Today I pronounced my first death, as a licensed physician.
I got my license to practice medicine in the state of Wisconsin about a year ago now. Although I am still a resident, as a licensed physician, I get to write and sign some documents I could not do a year ago as an intern.
There are patients who come into the ER or the hospital or the critical care unit whom you barely have time to get to know. They are either dead on arrival, or actively dying and slide down so quickly, no intervention works. When you 'call it' on one of these, there is the despair, frustration, anger, defeat and helplessness that comes with a battle lost.
It is worse when it is a patient you have cared for, for some time. It is even worse when the patient is young and dying of something you cannot identify. My 26 year old male patient died at 4:17 am. He was surrounded by his father, mother, sister and girlfriend of 6 years. Everything we could do had been tried and failed. The family did not wish an autopsy, so he carries the secret of what killed him to the grave with his body.
This is NOT what you train for. It is not why you come to work. It is not the outcome you study, struggle and work for. My grief cannot compare at all with that of the parents of a previously healthy 26 year old son who dies in a few months of unknown causes (he died of multi-organ failure secondary to ARDS (Acute Respiratory Distress Syndrome) but the cause of the ARDS is unknown.
I have no more words.
He died at 4:17 am. The day was one of busiest in the unit: while rounding on our eight patients, very sick ones, another patient arrived who had begun to bleed acutely while in the wards. She was unstable, in a lot of pain and may have been bleeding to death. We barely stabilized her when our beepers went off indicating a 'code blue' -- an elderly gentleman passed out in front of an elevator, had to be shocked back to life, was now intubated and was on the way to the unit. Rounds were over as quickly as we could run them and news of three more patients -- one en route from an outside facility, one in the ER and one being transferred from a floor ward arrived. All sick. No time to grieve, collect one's thoughts or dictate a death summary.
I got home after all this. Before I left, I walked past the CCU bay where my 26 year old patient had been. The bay had been cleaned, the bed re-made. We were crunched for space. Soon, another patient would be in that bay. I left for the day, after a day, night and day of call.
Over a dinner, while keeping sleep-deprived eyes open, I finally get to say my goodbye and grieve a little.
Tomorrow is another day.
Monday, August 20, 2007
Tale of Two Cities...
Charles Dickens' famous book began with these words:
A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.
26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.
In my head, I could almost hear the parellel conversations...
the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"
the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."
Both interventions were tried and failed.
the attending physician: "We will diurese him and keep him on steroids"
the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."
Both interventions were tried and failed.
It went on for some months.
Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?
The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.
In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.
?????
There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.
"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us..."
A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.
26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.
In my head, I could almost hear the parellel conversations...
the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"
the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."
Both interventions were tried and failed.
the attending physician: "We will diurese him and keep him on steroids"
the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."
Both interventions were tried and failed.
It went on for some months.
Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?
The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.
In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.
?????
There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.
Sunday, August 12, 2007
Look into my eyes...
It was a late night admission from the ER. Michael was a 40-something man being admitted for left-sided weakness. By the time he finally decided this was serious and not 'going away' he could not lift his left hand off the bed and his grip strength was down to 1/5 (5/5 being normal).
As we set him up in the medical ICU, starting him on a heparin drip after a head CT, we noted that his blood pressures were through the roof. The radiologist called me back with the results of the CT: he had had an infarct in a region of the brain called the corona radiata. Brain cells were dead. They were never coming back.
Through the course of the night, I sneaked into the room to see how he was doing. The first time around, I found him lying on his side with eyes open. I don't think I shall ever forget the look in those eyes -- fear, frustration, helplessness. He was a mason. When I said something to comfort me, he only replied in a soft voice:
"I should have come in earlier, shouldn't I? I should've come to a doctor before. I should've...."
What do you tell someone who has had a stroke? You cannot promise them that their functions will return. You cannot promise them that their life will be the same again. You cannot promise them anything.
We do what we can, with what knowledge we have. The chips will fall where they may. This gentleman was 1 year younger than me.
As we set him up in the medical ICU, starting him on a heparin drip after a head CT, we noted that his blood pressures were through the roof. The radiologist called me back with the results of the CT: he had had an infarct in a region of the brain called the corona radiata. Brain cells were dead. They were never coming back.
Through the course of the night, I sneaked into the room to see how he was doing. The first time around, I found him lying on his side with eyes open. I don't think I shall ever forget the look in those eyes -- fear, frustration, helplessness. He was a mason. When I said something to comfort me, he only replied in a soft voice:
"I should have come in earlier, shouldn't I? I should've come to a doctor before. I should've...."
What do you tell someone who has had a stroke? You cannot promise them that their functions will return. You cannot promise them that their life will be the same again. You cannot promise them anything.
We do what we can, with what knowledge we have. The chips will fall where they may. This gentleman was 1 year younger than me.
Saturday, August 11, 2007
Enjoying my work
I thought I would post one of the few pictures I have of me in Peds. This little boy has cystic fibrosis. We were out for a walk in the corridor the day before he was going to go home.
The Ward Team in Pediatrics with one of our patients.
Viruses that will save the world
I had a week off from the world of pagers, night call, ER admissions and clinic. I was in Pittsburgh attending the Phage Hunters Workshop (http://www.pitt.edu/~gfh/summerworkshop.html). This workshop is meant for High School Science Teachers, but I went to learn some of the techniques.
There is a group of viruses called bacteriophages. These viruses are specific for bacteria. They do not attack other kinds of cells. Before antibiotics were discovered, they were even used clinically to treat microbial infections.
