The chaplain that works at the House told me when I started that he can always tell when patients are brought up under a works based or faith based belief system. I started paying attention to this myself, and noticed the trend. Often when patients think that what happens to them after they breathe their last breath is based on what they've DONE in life, hey start getting nervous. They question if it was enough, they have bad dreams, they get agitated when awake and often fight dying right to the last moment. It's hard to feel secure if the only thing that counts was your actions in life. In contrast, those who believe they are loved despite what they've done are always calm. They sleep peacefully, spend time sharing memories instead of questioning the past, and they die gently. It seems oversimplified, but the pattern is present everyday that I work.
Tuesday, July 24, 2007
Sunday, July 15, 2007
The Cruise
This is not the way you'd like the end to be. A sweet elderly man with cancer had been living with his wife at home. She managed to arrange for him to be admitted to a rehab facility. This in itself is silly- because rehabs are for people who have things you rehab from- like car accidents, strokes, heart attacks. When cancer is riveting your body, doing physical therapy 3 hours a day isn't going to help you get better.
The real reason for the rehab soon was evident- because the day she dropped her dying husband off, she left town for a cruise with friends. Didn't call anyone while she was gone, never checked in with her husband. It was if she skipped town. The poor man was heart broken, like an old dog someone leaves at the pound. He declined very rapidly in the rehab place. The rest of the family had to step up to decide what to do next. That's when they opted for the "house". I met him when he arrived. He doesn't have long to go, but this sudden abandonment is weighing on his mind. Though he hasn't said a word, he's restless and sits, leaning forward with his head in his hands. Occasionally he slaps his fist against his other hand. He's struggling, and fighting his thoughts. He's angry and devastated, and dying with things unsaid.
The wife is due back in town today. The family wonders if she'll even try to find him. It might be good if she does come, perhaps giving him a way to let go of his anger. It's his only hope to go peacefully.
The real reason for the rehab soon was evident- because the day she dropped her dying husband off, she left town for a cruise with friends. Didn't call anyone while she was gone, never checked in with her husband. It was if she skipped town. The poor man was heart broken, like an old dog someone leaves at the pound. He declined very rapidly in the rehab place. The rest of the family had to step up to decide what to do next. That's when they opted for the "house". I met him when he arrived. He doesn't have long to go, but this sudden abandonment is weighing on his mind. Though he hasn't said a word, he's restless and sits, leaning forward with his head in his hands. Occasionally he slaps his fist against his other hand. He's struggling, and fighting his thoughts. He's angry and devastated, and dying with things unsaid.
The wife is due back in town today. The family wonders if she'll even try to find him. It might be good if she does come, perhaps giving him a way to let go of his anger. It's his only hope to go peacefully.
Wednesday, July 11, 2007
Unquiet mind
I've never been so close to an unraveling human brain. A 70ish man had collapsed after having a bleed in his brain. He'd had other complications in the hospital including a seizure and respiratory failure. We met him when he was already on the breathing machine. Unfortunately, even with no medicines to make him sleepy, he was still not responding, even when we caused him pain. This is a very ominous sign.
This man had a wife and a severely mentally challenged son. His wife and son would come visit every day at the same time. The son was in his 30s, with debilities in seeing and cognition. He was a gifted pianist and always had headphones on listening to music to keep him calm.
A helpful thing in this case, was that the patient had an advance directive that spelled out exactly what he'd want and not want in this situation. It was explicit that he'd not want to be on the breathing machine, or have dialysis or even tube feedings. Our team had begun the slow process of helping support his wife and walking her through the process of letting go.
Unlike any other person I'd ever met, his wife had this unnatural ability to control our meetings by not letting anyone else talk. She'd open her mouth and talk non stop for an hour. It was if she couldn't stop her brain. You could tell she didn't trust herself, so if she kept talking, she'd not have to hear the bad news we were telling her, and she'd not have to make any decisions on what to do next.
My last day I met with her for 2 1/2 hours. I was just trying to clarify her wishes, to either keep him on the machines even though he never wanted it or to change our approach. I remember listening to her talk, fascinated by her thought process. I didn't realize then, it really was unwinding. Think of someone on the brink of insanity, with thoughts popping in their mind, but the filter gone. She seemed to not be able to control the direction of what she was saying, and actually realized she was on the cliff of insanity. At one point I had been able to get in a sentence about her husband and she panicked. "Don't say another word" she half screamed as she grabbed my hands. "Okay" I said and was shocked as she reached out and literally grabbed my mouth to close it. "I told you, not another word...oh look what you're making me do, I didn't want to think about this today, I can't do this" Her eyes looked frantic, as she kept talking...it was as if I, by speaking, was some how stealing what little control she had on her brain. I stepped back worried if I did utter another sound she'd really attack me.
She managed to get it back together and we left the meeting calmly after another hour. Amazingly, she decided to withdraw care a few days later. Then, her fragile mind did collapse- she had a true psychotic break and is currently admitted to a psychiatric ward.
