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| Searching for hope
I've made it to my second year of residency before I had to watch someone die. Not that death is at all an unusual event in this business. From the moment you meet your first cadaver in medical school, death becomes a stark reality. It comes crashing into the ER several times a week, CPR on-going, and is pronounced: dead on arrival. It ends dramatically in the operating room with chest and abdomen filleted open, heart still quivering in the gaping chest. It passes uneventfully in the night, when the patient list is somehow shorter the next morning.
Death has become so commonplace, I sometimes wonder whether we've gotten too callous. The other day, my co-resident was signing out to me when I noticed a patient was missing from the list. "Oh, she died last night, finally." We did a triumphant high-five before I realized what we were celebrating. It's just... the old lady was kept alive for so long after a devastating stroke while her bickering family endlessly delayed the inevitable. It was a relief to hear she had passed away, yet it seems so wrong to care so little.
Last night though, it was hard not to care. He was a young guy riding a motorcycle. The neighbor heard the crash. It took half an hour of CPR before the medics got a pulse back. In the ER, they saw myoclonic jerks. Images of the head showed global anoxic injury. The neurosurgeons shrugged their shoulders the next morning. The writing was on the wall, and the family knew it. There were at least 50 of them, crowded into the waiting room. Blue collar folk. The men wore dirty boots and 5 'oclock shadows. The women were overweight and a little too histrionic. They weren't the most educated, but they had watched enough TV to know what brain death was, and what "pull the plug" meant.
I was paged stat to the bedside in the middle of the night. His vital signs were going haywire, and he had blown his other pupil. No cough, no gag. I knew his brain had herniated before the CT scan told me so. 20 people fell silent when I walked into the conference room. Quiet sobs told me that they had guessed things were bad. They didn't want an academic explanation. They just didn't want him to suffer anymore.
I signed all the paperwork to withdraw medical care, and the nurse started the fentanyl and ativan drips. Make him comfortable, please. And then I could have left... the respiratory therapist tells me most doctors do. After all, there were 30 other sick ICU patients to see. But the family knew no other doctor, and for some reason I stuck around... stood silent in the corner of the room. And watched.
It was quick; he had no brainstem function left. The respiratory therapist stopped the ventilator and removed the breathing tube. For a few seconds, there was still movement of the chest wall. Breath in, breath out, shallower and shallower. Have you ever watched a man die? Something melts off his face. It's not just the color change, or the eternal stillness that descends. It's not even really in his eyes, since this man's eyes had long since glazed over. Perhaps it's just all the facial muscles relaxing. Whatever it is, it's final. I looked at the mother, prostrate over his body. I looked at the uncles, rough faces wet with tears. I looked at the father, who had turned his face away but still clung to his son's hand.
There was no more carotid pulse. The chest was eerily silent. I tried to push the tongue back in to the mouth. 0407, time of death. The father looked over at me, and I nodded my head. He bent and kissed his son's forehead. Something caught in my throat, and I left.
Where, O Death, is thy sting? There is a lot of evil in this world, much of which ends in a hospital. Folks shoot each other, men rape women then slit their throats, mothers accidentally run over their children, desperate men jump off bridges... but whatever the journey, one common end awaits us. I wonder if it matters how we get there. The peaceful death of the 80-year-old woman is just as final as the violent death of a gunshot victim. It all stings.
Why is this so? I ask the darkness, alone in my call room. If it were a natural part of life, why does it hurt so much? If it is the punishment of sin, how terrible was the evil that was committed? And most of all, is there hope on the other side?
