Tuesday, August 31, 2010

You are all going to die.

That's the gist of my last month's work. I am finally done with helping patients die. From now on, I will be no help whatsoever in the dying process.

Ok, maybe that's a little dramatic.

It has been a very long time since I last posted. That is because my job sucked. Sure, there were moments where I felt like I'd helped a family. Or even a nurse, like when the S(urgical) ICU nurse asked me, "If we disconnect the monitors (which is something we do when people are dying so their families can hug them or get close to them or actually look at them without the monitors constantly reminding them that their loved one is circling the drain), how are we going to know when the patient is dead?"

Are you flipping kidding me? "Well, people have been dying since before we had monitors. Surely we'll find a way to figure it out. By the way, I'd like to introduce you to something I call the "Physical Exam."

I think he learned something that day.

To be more grotesque, you may not know the second someone has died. Their breathing is usually apneic (meaning long irregular pauses between breaths). I saw a guy go a minute and a half without breathing. I thought he was gone and stepped up to pronounce him, but then all of a sudden he took a huge gaspy breath. Geez. Now I wait outside until a nurse (who doesn't need monitors) comes to get me. I can't take the suspense.

Anyway, you may not know which is the exact last breath, but you know as soon as you walk back into the room. People change color. They look different. Not "oh he's on death's door" different, they're there already. I mean it is unmistakable and indescribable.

And on that note, I'm going to bed.

I'm currently on Radiology, which is AMAZING, then night float, which will probably give me some great stories about the batshit crazy. I still have some up my sleeve for this month; I just tried to forget work as soon as I got home. I got tired of having nightmares every night.

Tuesday, August 3, 2010

Dear Chiefs

Dear Chief Residents,

I'd like to take time out of my hectic life to thank you for this F#$% of a schedule.

I can tell you really put a lot of thought into what I might want to learn during this year. For example, how little you care about anyone who isn't going to do Internal Medicine for the rest of her life.

The ICU was a great place to start for someone who didn't go to medical school at this institution. Especially when she's the only intern on the service due to a little scheduling oversight (Oh, she'll be fine covering the work of two interns! )I got to spend several FANTASTIC hours those first three days learning both the computer system and how to manage 5 patients who were on the brink of crashing. Nothing like learning how to write an order when every order you make could tip a patient over the edge. What a thrill! I'm soooo looking forward to the next ICU month you scheduled me for (and I am so grateful for the chance to do TWO ICU months, when the other interns are only supposed to do one!)

Man, just when I thought things couldn't get any better, I switched to Palliative Care. Nothing like watching people die for 9 hours a day six days a week. It was such an intuitive place to put an intern who neither requested the experience, nor ever hinted that she liked patients in the first place! I'm sure you saw the fact that I was going into Radiology and just knew I was a lady who wanted to get in touch with her feelings. It's tons of fun for the attendings on the service too! I think they enjoy watching me cry several times a day--so much that they sent me home early for not handling things well! This really gives them a chance to focus on doing their job taking care of interns...I mean patients.

Well, I guess I better go get some sleep. The nightmares I've been having since all my patients started dying keep me pretty busy at night! I sure as heck don't want to be so tired I miss anything tomorrow, like the ability to control my emotions!

Thanks again for not following the ACGME recommendations for a pre-radiology clinical year! I'm sure I'm going to look back on all of this and think about how great of a time I had learning how much a real Medicine residency blows.

Your Pal Al

Monday, August 2, 2010

Oh Beverly.

It's my one day off out of the week, and a patient that I have taken care of from my very first day is leaving.

This lady was a doozy. None of my co-residents could understand why I was attached to her. I don't really understand it either I guess, but she was another patient who started out with one illness that snowballed until months later she was three weeks in an ICU stay that never should have happened. At one point she was my only patient who wasn't dying. She had a husband who visited every single day for the entire day, even after he found out she may have cleaned out their bank account in a manic spending spree.

Yet in an ICU full of patients who were either going to get better or get worse, she was the for whom I might make a difference.

Beverly was the same age as Peggy. She didn't use to run marathons, I'm pretty sure she used to eat too much and boss her husband around. You don't get to eat on a ventilator (so you basically get Ensure shakes down a tube in your throat, but on her clear days she could definitely boss her husband around.

She didn't have a lot of clear days. She had a bad case of ICU delirium, complicated by the fact that when she first came to the hospital, her home psychiatric medications (anxiety, depression, etc) were held. By the time I took over her care, she'd been without them for a week. We would NEVER recommend stopping psych meds cold turkey to a patient in the clinic. Or on a psych ward. All of a sudden, just when you're super stressed by being in a hospital, we've held the medications helping to keep your brain chemistry regular . Why patient's psych meds get routinely held when they come to a hospital is beyond me. After having seen what she went through, I'll never forget it.

I didn't figure out that she was supposed to be on these meds for another week. I was not informed by the team leaving the service, and the records were buried in a paper transfer from her previous hospital. Once we got Psychiatry on board, things started to improve, but it took another week to really get enough clear days to move her out. She couldn't go home anymore. I know it bewildered her husband. Before the surgery, she was fine. Then all of a sudden she can't get off a ventilator, she can't eat on her own and needs a tube coming out of her stomach, doctors are throwing around the words "Long Term Acute Care Hospital", and the wife he thought was healthy might not ever be home again. And I couldn't deny it. After we lost Peggy I couldn't tell him she'd ever be herself again.

Anyway, the nurses didn't see the story like I saw it. I think instead of feeling responsibility for holding her psych meds and possibly triggering the delirium, they saw a patient who could wave her arms for HOURS and a frustrated husband who constantly asked questions they couldn't answer. They really did have to deal with the brunt of her behaviors.

We were all set to send her to that care facility on a Friday (where it was less expensive, it was closer to home, and they were much better at handling ICU delirium), when she had a little problem with her feeding tube. Friday turned into a weekend when she didn't get physical therapy (they don't work weekends in this hospital), which was also the weekend that a particularly dumb shit of a psychiatry resident was on call. In the five minutes he saw her he managed to ask her every offensive psych question possible (so where do you get treated for your psychosis when not here?) and write a note that I would have spit on as a first year medical student ("Patient is going through a lot of medical stuff"). That agitation gave her another round of delirium, setting her back another WEEK.

So Thursday, when her PEG tube clogged, I knew the LTACH wouldn't take her if that tube weren't working. I felt like if she didn't get out Friday she wouldn't get out. Probably dramatic, but I didn't know who was on call for Psychiatry that weekend. "You have to get this done." my attending said, meaning I had to browbeat the interventional radiology team into taking her. "Yeah, wear your ovaries on the outside today," the fellow added.

It took hours of pleading and phone calls, some of which were spent convincing a male tech down in the department that I was the patient's DOCTOR, not nurse, before I finally told them my attending was going to yell at me if I didn't get it done and I just didn't know what to do. The lady on the other end was silent, then asked who my attending was. "Sampson." I said. "Oh. He will probably yell at you. Let me call you back."

Long story short, her feeding tube was fixed, and she went out. I have no idea if that will be the last time I see her, but I do know that she and her family were the first people I really felt like I made a difference for. In a month where most things are out of my control, I actually felt like a doctor.