Sunday, September 26, 2010

Breaking the Numbness.

Another day in the SICU. Another code. Another death. This time, I knew the patient; yet, just like last time, I felt nothing as the end of his life was pronounced.

The scene was pure chaos. Multiple people calling out orders for IV boluses of potent medications to break the man's arrhythmia (ventricular fibrillation, with intermittent runs of what looked like the ever-frightful Torsades de Pointes), other medications to support his non-existent blood pressure. An attending physician who appointed a chief resident to "run the code," yet persisted in overriding his decisions. So many people calling for equipment and labs and answers. So many alarms beeping. The heaving sighs of chest compressions, interrupted ever so often by calls to "clear" before the defibrillator attemped to convert the man's heart back to sinus rhythm. And failed, over and over and over again.

A needle placed into the sac surrounding the man's heart revealed that it was filled with blood. Cardiac tamponade. The pericardial sac was drained, but his arrhythmia continued to be unresponsive and his pulse never resumed. After 43 minutes, the attending made the call that we would not be able to revive him. "It is 6:57pm. Mr. A. is deceased."

My eyes glossed over. A chill passed through me. But in a moment, it was gone. I helped wipe up the blood, and discard all the equipment - all the usual things that happen after an intervention for a living patient. The man's motionless, cold body looked no different than that of any other patient in the ICU. I left the room feeling just as unrewarded as I've left every room on the unit -- no more, no less.

A few minutes later, Mr. A's wife arrived to the ICU. A frail, petite woman in a wheelchair, she was escorted into the room where her husband's body awaited her. I never saw her face, only her side profile in the distance as a nurse told her what had happened as she opened the door.
I'll never forget the gray color her skin took, as she dropped her jaw in horror.

Then, only then, did my own tears flow.

I think and talk and write a lot about empathy, the importance of "inhabiting someone's existence" - truly trying to understand the multiple facets of their lives, their values, their influences. I don't think I've ever experienced true empathy but for the moments where I imagine what it would be like to receive the news that my soon-to-be-husband has died, or is dying. Every organ in my body twists up and squeezes. My ribs stiffen, preventing my heart from filling and beating as it should. I get cold and light-headed. Everything around me feels purposeless. In that moment, there is nothing worth living for.

I need to keep this pain in mind every single time I deliver this kind of news.

The difference is now that the pain isn't permanent. It feels real as can be in that moment. But then I return to the rest of my day. I move on to the next patient, a 28 year old who suffered an aortic dissection the day after he married his college sweetheart and spent 18 hours in the operating room, receiving practically the entire blood product supply of our state. I've been checking in on him throughout the day, watching his unstable blood pressure and persistent blood leaking into his chest tubes, feeling the coldness of his limbs and the weakness of his pulses. He's intubated and unresponsive, the same as he's looked all day.

But when I enter his room this time, his new bride is by his side. She strokes his hair and whispers into his ear. My eyes brim with hot, burning tears all over again. I look up at the ceiling to drain them, afraid that the young woman may see.

She asks me questions about how he's doing, what the beeping alarms and numbers reflecting his cardiac and renal function mean. I bite my tongue inside my mouth to stay focused as she speaks, as even my lip is to much of a give-away.

She bends closer to her new husband, resumes stroking his face beneath the twisted cords of his endotracheal and feeding tubes. This time, I hear her as she speaks to him.

"You're so strong to fight this. You have so much to live for - we have so much to look forward to in our new lives together."

I say goodbye, find a supply closet, and bawl.

Thursday, September 16, 2010


Overnight call in the surgical intensive care unit. Arguably one of the scariest places in the hospital, the SICU consists of 30-something rooms with sliding glass doors lining the perimeter of a huge cluster of desks and monitors and collections of tubes and people and chaos. Most of the patients within each glass cubicle are hooked up to 2-10 different foreign bodies: central and peripheral IV lines, arterial lines, Swann-Ganz catheters, nasogastric tubes, drains, chest tubes, endotracheal tubes attached to ventilators, a dozen different kinds of ports of which I still don't know the names. Most of them are so heavily sedated that they do not even grunt when you poke and prod them, lifting their gowns to inspect their oozing wounds and measure the output of their bodily fluids. They're kept alive with positive pressure ventilation and potent vasoconstrictors to support their blood pressure. They're monitored more closely than anyone else in the hospital - besides the doctors (who actually do check on them repeatedly), they are cared for by ICU nurses, who are exceptionally smart and demonstrate more dedication and compassion than anyone around.

