YOLO

Heralded by screaming lights, a man was dropped on our doorstep. Sepsis. Diabetic keto-acidosis. The brink of death.

He was also cachectic from decades of drug abuse and malnutrition, and didn’t have much reserve to fight the illness. He was struggling to breathe. He looked on with hollow eyes. We knew right away he wasn’t going to make it through the night.

Because the foreseeable outcome was so extremely grim, we were upfront in asking this man exactly what he wanted from this hospitalization: How did he want to die? Would he have us pave for him a comfortable end? Or would he have us wring out every last drop of frail existence before throwing in the rag?

To our surprise, he didn’t give us permission to let him go. In previous months, his life had been repeatedly spared in hospitals. But each time, he was restored to lessons unlearned—if he was better, he was better enough to overdose. So said his family, but he didn’t believe it.

So onward we fought.

These are Medicine’s most trying moments. I have sent off many people from this world, now—always when they’re ready, and sometimes when they’re not. It’s humbling and gratifying to be the last friend in a well-lived life, the one to bestow a parting IV and hospital blanket in the final glow of sunset. It’s frantic and dissonant to be the desperate arm over the cliff, the one obliged to hang on until the last futile chest compression. So often I’m assigned the latter role by patients with too many regrets in too little time.

Miracles are doled out too, in small packages of insulin and antibiotics. This man survived to wake up tied to a hospital bed, and—this is the miracle—to think to himself, “This ain’t me.”

The next few days were excruciatingly painful. We gathered everyone—patient, family, and doctors—to have a big heart-to-heart. The man expressed his resolve to come off all narcotics forever. The family had heard it all before. The medical team decided to test his resolve by taking away his pain medications gradually. We had legitimate reason to be skeptical, as he had legitimate reason to be in pain. Every morning, I asked about his pain. The answers went from “Okay” to “It’s 8 out of 10, but I can get used to anything” to “It was more than I could take last night, but I’m bound and determined to do this.” I don’t know how, but every day his smile grew wider and he was able to walk farther. All the while, his severe joint deformities were a constant reminder of his strength in coming face to face with this pain for the first time in so many years.

He later told me of the transformation that came over him. The morning light was breaking through the blinds. He was strapped at his waist. The nurses were eerily quiet in the hallway. He thought of what we had told him, that we expected him to die from the consequences of his habit. “I haven’t been scared since I was in Vietnam crawling through the jungle. But that night, I was ready to put on my street clothes and run!”

I don’t know if all this will last. But thanks to him, I’m willing to give a second chance to many more of my future patients. I wouldn’t have believed that, with either his body or his mind, he would make such a recovery. Now I’m starting to think I’m in Medicine to be proven wrong—and, in the process, to be made better.

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Graveyards In A Hospital

I survived my first week of doctorhood! And, more importantly, so did my patients!

During one of our orientation lectures, we were told that as interns, we are “entitled to stupidity.” Despite all that we’ve been doing the past 4 grueling years, no one expects us to know anything right now. Therefore, we should take advantage of this time to ask questions and make mistakes… you know, as long as we don’t kill anybody.

Well, that’s awkward! In any other profession, I feel like “Don’t kill anybody” would be setting the bar pretty low. Granted, outside of medicine, customers generally aren’t dying to begin with; when people walk into a grocery store, they aren’t complaining of chest pain. But I’ve read enough textbooks and passed enough exams to know how not to kill any given patient, don’t you think?!

I changed my mind at about 3AM today.

My first shift covering the hospital’s Medicine service was overnight on a weekend, after a full regular workweek. Having never even pulled a true all-nighter in college or medical school, I had no idea how this would go. At 7PM I showed up to meet my day-shift counterpart. He was holding a handful of lists, and after about 5 minutes of brief introductions, all 25 or so patients on those lists became mine. That was a chilling moment!

I took the lists, and a slow deep breath. I asked, only half-jokingly, “Are you sure you trust me with all your patients?” He said, “Of course I trust you!”

By midnight I had admitted a couple more patients from the ER, written a handful of orders, and successfully fielded several pages from nurses. I’d finally gotten used to introducing myself as “Dr. Meservy,” and I was starting to feel like it too.

At 2AM, my fellow night intern and I were sitting side by side, typing up our notes on the new patients we’d admitted. I was trying to read up in the literature about my patients’ conditions so I could incorporate good reasoning into my notes. I was constantly interrupted by the pager. Neither of us could stop yawning. We agreed that pulling a life-saving all-nighter was just about the craziest thing anybody had ever expected us to do.

Shortly after 3AM, I received 3 consecutive pages from the same nurse. A critical lab value! Something might kill a patient! After calmly telling the nurse that I would call her right back, I ran over to my senior resident and asked, “WHAT ARE WE GONNA DO?!” Together we made a slew of fast decisions that ultimately reversed the danger and stabilized the patient. This was followed by more deep breaths and more note writing.

In the morning, our management was met with both praise and criticism. We did the right thing overall, but we overlooked some minor details and we didn’t meet everyone’s preferences. In the daylight, our little mistakes became blatant. But in the moment, we were scared and tired and didn’t have much time to act. If the situation had been more critical, with less room for error, maybe it would have made the difference between life and death for that person.