How strange to witness a brain unraveling. All the safety mechanisms gone, verbally I was witnessed what it was like to be in her brain as it spun out of control... In someways I'm lucky all she did was grab my mouth and hands, you can never predict what truly psychotic people may do!
This man had a wife and a severely mentally challenged son. His wife and son would come visit every day at the same time. The son was in his 30s, with debilities in seeing and cognition. He was a gifted pianist and always had headphones on listening to music to keep him calm.
A helpful thing in this case, was that the patient had an advance directive that spelled out exactly what he'd want and not want in this situation. It was explicit that he'd not want to be on the breathing machine, or have dialysis or even tube feedings. Our team had begun the slow process of helping support his wife and walking her through the process of letting go.
Unlike any other person I'd ever met, his wife had this unnatural ability to control our meetings by not letting anyone else talk. She'd open her mouth and talk non stop for an hour. It was if she couldn't stop her brain. You could tell she didn't trust herself, so if she kept talking, she'd not have to hear the bad news we were telling her, and she'd not have to make any decisions on what to do next.
My last day I met with her for 2 1/2 hours. I was just trying to clarify her wishes, to either keep him on the machines even though he never wanted it or to change our approach. I remember listening to her talk, fascinated by her thought process. I didn't realize then, it really was unwinding. Think of someone on the brink of insanity, with thoughts popping in their mind, but the filter gone. She seemed to not be able to control the direction of what she was saying, and actually realized she was on the cliff of insanity. At one point I had been able to get in a sentence about her husband and she panicked. "Don't say another word" she half screamed as she grabbed my hands. "Okay" I said and was shocked as she reached out and literally grabbed my mouth to close it. "I told you, not another word...oh look what you're making me do, I didn't want to think about this today, I can't do this" Her eyes looked frantic, as she kept talking...it was as if I, by speaking, was some how stealing what little control she had on her brain. I stepped back worried if I did utter another sound she'd really attack me.
She managed to get it back together and we left the meeting calmly after another hour. Amazingly, she decided to withdraw care a few days later. Then, her fragile mind did collapse- she had a true psychotic break and is currently admitted to a psychiatric ward.
How strange to witness a brain unraveling. All the safety mechanisms gone, verbally I was witnessed what it was like to be in her brain as it spun out of control... In someways I'm lucky all she did was grab my mouth and hands, you can never predict what truly psychotic people may do!
Sunday, July 8, 2007
Prognostication
There's a word in palliative medicine we talked about this 1st week of orientation called prognostication. It's especially important in this field. Doctor's make prognoses all the time- we tell people in clinic when we expect their infection will respond to antibiotic treatment, or when their rash will leave. We guess when broken bones will heal and when pain from a muscle injury should dissipate. However, when it comes to the time of death, doctor's are a bit more nervous. The thing is, just like all other things in life- most people WANT to know what we think. Knowing helps with the preparation, and with coping. It helps not just the patient, but the family too. The problem is historically doctors haven't done a good job of giving our prognosis on time of death. This has to do with several things- from not wanting to communicate bad news, to not wanting to be wrong when guessing.
In my field of medicine, when everyday I am seeing people who are actively dying- it's important to become good at prognostication. It will be one of many uncomfortable things I'll do this year. I'm to continually work on getting more accurate in predicting the time of people's death. The deep question then becomes 'is there such thing as becoming too accurate?' Hypothetically if doctor's could develop a system with computers and genetics, etc that had no error rate- 100% correct, all the time, at telling people when they would die - - - should we?
In my field of medicine, when everyday I am seeing people who are actively dying- it's important to become good at prognostication. It will be one of many uncomfortable things I'll do this year. I'm to continually work on getting more accurate in predicting the time of people's death. The deep question then becomes 'is there such thing as becoming too accurate?' Hypothetically if doctor's could develop a system with computers and genetics, etc that had no error rate- 100% correct, all the time, at telling people when they would die - - - should we?
Sunday, July 1, 2007
Eve of fellowship
Well, I guess it's time to be a little more regular at this- And perfect timing, as I start my new training tomorrow. That's right, I am officially done with residency. I survived what most would say are the roughest years of a doctor's career. Does it feel good to be done? Absolutely. In fact, as I am at the eve of my next life change, I recognize a different feeling within. Instead of the typical anxious, dreadful, excitement that accompanies life changes (I.E. high school, college, med school, residency). I finally only have excitement. The anxiety and dread of something new and challenging is gone.
That's for 1 huge reason- I'm going to be doing something I love. My fellowship is in palliative medicine, so I begin a career helping people and families through the process of suffering and death. I'm careful when I talk to people about this upcoming year- I try not to say "I'm looking forward to a good year", because that seems kind of glib. But I do say, "I'm looking forward to a meaningful year". And perhaps because I am someone who relishes meaning, that's why I'm truly excited about this start.
