ethics · PGY-1 · residency

Post-call

Three people died on my last call.

One was a middle-aged woman who overdosed on everything imaginable. Found down, apneic, cyanotic, brought in. God knows who called 911 on her. I called her family from the ER. They came in straight away, the father’s eyes rimmed with red, mother looking frazzled, a niece still wearing her ID badge from work. She was tubed by then, pupils dilated like belladonna, the beautiful lady. Six hours later, I sat down with the family, explained the situation, that she was gone long before we laid eyes on her, no reasonable chance of recovery. A pH of 6.7, I did not say but thought, is not compatible with life. They cried — I’d forgotten to bring in Kleenex, lesson learned — and decided on palliative extubation. Or in EMR-speak, “Withdraw from mechanical ventilation” and “discontinue pressors.” The parents hugged me and thanked me (which made me feel sick, because they were thanking me for their daughter’s death) and left, crying, clinging onto each other, through the big double doors of the MICU. I walked into the room with the nurse and respiratory therapist, we drew the curtain, and waited. Her pressure came down, slowly at first and then faster and faster like a small child tumbling down a slope. She brady’ed as her coronaries stopped perfusing and her myocardium shuddered to a halt. Pulseless electrical activity, and then asystole. RT hands me the stethoscope; I hate listening to a person’s chest who has died, it’s frightening because you expect to hear something in a chest, and the absence of that is bone-chilling. Thirty seconds after asystole, her face had already gone that horrible yellow-gray of death. So I pronounced her. I never knew what prompted her to kill herself. I’d never even spoken to her, and still I felt this indescribable sadness at her death, not at the waste of resources (which the nurse kept talking about) but rather at the waste of possibility. Maybe she was a horrible drug-seeking child abusing murderer, I don’t know. But I was in the room when her tracing went flat, and she was my patient.

Simultaneously overnight, across the hall, another patient whom I’d admitted earlier that day was hemorrhaging wildly into his lungs. My resident was intubating him and placing a central line. His wife stayed at the bedside the whole time, wrapped in a Fair Isle blanket. It’s cold in the hospital at night, colder when you are watching and waiting for someone to die. This guy made it through the night, and this morning, a long discussion with the wife and son, and they decided to extubate as well. I wasn’t there when it happened, but I like to think his wife was at his bedside, holding his hand.

And the third, an overhead code called in the middle of rounds, a new admission who suddenly unexpectedly stopped her heart in the corner room.  In a code, the first step is to take your own pulse. And mine was pounding in my ears as I slammed on her chest. Compressions for 45 minutes. Ribs snapped; they always do. She got a pulse back, briefly, lost it, returned, lost, and finally back for good. No brainstem function. They are cooling her in the hopes of saving something. I think she had overdosed as well, but accidentally.

I stayed another three hours, finishing my work, then left exhausted, arms aching.  I stopped by the local bakery on the way home, where the girl behind the counter was a college buddy but how have our lives diverged. She has a two-year-old, and I just killed two people (because they aren’t dead till a doctor pronounces, and it’s my signature all over the paperwork) and resurrected a third.

I don’t feel like a normal person right now. The sleep deprivation may have something to do with it, but it’s also the rawness of the ICU. I’m not a religious or even a spiritual person, but being so close to Death, and in that first case, standing in the room as it slipped itself around my patient, and you can’t help but acknowledge its power. Perhaps it was easier in the old days, when death and birth occurred at home and everyone was much closer to it. Now it’s in hospitals alone, behind drawn curtains, and we can’t talk about it outside, when the sun is shining hotly and the college kids are walking around in sundresses and polos.

ethics · MS-4

Confessions of a Clinical Ethics Weakling

I’ve been looking around from some decent readings on medical ethics. I took a course in college, which was taught by a lawyer and therefore had a totally non-clinical spin. It’s dry and academic and abstract, completely ignores any discussion of the relationship between patient and physician, which grounds any ethical discussion. Was flipping through the text the other day, to help me think through a challenging case we have on service, and I realized how utterly inadequate my understanding and ability to reason through ethics is.

So how ’bout it? Any suggestions for clinically-oriented, practical ethics* readings?

*An oxymoron?

clinic · ethics · MS-4 · narrative medicine · neuro

I spoke too soon. Last night’s class was the best yet; the debate was really intense, and even the really quiet ones had a lot to say. See, that’s the power of a really great story — it attacks you and forces you, sometimes against your will — to pay attention. Moments like that really make me love teaching.

Today, workwise, I was down on the Eastside practice with my preceptor, and then seeing patients on my own in the residents’ clinic.  It ran the gamut. The Eastside is private, very classy with paintings on the walls, patients who have done their homework, pleasant staff. The residents’ clinic is in the old, old part of the hospital, with cinderbrick walls and tiiiiny little exam rooms — I think the one I was in used to be a closet. Not even joking.