This all leaves me wondering, was it in a hospital that they came up with the term “graveyard” shift? Now I know: if somebody were to get killed, this is probably how and why!

Trauma, Death, and the Big Picture

In reading this eulogy of Steve Jobs written by his sister, I was tickled to learn that on his ICU bed, Steve was inventing hospital gadgets.
One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.

I told him: Steve, this is special treatment.

He leaned over to me, and said: “I want it to be a little more special.”

Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit.

For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.

By that, he meant that we should disobey the doctors and give him a piece of ice.

I just came off my first overnight call in the Trauma ICU, after working 31 hours straight. This sketch of Steve is just like the patients I’ve met this week: can’t eat, can’t breathe, can’t move, but would like to go back to skydiving ASAP.

I think there are generally two types of ICU patients. There are the vegetables subsisting on life support, and the rest are feisty. The bull-rider with multiple spine fractures insists on bull-riding again the next day, even as he struggles to sit up. The teenager, whose ATV accident required brain surgery, asks me every hour whether we can take out the tube draining the bleed within his skull: “Will it be later today? Not ’til tomorrow? I can’t sleep with this thing coming out the back of my head.” As I write this, a man whose brain is exposed by gaping holes in his head, is trying to pull out every IV and monitor and walk right out of the hospital.

It seems as though these patients have an entirely different set of priorities than their doctors have for them. We want to manage their fluids and electrolytes. We want to make sure they have an airway. We want to save them from dying of pneumonia, of ischemic bowel, of cardiac arrest. But all they want is to continue whatever they were doing that landed them in the hospital in the first place. Don’t they learn from their mistakes, and don’t they realize that they can’t live without these devices and measures we are taking for them?

But as damaging as it can be to a doctor’s ego, I get it. I don’t believe our work is more important than the lives we save. We bring out the defibrillators and ventilators to make people continue living, but that is not what I consider “saving a life.” People don’t live to have normal potassium levels measured in their blood. People live to bull fight, to dirt bike, to invent computers, to be home with their family.

Obviously the basic needs have to be met in the hospital. It can be a cruel process, and patients may not get that ice cube after they’ve already starved for days, but we take great consideration in the treatment plan and believe that what we’re doing is for the best. But after the healing is done, when bodily functions return to baseline, then what? Our story ends with the hospital discharge.

But the hospital discharge is the beginning of a longer road to recovery and life. Lots of changes and arrangements have to be made at home. The patient may be a burden to their family for a long time yet. That is why, beyond getting to leave the hospital bed, my hope is that these patients can survive to the next time they can do what brings them joy, whether it’s strapping on a parachute or bouncing their child on their knee. To me, that’s when their life has truly been saved, not a moment sooner.

To Fight

Have you ever had a doctor break down and cry with you as you received bad news? Sometimes I have to work really hard not to be that doctor.

Each day in Oncology clinic, I see all the stages of grief. Everyone battles cancer completely differently, and I get to experience it all as one giant roller coaster.

One minute an old woman comes in after her last round of chemo left her hospitalized. She absolutely insists on taking another round. Her doctors hesitate to give her more chemo and radiation than she could tolerate, yet she refuses to go to the grave without having pulled out all the guns. The defiance in her eyes is contagious. I want to shout, “Yeah!! Go get ’em!”

Next thing we see a young man whose cancer had no business interrupting the course of a well-plotted life. He’s already nauseated just worrying over how the treatments will affect his family. He and his wife raise a slew of questions, exploring every crevice of every possibility. Our uncertainty makes them visibly uneasy: Curing cancer is a numbers game, from our perspective. But for each individual patient, we either achieve a cure or we do not—and the side effects are definitely not worth it for a not-cure. I wonder if he might talk himself out of getting any treatment at all.

Then we get a happily oblivious patient, a guy with brain tumors so far gone that he no longer has the capacity to understand his own plight. We try to explain that he needs to take his chemo pills diligently. He smiles pleasantly and agrees, indicating that he clearly won’t do anything of the sort. While this is truly terrifying to me, part of me also thinks that perhaps, for a cancer patient, he is in the best of all worlds.

The tearful patient really gets to me. Someone had given her false hopes about her prognosis, so then it became our job to set the record straight. The doctor apologizes profusely. The patient retreats into heaves and sobs as she begins to mourn her own death all over again. In her mind, we have just killed her. I hand her a box of tissues—inadequate for the gravity of the situation. Yet she smiles briefly as she takes the box from me. We continue the conversation as she empties the box. Pagers ring, and we silence them without answering. Occasionally I stare at the ceiling so the tears won’t crash down.

Where in my medical training was I supposed to learn how to let a patient die? How do I tell the dark news, and then, how do I react? Do I grieve the disease, or do I fight it? What does the patient need to hear? Is it inappropriate to laugh with them? To cry? Is it unprofessional to admit that the cancer, in beating the patient, is also beating the doctors?

What is a good doctor?