The one patient, my favourite patient said to me, "Thank you, really, thank you -you doctors, you really saved my life!" and smiled with a twinkle in his eye. And then I was back in the ER, excited to do my second blood gas and boom, within 20 minutes, that other patient went from clutching my hand to dead -without warning, without family, without anyone to hold his hand. Just like that. And then there was jazz playing inside the window and cold drinks melting on the patio table, and the deep sigh. Prayers today. I nearly cried, I felt so sad and I didn't know why. It's warm, the air still fragrant with spring before the theoretical lazy bliss of summer. All of this impacted and compacted into a splinter of time, a moment's hair, the poo of the invisible speck that we are in this Universe. It's kind of unreal.
Days like today make you want to retire from it all. Friends moving away from their own cities, not even your own, and yet, you feel sad as though they were leaving you. Patients dying and you feel so shocked, when you know that this is part of your job -people die, just deal with it. But they were in pain, and they were sick and oh, they suffered like hell before the end. And you feel like the fact that it happened that way is like a violation of your own soul. And tonight the deep sigh doesn't reassure you, nor the deliciousness of your dinner. Because all you want is the embrace, the caress, the hand holding yours, someone telling you that it's going to be okay. So that you can still tell your patients the same, without feeling like it's all a lie. But that's the thing. Doctors hold patients' hands... who holds the doctor's hand?
Sunday, June 19, 2011
Sunday, June 12, 2011
Stories from the 'House of God' and Spring's Aphrodite
The confession is that I have never actually read that book. But it's been talked up quite a bit this first month of Internal Medicine. And my sense it that it's probably an apt title for this entry.
It's been a while. That's the nature of Internal Medicine and sweet, fragrant spring days -either slaving, studying or trying to live a little. It can actually be enough to throw you totally off balance sometimes.
My first month was on hematology-oncology wards and I got lucky: best senior residents I've ever had, amazing attending staff who loved to teach, told interesting, funny stories of their own experiences as medical students and residents, sharing their wealth of knowledge and experience, and yes, in the spirit of excellence and love. My patients provided me with challenges, new perspectives, nearly drowned me in the mud of the unfortunate circumstances that were their lives, and once in a while, inspired me with the blessings from their souls. All of them taught me something invaluable. That someone else's mistake would be mine too if I didn't catch it -that although it may take at least 3 levels of error to actually reach a patient, the ultimate responsibility rested with us, the physicians. But that when we find those errors, acknowledge them and apologize, and then try to find solutions, we're helping future physicians, pharmacists, nurses... evolving a system that can better benefit our patients.
I learned that your favourite patient (ah, yes, I will certainly admit to having favourites -they are the ones that keep you going through a possibly otherwise miserable, chaotic day), the one who was doing so well, the one who was meant to go home tomorrow, in the flash of a few moments, can go from stable and smiling to vomiting blood, crashing blood pressure and O2 sat and being rushed to the ICU. All the while, you watch in awe as your beloved seniors, calmly order units of packed red cells, bolus fluids and load him up with pressors before the transfer. But you, you are just frozen. And then you look back at the extremely slowly trending down hemoglobin, the slightly increased BUN that afternoon and think to yourself, "I should have known". But your senior kindly points it out "Okay, let's say you saw it coming. What would you have done?" To which my response was, "Call GI" and which he quickly finished, "and maybe they would have scoped him tomorrow [because until that sudden episode of hematemesis, he was stable -it was not an apparent emergency]" So it wouldn't have made a difference. But still. It scared the crap out of me. Massive GI bleed, requiring over 12 units of blood in 24 hours. One of my happiest moments was when that patient came back to the ward from the ICU. And he was smiling and joking and squirming antsy-ly in his hospital bed, in a grey sweatsuit, anticipating a nice lunch of spanakopita at home.
And for some patients it goes from pretty darn awful, to worse... and no one deserves that kind of hell. Imagine living with poorly controlled schizoaffective disorder, along with at least 7 other serious medical conditions. You come into the hospital with medication toxicity and new pulmonary embolus. And you leave with f-ing cancer. And now imagine being the spouse of that patient. Yes no wonder they're a bit of a grouch. Yet, it's so hard for a medical student to deal with that chronically grumpy, angry, accusing spouse in addition to our clinical responsibilities and trying to learn around our cases and get it all done efficiently. You kind of feel like you're helping nobody and maybe they even hate you, but you learn not to take it personally. Then one day your attending staff comes to you and says, "You wanna call back patient X's husband? I talked to him earlier and he said he only wanted to talk with you" What? Has the world gone mad. And you call back and he's still Grumpy McGrumpster. But he asked for you.
