Quality or Quantity?

I've had occasion to consider this with one of my patients. She is only a few months old, but she suffered some considerable complications during or before her birth, it isn't clear which. She will likely never progress from her current state, which is that she can swallow, weakly and only occasionally, she cannot protect her airway, so she aspirates food into her lungs, and she suffers recurrent seizures. She has an EEG displaying burst supression, which is just one step removed from brain dead. In a particularly difficult patient encounter, our pediatric neurologist told the father that, though pediatric brain injury prognosis is difficult to predict, his daughter would likely never feed herself, walk, comunicate, see, hear, or even have a thought. The father's response was "why didn't you kill her along time ago then?"

Though of course actively euthanizing patients in prima facie wrong, I don't know that answer is a good one. Should patients with no hope of recovery be kept alive like this? It's not like that media circus Terri Schiavo case, here the patient has never interacted with anyone. She was born unresponsive and displays nothing but the most primitive of reflexes now. She is only alive because of medical miracles and heroic support measures undertaken at birth, but right now, she doesn't need anything but a tube feed. The argument against letting Mrs. Schiavo die was that a tube feed is not a heroic measure. But I think that's a poor one in this situation.

True, it isn't heroic, but what is heroism but defense of a worthy cause? I'm no longer able to say I believe life is, in the abstract, a worthy cause. I don't know what is. What is it that makes a life worth defending? How do we define "humanness" here? "In the image of God we are made" but how much of that image is interaction, is thought, is contribution, is soul? And how much is the "crude matter" which comprises our physical form?

On the Bright Side

I'm no happier with the way this rotation is going. But there are two shining lights here. One, there are only two more days left with this part of it, and two, this part of it is not a disproportionate part of my grade. I would add that three is the fact that I get to review all the people involved, but a) I don't think that matters to my grade much and b) I'm too nice to really say anything like the cathartic pen-lashing I'd desire.

Ha!

One of Those Days

Some days, nothing goes right and your computer account that allows you to look up patient information (and which has been "in the works" according to the tech support people) is still broken after a week of pestering. Some days your chief resident calls you aside and kindly but frankly says she has concerns that you're even functioning as a low-level third year student, much less one about to enter fourth year. Some days your senior resident makes a point of reprimanding you in front of your intern, your chief and your attending.

Some days, I hate my job. This is one of those days.

One of those people

I was not on top of my game this morning. No excuses, I was just off. Way off.

So, on rounds this morning, I'm trying to relate the stories of each patient to the team. This is kinda funny, since everyone already knows what's going on, but more on that later. I started off with a patient I had just picked up and hadn't read about real thoroughly.

It showed.

I started with "this is a 2 year old male who presented with an acute exacerbation of asthma" and I didn't get any farther. My resident spoke up with "um, no..." and my attending jumped in with "this is unacceptable, you're wrong with the chief complaint."

See, this patient had actually come in because he had a seizure. No asthma, and he wasn't quite 2 either. I was reading the wrong notes.

I managed to piece something relating to him together, but I floundered, bad. "But," I thought to myself, "I have two more patients to redeem myself with."

This is what authorities refer to as "wishful thinking."

Patient number two is up, and I get a little farther. I manage to have the name and age right, and I even have her reason for being in the hospital down. I'm starting to relax, just glancing at the notes, when I say "an attempt was made to start a peripheral IV, but it failed, so she still has a scalp IV." This time the resident comes in with "I think you're a day behind. I placed a peripheral IV yesterday," and my attending, losing his patience with my idiocy, asks "did you even see the patient?"

Truth is, I had. It was just 6am, I'd had four hours of sleep, and I talked with her family for half an hour after my examination. I completely missed the missing scalp IV, and I just read what had been written in yesterday's progress note. This doesn't matter though, because if you can't be trusted to see, or rather note not seeing a tube 8 inches long taped to the side of your patient's head, you can't really be trusted for much.

In hindsight, this is funny.

The third patient actually went ok, I got everything right, but by that time, it was too late. I can only hope my attending and resident don't hold this one against me.

The whole experience has taught me that you shouldn't ever be too sure of yourself. You can always wind up as "one of those people."

Loveliest of trees, the cherry now
Is hung with bloom along the bough,
And stands about the woodland ride
Wearing white for Eastertide.

Now, of my threescore years and ten,
Twenty will not come again,
And take from seventy springs a score,
It only leaves me fifty more.

And since to look at things in bloom
Fifty springs are little room,
About the woodlands I will go
To see the cherry hung with snow.

-- A. E. Housman

Sometimes parents are the problem

One of the kids on our team is probably suffering the effects of Munchausen syndrome by proxy. The only way this kid could be suffering the problems she has is if her mom is injecting the child's own feces into her IV. She keeps developing new infections, which can only come from her stool, and even swallowing the feces wouldn't cause the symptoms she has. The problem is that we can't surreptitiously put a camera in the room to watch, and having a nurse in the room at all times isn't feasible either, because we're short staffed, and it probably wouldn't make a difference because the mother has succeeded in perpetuating the child's illness while she is in the hospital, so she's pretty good at being sneaky with this. So we can't prove it, we can only treat the child, and she's not going to get better if this continues.

The other problem is that this is a very, very serious accusation, and we can't really make it unless we have proof. And we can't have proof unless someone actually sees the mother doing this. It isn't enough, legally, that when the child's grandmother stayed in her room to give the mother a break, the child got better, only to worsen when grandma left. It isn't enough that she is continually being reinfected with bugs that are susceptible to the drugs we're already giving her. It may prove the diagnosis to us, but that's not enough. At least according to my attending.

I don't like bureaucracy, I don't like feeling guilty no matter which course I choose. I just hope this mother is caught.