January 2006 Archives
I had a startling realization the other day. I am cut off from the world. I have no idea what's going on. If it isn't on NPR between 5:45 and 6:15 in the morning, I have not heard of it.
For example. *Apparently* there was a humerous rap entitled "Chronicles of Narnia" that aired on Saturday Night Live a few weeks ago. It made a big splash and rapidly circulated on the internet and the entire world heard about it in a matter of hours. How did I get wind of this pop culture explosion? I heard about it a couple days ago on NPR's Marketplace, the daily economic show devoted to all things business and stock-market related. Apparently the rap was good product marketing for brands such as Mr. Pibb, who was experiencing a dramatic increase in sales because of the line "Mr. Pibb + Red Vines = Crazy Delicious."
I HEARD ABOUT IT ON MARKETPLACE.
I was also unaware of Kobe's near-record 81 point game, until Josh told me night before last.
This is simply ridiculous. I need help.
I assisted my intern on a "pronouncement" the other day. A death pronouncement. Whenever someone dies in the hospital the intern on call is paged, and it is their job to verify that the person is indeed dead and then officially document it in the chart.
We arrived at the room, to find a hand-written sign taped to the door. "DO NOT ENTER," it read, "Please go to nurse's station first." Obviously that was put there for the benefit of any unexpected visitors, to try to prevent the unimaginable shock of a family member walking in to find that their loved one was no longer of this world. We ignored the sign, and entered.
Now, I have been around a lot of dead people. I have observed and performed dozens of autopsies, and can honestly say that I do not find it gross or creepy to be in the presence of death. But it was an odd feeling to be in the position of having to prove death. In all my previous encounters with the departed, their death was a given. It had already been established, without question or uncertainty. Not that the death of this person in front of me wasn't certain - indeed, it was quite obvious - but it required the formality of proof.
Listening for a heart that did not beat... feeling for a pulse that was not there... watching for respirations that did not occur... shining light into eyes that were fixed and motionless. Holding my stethescope for such a long time against a startlingly silent chest. The skin was still warm. The mouth gaping. I had to gently press the eyelids closed, as they did not close on their own. Not that it mattered, really. Its funny that we desperately avoid having to see the eyes of the dead. Like somehow with closed eyes we can maintain that child-like fantasy that they are sleeping and comfortable. The eyes bring them back to earth.
It made me think about why we need a formal pronouncement by a doctor. Why did they need the 27 year-old intern, 8 months out of medical school, to call it? Why did her MD title make it official, when any nurse, or hospital worker, or person off the street could have easily come to the same conclusion? I think we have a fear in our society - a fear that is perpetuated by B horror movies and old Tales from the Crypt episodes - that it is actually possible for someone to seem dead and have an autopsy performed on them while they are in reality alive and screaming on the inside. I swear I have seen this on tv. I guess it even goes back to the poisons taken by desperate lovers in Shakespeare's day, where a potion could give all the appearance of death, enough to fool doctors and priests and forbidden boyfriends. I can gaurantee you, this is impossible. But I bet some weird stuff has happened in the past. Foul play involving inheritances and estranged wives and ilegitimate children and life insurance policies. I suppose it is good to have a system in place to legally and impartially declare death. It will be weird when I am the one to make it official. I guess that will be one thing that medical school has taught me: I know how to diagnose the absence of life.
I used my new calculator wrist watch the other day to calculate a patient's functional excretion of sodium. This was then used to determine the cause of their renal failure.
Medicine + Calculator watch = Saving Lives
I have a soft spot in my heart for little old folks. Perhaps they remind me of my own grandmothers. Perhaps they remind me of the fragility of the human body and the need to care for one's elders. Maybe I like them because, even though I have to yell sometimes or repeat things like "CAN I LISTEN TO YOUR HEART, MR. ALBERTSON?" multiple times, the elderly folks I meet in the hospital are nice to me. They are polite. I feel like I can squeeze their hands in an attempt at reassurance, and they may actually be reassured. I can chat with them about their pretty pink nail polish. Sometimes I can trick them into thinking that i know something. They often call me doctor.
