube down his throat and started breathing for him. Mr. Baker was an old, old man with lungs that had pretty much given up on him. Thanks to the miracle of modern medicine, he now has at least a few weeks of drug-induced sleep ahead of him before he can rest eternally.
I've not been able to get those words out of my head, or the next ones, a muffled repetition of "stop, you're hurting me" to the anaesthesia resident who was clamping a bag mask over the man's face prior to intubation.
I like the guy, a lot. It had been a while since I had liked a patient, since I've spent the last month or so in the ICU, dealing with the surprising tide of alcoholics, drug abusers, and the merely testosterone poisoned who wind up, along with the occasional patient rescued from the clutches of the surgeons, on the MICU team.
The work itself is exciting. It's been amazing to see what is possible, and at the same time, I'm now the resident, responsible for supervising the interns, which is more work than I expected.
I wanted to write about that. About how I've been following orders for so long, I hadn't realized I knew anything. About how I've come to realize how much I have learned, and about how much there is left to learn. But "stop it, you're hurting me" was the first thing that really seemed important enough to write.
A lot of this month has been hellish. I've realized that, no matter how good they are with knives, a lot (I'm tempted to say most, but I do have a limited perspective here) surgeons are absolutely clueless where complicated medical problems are concerned. Most than one patient I've managed this month had their conditioned worsened by a surgery resident, and in at least one case, the surgery team managed to induce both diabetic ketoacidosis and a myocardial infarction in the same patient. I've realized that seemingly competent medicine interns still have to watched like a hawk by their medicine residents. And I've learned that even I can make mistakes.
I've changed. The show-cynicism of internship is now mostly heartfelt, as I start to see the same cases of self harm, sometimes even the same patients, and I feel the helplessness than undergirds all of what we do.
This was in even sharper perspective somehow the month before, on the heme/onc service, where I realized that all we are offering people with medicine is time. No one cures anyone. We treat and postpone, but rarely cure. Even when we do, for instance saving the third Tylenol overdose of the month with some well timed N-acetyl cystine, I know the fourth is right around the corner. And who knows, this one may come back with more success in her strivings at a later date.
I treated him, God healed him
In the last analysis, that's really all anyone is doing, even outside of medicine. The gas station attendant, the bus driver, and the coffee shop owner are all united with the physician in that all we are doing is allowing others to continue their lives. Some lucky individuals may even help improve them.
Which is of course the point, and it's what keeps the cynicism at 3am while admitting the fourth intubated overdose patient of the night from becoming full blown despair. We're all here to help people, to love our neighbor as ourselves, in the manner we're most fitted to do it. And if I can maybe relieve a little of the pain I see, and maybe give these people and their families a little more time, I will have succeeded.
I hope, or I could not live.
Tuesday, May 13, 2008
In conversation
"You know doctor, we put down my little poodle last week. I'm still in mourning, but what got me thinking was my husband. We took her little body out to a field to bury her, and he said 'it's a shame she can go like this, the shape we're in, but there's nothing similar for us, with all our problems.' And you know doctor, I'm not sure he's not right. Look at me, all the money people spend on me keeping me going. And all I have left is my china to paint."
It is a young man's conceit that the world is for the young. But people like Mrs. Parkin, who made that declamation as she walked through the door on the way out, force me to wonder about the ends of life. My life now is so centered on doing, on accomplishing, on driving hard to meet ends, that a time without ends, without accomplishment, where I measure success in terms of a hobby, is inconceivable to me.
Looking at the impressive list of maladies plaguing my patient, my entreaties to reconsider her assessment were not wholehearted. She is a life lesson in morbid anatomy, a walking textbook of internal medicine. Diabetes, heart failure, hypertension, obesity and all the complications thereof. Most depressing is that she's reached the point where we can't do anything for her. While weight loss would help, she can't exercise because of her heart failure and hypertension. And until she gets those under control, she can't get gastric bypass.
I've reached the point in my intern year where most the common things are becoming automatic. I can cite studies and counsel this patient for any of her problems individually. But the big picture, the pitiful living compendium of pathology that modern medicine allows still saddens and confounds me.
It is in discussing these patients that the macabre side of the intern comes out. When we toss these stories around the intern work room, everyone has a different reaction, but at the same time, our core thought is the same. While one person may declaim "that's why I exercise" and another "that's why I sky-dive" the underlying conviction is "that will never happen to me." The black humor and macabre attitude hides our discomfort. The discomfort comes from facing our own mortality through the lives of our patients.
All flesh is grass, and all the goodliness thereof is as the flower of the field
Even so, I'd like to leave something more permanent than painted china behind. Something more than the accumulated bits of plastic which mark my life as a twenty-first century man. But I'm thinking it's really only the effect we have on others that we can hope to leave behind. Mrs. Parkin's china may not survive the ages, but it certainly reminds me of the desperate sadness all around me. And though I failed to do more than smile sadly with her, next time, I'm going to be five minutes late for my next appointment.
It is a young man's conceit that the world is for the young. But people like Mrs. Parkin, who made that declamation as she walked through the door on the way out, force me to wonder about the ends of life. My life now is so centered on doing, on accomplishing, on driving hard to meet ends, that a time without ends, without accomplishment, where I measure success in terms of a hobby, is inconceivable to me.
Looking at the impressive list of maladies plaguing my patient, my entreaties to reconsider her assessment were not wholehearted. She is a life lesson in morbid anatomy, a walking textbook of internal medicine. Diabetes, heart failure, hypertension, obesity and all the complications thereof. Most depressing is that she's reached the point where we can't do anything for her. While weight loss would help, she can't exercise because of her heart failure and hypertension. And until she gets those under control, she can't get gastric bypass.