Of course, the quality of care is no different, because these are the same doctors, with the same brains. But I can’t help but wonder how much the ambiance affects the patient’s perception of the visit. It really disturbs me, the extent of the rich/poor dichotomy here. (Fun fact: our ED is in a different building from the hospital because the donors apparently did not want the uninsured rabble being too loud for the private patients. And don’t get me started on the Fancy Rich People’s Ward.)

I suppose that in the end, it doesn’t really matter, because the doctors are the same, the medicine is the same, even the computer system is the same. How much difference can a pretty painting make, when you’re sick? Both practices have access to Really Smart People, and both function very smoothly. But as a patient, I definitely know which one I would rather go to — even if that induces a fair amount of middle-class guilt.

ethics · narrative medicine · news · pharm

Finally, the Well blog, that bastion of doctor-bashing, has a pro-allopathic medicine article.

As with all posts on Well, the comments are where the real money’s at.  People share their encounters with physicians that are (usually) related to the topic at hand. Usually these are negative, because complaining is more fun than being supportive.  (I know. I complain a lot.)

Today’s are negative as well, but for once they are pointing out the problems with the quackery of alternative medicine.  Not all alternative medicine is crap (e.g. acupuncture for relief of nausea during chemo, which one of the comments mentions), but as people point out, but when you start to say that you can move energy spheres around, and don’t back it up with a study — I’m sorry, you’ve lost me.  There’s not a lot of difference between a GNC herbalist store and the patent medicines that peddlers sold at the beginning of the 20th century.

The article itself talks about the problem with celebrity endorsement of alternative medicine. For sure, celebrities are very visible, and people are sheep (including myself; I pretty much want to beEmma Thompson when I grow up) but taking a single person’s anecdotal experience over the recommendation of someone who has studied a subject for 15 years seems … idiotic. I would be like me telling someone that I won the lottery by framing the card upside down and dancing a jig — so you should too!

Emma Thompson approves of my plan to take over her life

(I probably just pissed some people off by implying that alternative medicine is doohickey. But here’s the thing: medications and procedures proposed by Western medicine have to be carefully studied to see if they are safe and effective. This process often takes years, especially to study long-term effects. Alternative medicine people, bring me your evidence. Then we’ll talk.)

Actually, I’m just glad — especially after the disability studies talk — to see that there’s still support for the type of medicine I’m learning: evidence-based, pro-patient, let’s-not-kill-people medicine.

ethics · MS-1

Everyone’ s a little bit …?

As part of my student membership in the AMA (because I like to maintain some semblance of political understanding), I get a free four-year subscription to JAMA. I don’t often read it, because I have enough to read, and I can never really understand all the drug trials and whatnot anyway. All that doctor-y stuff seems so far away.

But today, as I was idly flipping through it on Google Reader, I came across this article, which echoes many of the sentiments I’ve felt in the past. As the American-born child of Indian immigrants, I’ve had to deal with back-handed “compliments” like “Wherever did you learn to speak English so well?” “Um… Northern Virginia.” (I was tempted to add “What about you?”, but as it was my supervisor at a summer job, I thought it unwise.) The worst that’s happened to me, I think, was profiling by the police at Times Square on New Year’s Eve.

Usually, it’s older people who say things like this, but I’m not sure that’s such a great excuse. After all, by “older” I mean people in their 40s and 50s, the generation that grew up during the civil rights marches. And sometimes, even from my peers. (One of my classmates once said, laughingly, that she was the only American in our group of 2 Canadians, 1 Chinese girl, 1 Colombian, her, and me. “Hey,” I responded with a smile, “I’m just as American as you!”) There was even a time — and I’m ashamed to admit this now — that the frequency of these comments made me wish to be Caucasian, just so that people would accept me as the nationality I am.

There is a lot of talk about the melting pot (I believe the new PC metaphor is the “salad bowl”) but when it comes down to it, this country — or certain segments of it — unfortunately say or do things that are xenophobic. Not even xenophobic, because as I say, I’m not foreign-born, and immigrants of European ancestry, as the article points out, usually never encounter these problems. Come on, come on, let’s use the word: racist.

The author of the article is, I think, a little overgenerous in her dismissal of the racist comments she’s encountered. A diagnosis of a serious illness is certainly overwhelming, but it doesn’t give you a free pass to be an ass. She also argues that her own “profiling” of physician-colleagues encourages patient discrimination, but again, that doesn’t excuse the patient at all. Each of us is responsible for our own actions and thoughts.

Which begs the question: how to deal with patients who make openly racist or discriminatory comments? I’m sure I’ll encounter some. Is there any sort of recourse for physicians who are discriminated against by the people we are supposed to be helping? Does professionalism really demand that one ignore these issues? At what point will I be confident enough in myself to say — both in my professional and my personal life, “Excuse me, I find your comments to be unacceptable.”

[Edit: I think I should point out that I wouldn’t withhold care as “revenge,” though I suppose I would ask that another physician take over the case. But really, that’s just running away from the issue.]

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