I admitted a guy a few days ago who, when I asked him whether or not he drinks alochol, launched into a detailed acount of leaving Germany in the 1930's to escape the Nazi's. The Nazi's! This man lived through all of that, and now I am talking to him in his adjustable hospital bed, surrounded by IV lines and beeping monitors, in this modern, hectic hospital. Medicine usually doesn't have time for stories about Nazi's. I think my team was frustrated with me for not interrupting and getting a quick answer to my question. But seriously. He's lived through so much; the least I can do is listen to his stories for 2 minutes before scurrying away with my clipboard and list of orders.
My team has been indundated recently by a wave of geriatric patients. A "geri invasion" as my resident said. In general old folks are more complicated, more medicated, and much more work, but they are fun to work with. Most of them.
But working with the elderly means confronting death, or atleast the thought of it, on a daily basis. I have been a part of 2 conversations in the past 2 days with patients who have an estimated 6 to 12 months of life remaining. And both were content, satisfied with their lives, excited about the thought of joining loved ones. I know it could never be that easy for me.
Question for the day: part 1: When will it stop raining? part 2: Why did that lady crash into my brake light with her car? And why did I only tell her it would cost me $20 to fix? I should have gone for atleast $25.
First week of medicine rotation: DONE.
Things I have learned:
- renal failure is bad
- heart failure is bad
- pneumonia is bad
- hyponatremia is bad
- heart attacks are bad
- arrhythmias are bad
- these things invariably happen to every single patient who is admitted to a medicine ward.
Well, perhaps that is a slight exaggeration, but man, these people are s-i-c-k. Its funny the terms that you aquire after being in a medical field for a long time. The best word that I can use to describe the patients that I have been seeing is: complicated. One of the patients my team recently admitted was introduced to us by the ICU team as a "trainwreck." They are far different from the patients I have worked with on my surgery rotation, or on my family rotation, who mostly have like one thing wrong with them. Two tops. But it seems like everyday that goes by something goes wrong with a major organ system of every patient.
Like I admit you for pneumonia, and then you into a-fib, and then you go into renal failure, and then your electrolytes get all out of wack, and then your bowels stop working. And I'm like "Why??" Why are theses things happening? And its such a scramble for me to understand whats even going on, much less formulate a diagnostic and treatment plan. And every day I feel like I have the most tenuous grasp on what's going on. And I feel so inefficient.
Maybe some day that feeling will go away.
In the mean time, just give me someone who needs some stitches or something. I might be able to handle that.
On the up-side: everyone on my team is a vegetarian!
With monk-like fervor. With glorious ferocity. With pureness of purpose I will give myself over to the study of healing. Completely. In the cloister framed by the walls of anatomy texts and computerized lab results I will battle back the deep-eyed demons clawing at my soul. I will win. I will learn. I will create warmth out of knowledge. I will win.
This is not a new years resolution.
Even as I write this, I know that I will not do this. I am not the kind of person who is able to do this. I wish that I was. My life would be so much easier if I could honestly just study and study and sacrifice everything to the multi-armed medical school gods. They are vengeful gods, I swear. But alas, I like tv too much.
My life now officially belongs to Medicine, whether I'm ready or not. With a capital "M"- Medicine. As in the Internal Medicine rotation that i started today. Its funny, beginning a new clerkship. If you're like me, you start it by showing up late because you have to ride your scooter across town instead of using the highway (the gods were forgiving - they have been briefly appeased by the studying I did on my vacation - and my lateness went unnoticed and unpunished).
Then, as you enter the resident call room filled with residents who turn and stare at you in your little white coat, you can't decide whether it would be better to address your intern (who has only recently graduated from medical school) by her first name or by "doctor so-and-so." Then you realize that you don't remember her last name. Then you mispronounce her first name.
If you're like me, you have spent the first half of the day hoping against hope that you will not have to work up a patient today. That would be entirely too much. They must see that. Then the first thing your senior resident says is "we have a patient to admit this afternoon." "Great!" You say. "She can be your patient." "Awesome!" you say. And on the way to her room, you still cling to the ridiculous notion that perhaps they will let you observe, just this first time, being as its been so long and all. And then he says "we will observe you while you do the history and physical." And you say, with a nervous laugh, "I warn you, I'm a little rusty." And no one else laughs.
Then you do it and it is rambly and sucky and disorganized. But they are nice and lie to you and tell you that you did a good job. And then later you have to go back and watch the intern ask all the questions you forgot to ask.
And hence it begins. The battle commences. I resolve to try.