I've reached the point in my intern year where most the common things are becoming automatic. I can cite studies and counsel this patient for any of her problems individually. But the big picture, the pitiful living compendium of pathology that modern medicine allows still saddens and confounds me.
It is in discussing these patients that the macabre side of the intern comes out. When we toss these stories around the intern work room, everyone has a different reaction, but at the same time, our core thought is the same. While one person may declaim "that's why I exercise" and another "that's why I sky-dive" the underlying conviction is "that will never happen to me." The black humor and macabre attitude hides our discomfort. The discomfort comes from facing our own mortality through the lives of our patients.
All flesh is grass, and all the goodliness thereof is as the flower of the field
Even so, I'd like to leave something more permanent than painted china behind. Something more than the accumulated bits of plastic which mark my life as a twenty-first century man. But I'm thinking it's really only the effect we have on others that we can hope to leave behind. Mrs. Parkin's china may not survive the ages, but it certainly reminds me of the desperate sadness all around me. And though I failed to do more than smile sadly with her, next time, I'm going to be five minutes late for my next appointment.
Monday, April 07, 2008
Growing old together
Twenty years hence my eyes may grow,
If not quite dim, yet rather so;
Yet yours from others they shall know,
Twenty years hence.
Last week in clinic I saw a couple in a joint appointment, and in the course of conversation, I discovered that they were about to celebrate their 60th wedding anniversary. What touched me about the discovery was how very much in love they still seemed to be. When I encouraged the wife to be sparing in her use of narcotic pain relievers for her chronic back pain, her husband jokingly chided her, calling her "you drug addict," but with a twinkle in his eye that made the sarcasm obvious.
"60 years of gentle harassment?" I inquired.
Before the husband could say anything else, his wife replied: "Best decision I ever made. And I figure we're good for another 15 or so."
I've been smiling all week remembering the look they gave each other at that point.
If not quite dim, yet rather so;
Yet yours from others they shall know,
Twenty years hence.
Last week in clinic I saw a couple in a joint appointment, and in the course of conversation, I discovered that they were about to celebrate their 60th wedding anniversary. What touched me about the discovery was how very much in love they still seemed to be. When I encouraged the wife to be sparing in her use of narcotic pain relievers for her chronic back pain, her husband jokingly chided her, calling her "you drug addict," but with a twinkle in his eye that made the sarcasm obvious.
"60 years of gentle harassment?" I inquired.
Before the husband could say anything else, his wife replied: "Best decision I ever made. And I figure we're good for another 15 or so."
I've been smiling all week remembering the look they gave each other at that point.
Thursday, March 13, 2008
Denial
The certainty of death is attended with uncertainties...
Mrs. Harding is not the kind of woman who seeks help.
She tripped over a dog's leash and fell down the short flight of wooden stairs from her balcony to the grass and discovered she was unable to rise. Despite some pain, she managed to drag herself back inside, and into her bed, where she was when her family returned home. As they had a spare wheelchair around, she just adapted to using it to get around as attempting to walk caused her excruciating pain.
That was six weeks ago. She hasn't walked since then, but her family took her to the hospital against her will finally because she stopped eating. They convinced her, eventually, that going to the hospital, being admitted, and doing everything medically possible was the best course. I'm not sure they were right.
I did a physical exam prior to admitting her, noting her to be dehydrated, malnourished, and unable to move her externally rotated and shortened right leg. She had no medical records because she could not remember the last time she had been to a doctor.
Incidentally, I noticed that most of her upper right chest wall was being eroded away by an obviously cancerous lesion. I asked her how long she had noticed something wrong with her skin there, and she told me "a few years." She hadn't shown another soul.
This kind of story has no happy ending. Trying to fix the broken hip revealed that what was left of the hip socket was a massive abscess, necessitating drainage and debridement, but no hardware to fix the problem. It also dislodged a clot, which went to her brain and cut off blood to the entire left hemisphere rendering her unable to speak clearly or move the right side of her body. Treating the stroke with blood thinners caused her to bleed into the surgical site in her leg. In the end, there was nothing we could do except hope her stroke left her unaware of her last days.
All I could think about through the last days was her last words to me before her family convinced her to change her mind: "just let me go home to die."
I wish we had.
Mrs. Harding is not the kind of woman who seeks help.
She tripped over a dog's leash and fell down the short flight of wooden stairs from her balcony to the grass and discovered she was unable to rise. Despite some pain, she managed to drag herself back inside, and into her bed, where she was when her family returned home. As they had a spare wheelchair around, she just adapted to using it to get around as attempting to walk caused her excruciating pain.
That was six weeks ago. She hasn't walked since then, but her family took her to the hospital against her will finally because she stopped eating. They convinced her, eventually, that going to the hospital, being admitted, and doing everything medically possible was the best course. I'm not sure they were right.
I did a physical exam prior to admitting her, noting her to be dehydrated, malnourished, and unable to move her externally rotated and shortened right leg. She had no medical records because she could not remember the last time she had been to a doctor.
Incidentally, I noticed that most of her upper right chest wall was being eroded away by an obviously cancerous lesion. I asked her how long she had noticed something wrong with her skin there, and she told me "a few years." She hadn't shown another soul.
This kind of story has no happy ending. Trying to fix the broken hip revealed that what was left of the hip socket was a massive abscess, necessitating drainage and debridement, but no hardware to fix the problem. It also dislodged a clot, which went to her brain and cut off blood to the entire left hemisphere rendering her unable to speak clearly or move the right side of her body. Treating the stroke with blood thinners caused her to bleed into the surgical site in her leg. In the end, there was nothing we could do except hope her stroke left her unaware of her last days.
All I could think about through the last days was her last words to me before her family convinced her to change her mind: "just let me go home to die."
I wish we had.
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