Still, I hate it here. I am so viscerally uncomfortable, the minute I punch the combination code to enter the SICU fortress. Every time I hear something beeping, my stomach curdles and I want to go home. This is why I requested to do a 27 hour shift here: to own my discomfort, immerse myself in the overwhelming chaos. And maybe, just maybe, learn a little bit about how to take care of the sickest patients I'll ever meet.

I've spent most of the day being just as useless as on my other surgical rotations - tagging along and lurking behind hardworking residents. But I'm actually learning a ton. I'm already far less overwhelmed by the mysterious collections of "things" to which people are attached, and things that beep. It's been a relatively smooth day...

... until tonight.

I accompanied my resident to see an 86 year old woman whom we intubated earlier this afternoon, who was now coming off of her sedation and beginning to appreciate the circumstances of her world. She was not pleased. Pulling at her breathing tube, moaning, gesturing to us to take it out. My resident explained that she needed it to breathe for now.

Out of the corner of my eye, I saw her tapping her bed - waving, almost. I asked her if she were trying to tell us something. She nodded.

I offered her paper and a pen. She began to scribble, slowly. I translated aloud, spelling the letters as she wrote.

D ...a....e...d....d...p...u...d...e...d...

This went on for five minutes. She kept tapping the pen in frustration every time I misread a letter.


My heart sunk. I knew exactly what she was trying to write now. Should I continue? What if I were right? Or worse - what if I were wrong? I ignored my predictions. I dared not suggest it, just in case -- how scary and rude and horrific for her to hear this if it had not already been on her mind.


I read it, silently. Now there was no mistake. I couldn't ignore it -- now it was in plain sight. She was truly communicating to us that she wished us to withdraw support, right here on my little scrap of paper. My eyes glossed over. Chills down my spine, down my left leg.

"I can't read what you're saying -- maybe we can talk later?" said my resident.
I wasn't sure if he was dodging the issue, or truly couldn't see what I saw.
"I think she just spelled out d-e-a-d..." I said, softly.

Our patient began to tap fervently and nodding her head. We both stood there, frozen. I didn't know what my role was supposed to be at that moment. I hadn't even introduced myself as I tagged along with my resident into the room. I didn't know her, I didn't know her family. I didn't belong here. But here she was, telling us that neither was she. We had something in common.

I don't know anything about ventilators and central venous catheters and fixing people who are dying. But I knew a little bit about being scared in a hospital.

"I know you're scared. The breathing tube is just temporary. It comes out soon, as soon as your blood tests come back normal to make sure you're safe."
Blank stare.
"Is that what this is about? The tube?"
She shook her head no. I had no idea where to go from here.
"In the hospital, it's very common and normal to feel depressed and scared and hopeless. It goes away, it gets better..."
Blank stare.
"Your family -- do you remember them coming today?"
Shook yes.
"How about we wait for them to return tomorrow so you can talk with them?"
Shook no.
"Have you spoken with them before about your wishes?"
Shook yes.
"Are you close with your family?"
Shook yes.
"So how about we wait til tomorrow - maybe the tube will be out and you can speak freely..."
Shook no. She pointed again to her tortured letters on my notepad.

I hurt for her. She was so hypovolemic that her eyes were tearless. Mine made up for hers, I guess. I was at a loss. I understood her. I understood her loud and clear.

And I didn't know what on earth to do about it.

Monday, September 13, 2010

My First Death.

Rule #1 of a medical student on a surgical rotation: Never walk into an OR without first meeting the patient.

Today, I broke that rule. And it's probably the one reason I'll be able to sleep tonight. If I'm able to sleep tonight.

I was assisting my surgery preceptor with an elective surgery for a man with end-stage renal disease who needed better vascular access for dialysis. Was it the most fascinating thing in the world? No. Was it cool to see named vessels in a real, live person? Definitely. But then the phone in the OR rang, alerting us to an emergent case of a women presenting to the ED with a ruptured abdominal aortic aneurysm. See also: the scariest thing in all of medicine, wherein people bleed to death into their abdomens and/or their pericardial sacs.

