Wednesday, October 20, 2010

On Learning Another Lesson, or, To Every Thing There Is A Season

"I've got one for you."

The most ominous words that you hear as an intern are actually just that benign. Not because of the words themselves, but because of what comes next. And this time it came rapid fire.

"Mr. RM* is an 83 year old man who became unresponsive at home several hours prior to presentation, and he vomited three times. He's got a history of seizures, has a sodium of 128, a potassium of 5.7 but his troponins and CK and MB are negative. His chest film was pretty normal, and his brain scan was negative. We're checking his tegretol level, and admitting him for all of these problems, and also for the ones we haven't figured out yet. Don't really know why he isn't responsive." **

This all came out in one breath. Like an M-16 on full-automatic. I had stuck my head out of my foxhole by answering the phone with my usual, "Hello, this is Bryce." And I had been hit.

Needless to say, two weeks into my actual internship, I was feeling overwhelmed. As in, Polish-cavalry-facing-Nazi-Panzer-divisions overwhelmed.

Unfortunately, that was pretty much exactly what happened. But let's not get ahead of ourselves.

I went down to the Emergency Department, and turning to the electronic record, I did the “chart biopsy,” where I looked up what I could on this patient. He has a history of seizures, well controlled on tegretol. He was in the hospital most of last month after a stroke, and while there he also had ischemic colitis. Ischemic colitis means not enough blood flows to feed the intestines, so a portion of them die. He also had two pituitary surgeries in years past for a slowly growing benign growth. These surgeries can often affect the brain itself. He has high blood pressure, high cholesterol, low thyroid, and a funny heart rhythm. Walking into the little patient bay in the emergency department, I see he is also still not responsive.

His wife is sitting by the bedside. She confirms most of the history, adding a detail there, creating holes elsewhere, and usually not being able to confirm or deny my questions.

"Why is he on fludrocortisone? How long has he been taking that medication?"

"Has anyone ever told your husband to be careful about how much water he drinks?"

She has no idea about these, but she is able to tell me that she thinks her husband would want to be a “full code” where we try everything we can to save him in the event of his heart stopping. I dutifully note that down on his admission papers.

Continuing through my admission interview, I am nearing the end when the attending suddenly appears at my side, deus ex machina. I update him on what I had gleaned, he asks a couple questions, and then we excuse ourselves to talk about the plan. What did I think? Was this a seizure? Was it a new stroke that the CT did not pick up? Since we can't get an MRI because of his hip, what should be our next step?

"Well, it's straightforward, you see," said the young and smart and dashing young attending, quickly. "You need to figure out if this was a seizure or a stroke or his heart, or maybe it could be his lungs. So, here's what you do. Order an EEG tonight, get a neurology consult for the morning, and with no MRI available (because of his fake hip), recheck a CT of his brain in 24 hours. Keep checking his cardiac enzymes and EKG's for signs of myocardial infarction, and watch him overnight on the heart monitor. It very well may be his lungs, since he could have gotten some of that vomit down the wrong tube. So just check his chest film again in the morning. There is going to be a blossoming pneumonia there. Dollars to donuts, Bryce, there'll be a pneumonia. But he might have a big clot in his lungs, and since we can't get a CT scan for that because of his kidneys, we'll check his legs for clots, since that's where those would have come from, and then we can get a V/Q scan sometime tonight. OK? So I'm going to take off now, but why don't you go get him tucked in tonight and write these orders. I'll see you in the morning."

And just like that, my deus ex machina went right back to wherever it was he had come from. I do not know where backstage is at the hospital, but I am desperately trying to find it. I was left there, center stage, to walk this patient upstairs. Once we were on the medical floor I noticed that Mr. RM seemed to be breathing pretty heavily. Thinking on my own, I asked the respiratory therapist to come down and get a blood gas, and to get ready to start him on BiPAP while I kept working on his admission paperwork.

His new nurse, on the other hand, was more concerned. "He looks pretty sick,” she said. “Don't you think he needs to go to the ICU?"

“No. He was just seen by the attending a few minutes ago. He said the patient should come up here. Let’s get the gas and BiPap him.”

(I should interject here that my training situation is likely different than any you may have heard of elsewhere. It is nothing like TV, and it is almost certainly not like your hospital. At my residency, there is no team with intern, senior resident, and fellow in a hierarchy before reaching the attending. There is the intern. Then there is the attending. I do not have a senior resident that I report to before either of us discuss the case with the attending. Any patient you admit on call is yours and yours alone. You call whichever attending normally sees that patient as an outpatient (or the hospitalist on the case) to staff the patient each day. There are no table rounds. There are no herd rounds. Again, it is just you, sitting alone on your horse, holding your shiny-new-MD-diploma-of-a-sabre, staring across the battlefield as diseases launch their Blitzkrieg).

As I continued working on his orders, the respiratory therapist came and told me she could not get the blood gas. Poking my head in the room, I reassess the breathing. The patient now seems to be having Cheyne-Stokes respirations, where they breathe quickly for a period and then slow down, almost stopping, then start breathing quickly again. I tell her to go ahead and start the BiPAP now and then get the gas. I do not, however, return to my paperwork.