And there's the vibrant, smiling, rosy-cheeked woman with multiple myeloma (a kind of bone marrow / blood cancer) who lights up every morning when you round, and tells you every day that you'll be a wonderful doctor someday, and thanks you for doing your best for her everyday. Her platelets are dropping everyday and then it's time to transfuse her. And she is in tears, and her eyes are filled with fear. This is how her beloved started their downward spiral into the grave... all she can remember was the many transfusions. You explain to her that we expected this though. That this one transfusion does not mean she's going to die too. And you sit there and hold her hand and then, she's smiling again. You have her blessing too, but only because you were blessed enough to know to listen, to know to explain.
At the end of that first month, I admitted an older woman in her 90s. She was basically palliative, with multiple comorbidities, not the least of which was an Aortic Stenosis with an ASA of 3 mm (basically a 3mm diameter through which the heart was meant to pump blood to the whole rest of the body)... 4 years ago (which means, even smaller now). She couldn't talk, she could hardly breathe, she was in pain. She had no family, no friends. She was a Level 3 -no Code. We gave her oxygen, we managed her pain. I would check in on her every morning. And then on my last Friday on the wards, as usual, I couldn't understand a muffled word she uttered. Then distinctly made out her plea: "stay". So I pulled up a chair, took her frail hand in mine, "I'm here now, you rest". The struggle abated, her breathing slowed, her facial muscles relaxed and she held my hand firmly. It reminded me of when I held my grandmother's hand right before the end. That evening at sign-out, the new attending on the wards said, "Oh for goodness sakes, there's nothing really we can do for this patient. What she really needs is someone to sit by her and hold her hand." To which I responded gently, "Yes, I did that for a bit earlier today". "Well, good for you for taking the time to be a human being". She passed away the following morning.
I'm now one week into my second month of Internal medicine and well, let's say the blinders are off. The idealism... has metamorphosed into a compassionate realism. This world is both the filthy garbage dump and the rose garden. And medicine is no different. It's about what we choose to focus on once the sun has set, the moon has risen and we're collapsing into bed. Those fleeting pre-dream thoughts.
Believe it or not though, through the frenzy and chaos, we still make time for a little romance. Walks through pot-holed sidewalks and cobblestone streets, kisses in the park, those fabulous kinds of conversations with the eternal tangent, new flavours in sizzling bowls, or sweet mapley desserts melting in your mouth amidst brightly coloured flowers and live jazz. Or learning a new board game, discovering a funny TV show. Or the beauty of the still, in calm, soothing, comfortable company. Life blesses us with those joyous, carefree moments too.
Whether it's the dark black waters of a bottomless ocean, or the golden shimmer or sunlight hitting petals and leaves in the garden, for such adventure and all these opportunites to learn, grow and share my joy, yes, I am so grateful.
It's been a while. That's the nature of Internal Medicine and sweet, fragrant spring days -either slaving, studying or trying to live a little. It can actually be enough to throw you totally off balance sometimes.
My first month was on hematology-oncology wards and I got lucky: best senior residents I've ever had, amazing attending staff who loved to teach, told interesting, funny stories of their own experiences as medical students and residents, sharing their wealth of knowledge and experience, and yes, in the spirit of excellence and love. My patients provided me with challenges, new perspectives, nearly drowned me in the mud of the unfortunate circumstances that were their lives, and once in a while, inspired me with the blessings from their souls. All of them taught me something invaluable. That someone else's mistake would be mine too if I didn't catch it -that although it may take at least 3 levels of error to actually reach a patient, the ultimate responsibility rested with us, the physicians. But that when we find those errors, acknowledge them and apologize, and then try to find solutions, we're helping future physicians, pharmacists, nurses... evolving a system that can better benefit our patients.