So, on to a life of endings- but a huge new beginning for me -
That's for 1 huge reason- I'm going to be doing something I love. My fellowship is in palliative medicine, so I begin a career helping people and families through the process of suffering and death. I'm careful when I talk to people about this upcoming year- I try not to say "I'm looking forward to a good year", because that seems kind of glib. But I do say, "I'm looking forward to a meaningful year". And perhaps because I am someone who relishes meaning, that's why I'm truly excited about this start.
So, on to a life of endings- but a huge new beginning for me -
Sunday, May 6, 2007
Nature and Nurture
I love psychology - but it's frightening what we parents can DO to those in our charge! Last week I got to observe a counseling session. The session itself was pretty boring, but the background was fascinating. This 50 year old woman was the eldest child in her family. When she was 5 or 6 her parents realized that her 4 year old sister was mentally challenged. Not knowing how to be "fair" to both girls, they decided to just treat them both as if they were mentally handicapped!
For her whole life, this intelligent woman had all of her decisions made for her as if she was incapable of making choices. A smart woman, avid reader, good at math, etc -she is socially a mess. She's 50 and has lived 20 years in the same apartment- that was after moving from her parents house. She has never dated, EVER. Why? because her parents told her not too. In the session it was fascinating to see that she still can't make decisions, she has been trained to ask her mom and dad (now in their 70's). She has no depth whatsoever, was never trained to THINK.
2 lessons then: 1)Just because you are given the capability, I.E. "IQ", if the right environmental cues aren't available you can still be "dumb"ed down. 2)Seeing the consequences, I don't recommend this form of "fairness" in parenting!
Friday, April 20, 2007
First Intubation
Another fun first. Some would say it’s a little late for this first, as I am 2 months shy of finishing residency.
I was doing an ER shift last Friday the 13th. I had heard the ambulance tuner go off, and minutes later the paramedics came rushing in with a woman in her 50’s. I heard them saying she’d been found on her couch, unresponsive. The ER doc looked at her and then said loudly, “this would be a good one for a resident to intubate”
It was the moment of truth. I could easily stay where I was and pretend I didn’t hear his statement. Surely someone else would love to practice putting a small tube down a dying woman’s airway? The thing was I had done precisely this for the last 3 years; let others practice this last scary skill of medicine. I knew it was my time. I took a deep breath and put on my confidant actor self.
“Dr. Wood, I’d like the practice” I said as I s tepped into the chaotic room with the code in process.
He handed me the laryngoscope and tube and said “Go for it” , then asked, “how many of these have you done?”
I think the 8 nurses busy putting in IV’s, drawing blood and bagging the patient all stopped at once to hear my response. “Uh, none, this is my first.” I definitely heard some chuckles.
“When you’re ready doctor” the nurse to my left said. I said okay and they took off the mask that had been pushing air into her. I moved her tongue, but the blade and light in and lifted her chin towards the ceiling. I then hoped the tiny black hole I saw deep down her throat was her wind pipe/trachea. I grabbed the tube and I heard someone say “It’s a good sign, she has the one eyed wink” To see better my left eye was scrunched together tightly. With a little fumbling with the tube, I finally slid it in and prayed I hadn’t picked the wrong hole leading to the stomach. A few moments later all the confirmatory signs showed I was in. “Great job” I heard with a small applause.
I was doing an ER shift last Friday the 13th. I had heard the ambulance tuner go off, and minutes later the paramedics came rushing in with a woman in her 50’s. I heard them saying she’d been found on her couch, unresponsive. The ER doc looked at her and then said loudly, “this would be a good one for a resident to intubate”
It was the moment of truth. I could easily stay where I was and pretend I didn’t hear his statement. Surely someone else would love to practice putting a small tube down a dying woman’s airway? The thing was I had done precisely this for the last 3 years; let others practice this last scary skill of medicine. I knew it was my time. I took a deep breath and put on my confidant actor self.
“Dr. Wood, I’d like the practice” I said as I s tepped into the chaotic room with the code in process.
He handed me the laryngoscope and tube and said “Go for it” , then asked, “how many of these have you done?”
I think the 8 nurses busy putting in IV’s, drawing blood and bagging the patient all stopped at once to hear my response. “Uh, none, this is my first.” I definitely heard some chuckles.
“When you’re ready doctor” the nurse to my left said. I said okay and they took off the mask that had been pushing air into her. I moved her tongue, but the blade and light in and lifted her chin towards the ceiling. I then hoped the tiny black hole I saw deep down her throat was her wind pipe/trachea. I grabbed the tube and I heard someone say “It’s a good sign, she has the one eyed wink” To see better my left eye was scrunched together tightly. With a little fumbling with the tube, I finally slid it in and prayed I hadn’t picked the wrong hole leading to the stomach. A few moments later all the confirmatory signs showed I was in. “Great job” I heard with a small applause.
It wasn’t until I was out of the room I started shaking. Now I'm a doctor, right. Intubating is some understood right of passage of residency. And now I can’t think of any other milestones left to cross!
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