Watching the patient makes me more and more nervous. After waiting only two minutes for the respiratory therapist to grab the BiPAP machine, I begin thinking the nurse was right all along.

“How do I get a tube in a patient on the floor?” I ask.

“That has to be a doc-to-doc. Call one of the intensivists.”

“Well, why don’t we do that. Would you call one for me?”

A few minutes later I am on the phone with Dr. H, updating her on the situation with this patient. She would be happy to come down and help me out.

And that was when everything started to fall apart.

Since I am new to this process, I do not try and intubate myself. Shortly after Dr. H intubates, however, she asks me if we should call a code blue. Feeling for a pulse, we discover the patient had entered the realm of pulseless electrical activity, where the monitor looks fine but the heart is either not beating or only beating so poorly no blood is actually being pumped. We roll the patient up, put a backboard under him, and I start to give chest compressions.

It is difficult to describe, but when you feel an octagenarian’s ribcage crumple like a box of Kleenex under your hands as you start CPR, you can almost feel your own chest collapse. At least that is how you feel when you’re the admitting intern. As people continued to pile into the room, responding to the code, I feel myself stop thinking. Brain dazed, I keep thinking that the attending just saw him, not 30 minutes ago. What did I do? How did I let this patient get to this point?

I have been in codes before this. I have given CPR. I have seen patients die. I have been there after codes for those discussions with family afterwards. I have pronounced patients dead before who had died in front of families. This time, however, was different. Very different. This was my patient. I could not escape the feeling of horror as I watched, almost in third person, as we struggled to save his life.

After fifteen minutes, I walked down the hallway to talk with the wife, who was sitting with the social worker in a consultation room. Her face mirrored the emotions I felt surging within me: confusion, horror, and fear. I found myself having a discussion I barely understood.

“Mrs. RM, I’m sorry to have to come and discuss this with you. We are not sure why, but your husband’s heart is not beating effectively, and as you are aware, he was not breathing well by himself. Right now we are breathing for him and keeping him alive with chest compressions. We are still trying to figure out the different reasons why his heart is doing this. I know this is difficult, and we talked about this already downstairs, but should we keep doing this? Do you think your husband would want us to be giving him these chest compressions?”

As she said yes, I could see the fear and horror crowding her eyes. After walking down the hallway to his room, we kept going. Fifteen minutes later, I walked the reverse course, back to the consultation room.

“We are still looking for a reason, but the treatments we’ve tried have not been successful yet. We will keep trying.”

After another quarter of an hour, however, we had exhausted all of our ideas. We had checked the labs we could, given the drugs that might have helped. There was nothing left to do. Despite everything we had tried since he got to the hospital, some things had not changed. Mr. RM was still unresponsive. But now it was much worse. And much more permanent.

While the code team dispersed, a few people staying to help clean up the body, I slowly made the walk back towards the wife’s room. While I have had classes that covered how to deliver bad news, I have never felt as unprepared as I did at that moment.

“Mrs. RM, as we talked about, your husband’s condition was very serious. We have tried everything we could, but the other doctors and I agree, there was nothing more we could do. I’m very sorry to tell you that your husband has passed away.”

And just like that, I realized I was in way, way over my head.

*(actually not really his real initials, because even though I've worked with HIPAA rules my entire career, I have no idea what they really mean).

**I’ve taken the liberty of rearranging the order of this ED doc’s presentation, because he practically gives it backwards. Literally the last thing he told me was the patient’s age. I knew about his negative CT before I knew he was unresponsive.

Allow me to offer one additional thought, which I don’t mean to sound pretentious. I am not trying to pretend here that physician's have the hardest/best/most anything job on the planet, so please don't take that from this thought. Everyone I talk to about my training gasps about the hours. “You’re working 80-90 hours a week? That’s horrible.” Well, nearly everyone. The old-guard physicians think we're pansies for not spending 120 hours in the hospital a week like they did. Regardless, the hours can be tough, for sure. 30 hours straight of being awake is difficult. There is a very good reason no one stays awake all night after they graduate from high school – because it’s not actually any fun. But the hours are not what makes residency difficult. A 30 hour shift is actually pretty manageable. What makes residency hard, such a challenge, so draining, is the weight. The weight that comes with the decisions you make is what makes this different. It’s not about putting in hours. It’s not about “surviving” three to seven years of residency so that you can live the good-life of an attending, golfing to your heart's content. Residency is about a lot of things, sure. Learning how to remove an inflamed appendix or how to best manage diabetes are important, sure. But so far I think it is more about learning to deal with the weight. And I’m not sure that weight will ever go away. Because Mr. RM isn’t ever coming back. And that has some weight.

(As an aside to those of you close to me. I know this sounds depressing. It was. It happened in August. I’m doing alright.)

Sunday, October 17, 2010

Quote of the time-period

Le mieux est l'ennemi du bien,
The perfect is the enemy of the good.