"Go see that, Melissa!" my preceptor said. "That'll be definitely more interesting."

I didn't want to go. I knew I wouldn't be useful. I knew I'd be overwhelmed. I knew I wouldn't have met the patient before she was intubated and put under general anesthesia. I figured, however, that any other medical student would have loved the opportunity to observe the surgical management of a ruptured "triple A." I figured that I'd be an idiot for passing it up.

So I went. I gently opened the OR door -- and then *BAM* was blown away by the sights. There were 30 people, scrambling all over. Blood everywhere. Lots of monitors beeping. Surgeons calling out orders, calling for equipment and instruments. Organized chaos, if you will.

I slid up against the side of the wall. This was not my world. I didn't want to engage.

After a few minutes, the EKG alarm started going berserk. I recognized the pattern from televsion. The patient was in SVT. In my head, I silently reminded myself what drug to give her. Immediately thereafter, I heard the anesthesiologist announce that he was giving the patient this very drug. But the alarm continued to sound -- crazy fast beats, all over the place. Then, they slowed.

"She has no carotid pulse!" someone called out.
"That's your indication for ACLS."
"Beginning chest compressions now..."

I watched in horror. The surgeons continued to frantically attempt to stop the gushing blood from her aorta while the anesthesiologist rhythmically moved up and down behind the blue curtain separating her abdomen from the rest of her. I could only imagine how much force was being generated into her chest.

"This is useless - when do we call it?"
"Another 2 minutes..."

Two minutes later, they stopped. I didn't hear anyone call the time of death. I just left.

I felt numb. Kind-of like when I suctioned a demised embryo. I didn't feel anything, except the feeling that I "should" be feeling something.

I left the room. I saw my preceptor in the hallway a few minutes later. He started teaching me about the statistics of AAA ruptures and cardiac arrests and fatalities, and how the present situation had a 90% chance of occuring. I was silent. I realized that this perhaps projected disinterest.

"I'm sorry for being quiet. I've never seen anyone die before."

He asked me if I were ok, was truly kind and supportive. And I truly was ok.

Until an hour later, when I learned that this woman presented to the ED while her husband was being evaluated elsewhere in the hospital by a neurosurgeon for his own brain aneurysm.

When he came out of his appointment, after dealing with his own very scary reality, he would receive news that his wife was dead -- the very last thing he could ever have expected.

Then, I felt something. I felt a cold sweat break out, a deep ache in my stomach. I imagined what that might be like, and I felt like vomiting. I felt like crawling up into a little ball and bawling.

But instead, I cried just where I was.

Monday, September 6, 2010

This is not ok.

The sweltering OR lights dilate the vessels in my head and make me woozy. I alternate between being so overheated that I can barely stand upright, and with freezing chills from my sleep deprivation and the intermittent unbearably cold air conditioner. My face shield is fogged from my breath, my mask perpetually threatening corneal abrasion with its proximity to my fatigued eyeballs. The bottoms of my feet burn mercilessly from standing in place for 4.5 hours. I focus moreso on my duty to flex and extend my knees periodically to prevent venous pooling (and, accordingly, prevent passing out) than my duty to learn anything about surgery.

And then there's the smell of burning flesh, singed from the cauterizer. That, I pay attention to. It's grounding, somehow.

It is 10:30am. My shift was supposed to end at 7am. I've been here overnight, been awake 27 hours, and am scheduled to be back again in 8 hours. Sleep, studying, quality time with my fiance (who's been away for almost a month), and everything else that is supposed to comprise my "balanced" life is all supposed to fit in there. Yet, here I am in the OR, passively observing a 4.5 hour colon resection - with a field of vision more obstructed than the colon itself.

Ironically, this was quite possibly the one operation to which I was most looking forward to seeing on this rotation (I think the gut is amazing, and lots of my patients when I was a GI clinical research coordinator had colon resections by protocols that I only vaguely understood). I'd been able to spend time with the patient pre-operatively, who reminded me very much of a man I took care of in Maine on my medicine rotation (of whom I was very fond, who afforded me opportunities to build confidence and to be truly useful). So here we were, his abdomen sliced open with his oozing loops of bowel spilling out of his body - with so much promise to make him well! Perfect, right?