I learned that your favourite patient (ah, yes, I will certainly admit to having favourites -they are the ones that keep you going through a possibly otherwise miserable, chaotic day), the one who was doing so well, the one who was meant to go home tomorrow, in the flash of a few moments, can go from stable and smiling to vomiting blood, crashing blood pressure and O2 sat and being rushed to the ICU. All the while, you watch in awe as your beloved seniors, calmly order units of packed red cells, bolus fluids and load him up with pressors before the transfer. But you, you are just frozen. And then you look back at the extremely slowly trending down hemoglobin, the slightly increased BUN that afternoon and think to yourself, "I should have known". But your senior kindly points it out "Okay, let's say you saw it coming. What would you have done?" To which my response was, "Call GI" and which he quickly finished, "and maybe they would have scoped him tomorrow [because until that sudden episode of hematemesis, he was stable -it was not an apparent emergency]" So it wouldn't have made a difference. But still. It scared the crap out of me. Massive GI bleed, requiring over 12 units of blood in 24 hours. One of my happiest moments was when that patient came back to the ward from the ICU. And he was smiling and joking and squirming antsy-ly in his hospital bed, in a grey sweatsuit, anticipating a nice lunch of spanakopita at home.
And for some patients it goes from pretty darn awful, to worse... and no one deserves that kind of hell. Imagine living with poorly controlled schizoaffective disorder, along with at least 7 other serious medical conditions. You come into the hospital with medication toxicity and new pulmonary embolus. And you leave with f-ing cancer. And now imagine being the spouse of that patient. Yes no wonder they're a bit of a grouch. Yet, it's so hard for a medical student to deal with that chronically grumpy, angry, accusing spouse in addition to our clinical responsibilities and trying to learn around our cases and get it all done efficiently. You kind of feel like you're helping nobody and maybe they even hate you, but you learn not to take it personally. Then one day your attending staff comes to you and says, "You wanna call back patient X's husband? I talked to him earlier and he said he only wanted to talk with you" What? Has the world gone mad. And you call back and he's still Grumpy McGrumpster. But he asked for you.
And there's the vibrant, smiling, rosy-cheeked woman with multiple myeloma (a kind of bone marrow / blood cancer) who lights up every morning when you round, and tells you every day that you'll be a wonderful doctor someday, and thanks you for doing your best for her everyday. Her platelets are dropping everyday and then it's time to transfuse her. And she is in tears, and her eyes are filled with fear. This is how her beloved started their downward spiral into the grave... all she can remember was the many transfusions. You explain to her that we expected this though. That this one transfusion does not mean she's going to die too. And you sit there and hold her hand and then, she's smiling again. You have her blessing too, but only because you were blessed enough to know to listen, to know to explain.
At the end of that first month, I admitted an older woman in her 90s. She was basically palliative, with multiple comorbidities, not the least of which was an Aortic Stenosis with an ASA of 3 mm (basically a 3mm diameter through which the heart was meant to pump blood to the whole rest of the body)... 4 years ago (which means, even smaller now). She couldn't talk, she could hardly breathe, she was in pain. She had no family, no friends. She was a Level 3 -no Code. We gave her oxygen, we managed her pain. I would check in on her every morning. And then on my last Friday on the wards, as usual, I couldn't understand a muffled word she uttered. Then distinctly made out her plea: "stay". So I pulled up a chair, took her frail hand in mine, "I'm here now, you rest". The struggle abated, her breathing slowed, her facial muscles relaxed and she held my hand firmly. It reminded me of when I held my grandmother's hand right before the end. That evening at sign-out, the new attending on the wards said, "Oh for goodness sakes, there's nothing really we can do for this patient. What she really needs is someone to sit by her and hold her hand." To which I responded gently, "Yes, I did that for a bit earlier today". "Well, good for you for taking the time to be a human being". She passed away the following morning.
I'm now one week into my second month of Internal medicine and well, let's say the blinders are off. The idealism... has metamorphosed into a compassionate realism. This world is both the filthy garbage dump and the rose garden. And medicine is no different. It's about what we choose to focus on once the sun has set, the moon has risen and we're collapsing into bed. Those fleeting pre-dream thoughts.
Believe it or not though, through the frenzy and chaos, we still make time for a little romance. Walks through pot-holed sidewalks and cobblestone streets, kisses in the park, those fabulous kinds of conversations with the eternal tangent, new flavours in sizzling bowls, or sweet mapley desserts melting in your mouth amidst brightly coloured flowers and live jazz. Or learning a new board game, discovering a funny TV show. Or the beauty of the still, in calm, soothing, comfortable company. Life blesses us with those joyous, carefree moments too.
Whether it's the dark black waters of a bottomless ocean, or the golden shimmer or sunlight hitting petals and leaves in the garden, for such adventure and all these opportunites to learn, grow and share my joy, yes, I am so grateful.
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