Think about this. In nature, exists the ultimate enemy of pathogenic bacteria. These bacteriophages (phages, for short) invade, multiple within and destroy these pathogenic bacteria. Of course, just as with antibiotics, bacteria evolve resistance to them. Unlike antibiotics which are static however, phages co-evolve to once again be able to target their hosts. This host-parasite dance continues through time. The phages are ubiquitious. There are a billion of them per cc of lake, river and sea water. We ingest them all the time. They are easily isolated from soil, sewage... anywhere you care to look. They are so easy to isolate and grow, in fact, that middle and high school kids can do it.
The Pittsburgh Bacteriophage Institute holds a Summer Workshop that teaches High School Science Teachers how to 'hunt' for phages in their environment. For several years now, high school students have been isolating and purifying their own phages. They get to name them too.
What excites me about these wonderful little critters is that they may hold the answer to multi-drug resistant superbugs. The Pittsburgh group and collaborators are working on phages against Mycobacterium species -- the group of bacteria that cause the deadly diseases of tuberculosis and leprosy.
My own research (if I can continue to squeeze it into the busy life of a medical resident) is to isolate and purify phages with activity against Staphylococcus aureus. In fact, I declare my life's research ambition to become the world authority on lytic phages of S. aureus. Okay, I'm a dreamer. But I'm not the only one. (Check out the Courses Web site at http://hatfull12.bio.pitt.edu:8080/
Suicide
I HATE suicide!
There is someting sinister, evil and perplexing about suicide that drives me to tears of anger and frustration.
A couple of weeks ago, it was a Monday (and a full moon day) in clinic. I saw a 46 year old man who came in for some minor health issue. I noted that the last provider he saw had started him on a medication for depression, so I decided to ask whether he had noted any difference since taking it.
He shook his head. When I asked about suicidal ideation (thoughts of wanting to kill himself) I was stopped dead (pardon the pun) in my tracks. He replied "Actually, on the way here I thought of throwing myself in front of a semi." This was a middle-aged man with a wife and two kids who wanted to kill himself.
I inquired further. He did not think his life was worth living. His job was a dead end. His marriage was falling apart. He had no desire for sex. We had given him Viagra on a previous visit. He had not used it. Not interested.
Further investigation from the psychiatrist (to whom he was directly referred from my office) revealed that he had a lifetime battle with ichthyosis -- a rare skin condition that causes the skin to appear scaly or reptilian in appearance. His school nickname was 'scales'.
The following day, I saw a young man in clinic with with a weight problem. He too was suicidal. His plan was to turn the fumes from his tailpipe into the car and breathe it in. He too had no reason to live.
That same day, I saw a middle-aged woman who had attempted suicide at the age of 18. She suffered from crippling depression and schizophrenia (the latter adequately controlled on medication). Unfortunately, she lived with a 'partner' who had an autistic 4 year old. I imagined this dysfunctional household: each one's condition exacerbating the other's.
It is horrifying but not uncommon to see that in all three of these patient's families there was a strong history of depression, psychiatric illness and yes, multiple suicides. It is almost as if a demon has these families in his grip, killing one after the other.
The following week in the ICU I took care of a middle-aged woman who sat down at 11:30 pm and drank Anti-freeze till 4:30 am. Yes, she was trying to kill herself. (This is a picture of the actual can from which the patient drank).
There is someting sinister, evil and perplexing about suicide that drives me to tears of anger and frustration.
A couple of weeks ago, it was a Monday (and a full moon day) in clinic. I saw a 46 year old man who came in for some minor health issue. I noted that the last provider he saw had started him on a medication for depression, so I decided to ask whether he had noted any difference since taking it.
He shook his head. When I asked about suicidal ideation (thoughts of wanting to kill himself) I was stopped dead (pardon the pun) in my tracks. He replied "Actually, on the way here I thought of throwing myself in front of a semi." This was a middle-aged man with a wife and two kids who wanted to kill himself.
I inquired further. He did not think his life was worth living. His job was a dead end. His marriage was falling apart. He had no desire for sex. We had given him Viagra on a previous visit. He had not used it. Not interested.
Further investigation from the psychiatrist (to whom he was directly referred from my office) revealed that he had a lifetime battle with ichthyosis -- a rare skin condition that causes the skin to appear scaly or reptilian in appearance. His school nickname was 'scales'.
The following day, I saw a young man in clinic with with a weight problem. He too was suicidal. His plan was to turn the fumes from his tailpipe into the car and breathe it in. He too had no reason to live.
That same day, I saw a middle-aged woman who had attempted suicide at the age of 18. She suffered from crippling depression and schizophrenia (the latter adequately controlled on medication). Unfortunately, she lived with a 'partner' who had an autistic 4 year old. I imagined this dysfunctional household: each one's condition exacerbating the other's.
It is horrifying but not uncommon to see that in all three of these patient's families there was a strong history of depression, psychiatric illness and yes, multiple suicides. It is almost as if a demon has these families in his grip, killing one after the other.
The following week in the ICU I took care of a middle-aged woman who sat down at 11:30 pm and drank Anti-freeze till 4:30 am. Yes, she was trying to kill herself. (This is a picture of the actual can from which the patient drank).Her life was saved by CRRT. The picture shows her getting the treatment.
I remember coming home from work the evening of the day I saw the two suicidal patients in clinic. I finally broke down in my car. Tears of frustration, anger and a feeling of helplessness swept over me.
As a physician I fight disease and sickness all day (and nights on call). We struggle to save broken bodies ravaged by disease. Here were relatively 'healthy' people trying to take their own lives.
The book that has most ilumined the subject of suicide to me is Kay Jamison's Night Falls Fast (http://www.amazon.com/Night-Falls-Fast-Understanding-Suicide/dp/0375401458). As a professor of psychiatry and a lifelong patient with bipolar disorder who has attempted suicide several times herself, she is emininently qualified to comment on the subject. I recommend the book highly.
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