And yet, here I am: hard-pressed to recall any moments of my life as miserable as this one.

The back of my calf has a strange, sharp, throbbing pain. I am convinced that I have a DVT. I visualize it, ruminate over it. I imagine part of it breaking off and embolizing through my patent foramen ovale (a congenital hole in my heart that I conveniently learned this spring that I have), travel to my lungs and kill me. I try to make a Top 10 list of things about my present "learning opportunity" that are better than this scenario, and I truly can't come up with more than two. I instantly appreciate this as crazy. I become angry that this situation has driven me to think so irrationally.

Four times, I fall asleep while standing up. Once, I nearly fall onto the Mayo stand, the sacred base of sterility where all the instruments are kept. I resort to stepping side to side, or up onto and down from the step stool they've given this 4'11" medical student to be able to see over the surgeons' shoulders. I still can't. All this, and I can't see a thing.

The surgeon and the resident were too tired to teach me anything or engage me in any way. I wasn't being useful, I wasn't learning anything, and all I wanted to do was go home and snuggle my fiance and fall asleep for the rest of my life. And if that couldn't happen, I thought the DVT to pulmonary embolism plan was a good back-up.

The resident, the one with the scalpel in hand carving up segments of bowel, had been awake just as long as I had.

I "get" all the arguments about continuity of care, and how frequent hand-offs make for communication lapses that compromise patient care. But if the man with the scalpel feels half as dysfunctional as I do right now, there's something very wrong.

Thursday, September 2, 2010

A blast of sunshine.

I'm post-call for the third day in a row. I've been awake for the past 20 hours, and have only slept 9 hours since Monday. I only have 4 hours off today before I have to leave for work again (see also: only 4 hours to sleep/study). But I aaaaaaabsolutely have to write before I attempt. (It's pretty nice to genuinely feel motivation to write again).

Since beginning night float, there's a new character in my life: the morning attendant at the hospital parking lot. I've never been LEAVING the parking garage at 9am before, so I've not previously made his acquaintance during my two years here. He looks about 70 years old, wears a big wicker cowboy hat, and always has a huge smile on his face. But that's not all. He doesn't just take your ticket and parking fare; rather, he chats you up about your day and your life outlook, and tells a select relevant anecdote. Literally, one spends 5 minutes at the parking window - even with traffic backed all the way up. And it's, like, the best 5 minutes of the day. You have to remember how many factors exist that drastically reduce the probability of my enjoying ANYTHING at this moment: I'm exhausted. I'm grumpy. I'm hungry. I miss my bed. I miss my fiance. But after this insanely long, totally context-inappropriate encounter with this character, I am glowing. I smile the whole drive home. I smile the whole way from my car to my apartment, and up the stairs. I'm still smiling now.

And the thing is: in my old life in NYC, this would never fly. In my old life, the old me wouldn't even have wanted this to fly. Five minutes to chat with a stranger about a gift his son bought him 20 years ago in Montana, and where he bought it, and how he sent it to him across the country (today's topic, for example) while I've been up 20 hours and haven't eaten in 12, and know that I only have 4 hours off between now and 24 hours from now?

This guy is SO good at his job. He makes every moment count. I'm sure that I'm not the only one whose entire day is brightened by his presence. I may be exhausted and I may be living according to a completely absurd, largely unreasonable life schedule -- but I'm hereby going to do my very best to be this kind of presence to at least one person every day.

My fiance has talked of how content he'd be to work an oft-underappreciated, underpaid job like this. He says he'd be really happy to work in the service industry as a McDonald's cashier or Starbucks bartender, or a school janitor: he's talked specifically of encounters like I've described -- "moments" of unexpected connection, the opportunity to brighten someone's day like none other. The elitist and realist in me, mindful of both of our massive student loans (and their obstructiveness to our having a comfortable life and starting to have children within a few years of getting married) and the discrepancy between societal (and my) expectations of how he'd use his very expensive, private university-earned Master of Business Administration degree, compels me to be vehemently opposed to these thoughts. I feel guilty about that sometimes, even though he's only half-serious to begin with. I suppose it's a good thing that my realism balanced his enlightenment -- but it's still a good reminder, today, to focus on those "moments" that can literally change the course of a human being's existence. At least for the moment.