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| Life from the Ashes
I saved a kid's life the other night. Or at least, that's what everyone is saying. If I did, it was pure luck. And if I did, I can't help but regret it. I was on call, the only doctor covering about 60 floor patients. It was one of those absurdly irritating nursing calls, the kind where the nurse, either out of pure ignorance or in a fit of cover-her-assness, pages you to "make you aware" that her patient's hand is cold. Now technically, the word "cold" should raise immediate concerns in your mind of ischemia, lack of blood flow, a threatened limb. But in reality, there isn't a damn thing wrong with the patient's hand. The nurse just wanted the monkey off her back so she can document in her shift note that "MD is aware" (therefore nurse not responsible). At this point in the year, we've all learned to ask a few pointed questions (i.e. does the patient have a pulse), say "fine, thanks" and hang up. For some reason though, some trick of Providence, I told the nurse I'd come to check it out. Maybe a part of me wanted a chance to tell her in person not to bother me with useless pages.
Lo and behold, half an hour later, I was at the patient's bedside holding a warm, normal hand. I went through the motions of a quick physical exam... squeeze my fingers... squeeze my fingers... SQUEEZE MY FINGERS. The kid moved all his fingers alright, but not to any command. Is he always like this? The nurse shrugged, not really. The kid was building a pipe bomb between his legs when it exploded, taking both legs and causing significant brain injury. He now thrashes around in bed at baseline, yelling nonsensical things. But at this particular moment, he was listless, lethargic, unable to follow commands that he was able to a few hours ago. There was nothing wrong with his hand, but his mental status was not right. A quick blood draw later, and it turns out his serum sodium was 117. Cerebal salt wasting, from the traumatic brain injury. He was well on his way to a coma, perhaps death before the medical team rounded in the morning... if it weren't for the irrelevant call.
Every medical TV show and every hopeful pre-med student labors under the giant delusion that being a doctor is about saving lives. I think it'd be more accurate to say we're in the business of delaying death. Few pass from my care in the same state they were in before they met me. They leave with huge surgical scars, incontient of urine and stool, with strange tubes protruding with orifices and man-made holes, in chronic pain, with altogether different personalities from all the brain damage they suffered. Sometimes I look at these unfortunate creatures and wonder hard whether it was worth it to delay their death. Or, as in the case of the pipe bomb kid, I regret not ridding society of such a menace, and not saving his poor, long-suffering mother another long night at his bedside, enduring his curses.
I went to an Ash Wednesday service tonight. As the congregation moved forward to receive ashes, I could hear the pastor repeating "you are of dust, and to dust you shall return" as he painted their foreheads. I guess most people need a reminder of our mortality. Trouble is, an hour before church, I had my hand thrust deep into the neck of a young man who'd been shot in the jaw. The bullet tore through his esophagus and trachea. What is that, a >50% mortality rate? I could still smell his blood and remember the squelch his fat tissues made as I dug around, trying to find his carotid artery. You are of dust, and to dust you shall return. What's hard to believe is that any beauty, any redemption is going to rise from this shitstorm of decay.
February is a difficult month. It's cold, it's dark, and we're all exhausted. 30 years ago, the then-chairman of the surgery department faced a riot of unhappy residents. He solved the problem by booking a bus, loading it with a keg of beer, and sending all the surgical residents skiing for a day. Thus began the annual Ski Trip. We went last week, on a gorgeous, sunny day. It was the first time in weeks many of us had even seen the sun. I was planning to sit in the lodge and drink, but changed my mind when I saw how inviting the mountain was. The ride up the ski lift was exquisite. Snow and blue skies, evergreen trees marching up the slopes, the muffled silence of a world in winter. For a brief moment, I forgot about blood and pus-filled wounds, about nurses and patients, about being a doctor who's expected to fix death. We all did. It was wonderful to feel dwarfed by the majesty of the mountains, to be free to revel in the stunning beauty of Creation.
Life is one long march toward death. But there is still beauty. There is. Hidden in forgotten crevices, shouted unheard from the mountaintops, winking from behind the clouds... undeniable, persistent, hopeful. Dark as it is here in the trenches, praise God that I can still say with confidence that all is not lost. Somewhere in the depths of time, I hear a tomb stands empty. And to the One who was raised, I've attached my lifeline of desperate hope.
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| A Jaded, Exhausted Post
8 months. 8 long, exhausting, soul-deadening months. We who were excited, nervous new interns donning long coats for the first time in June are now jaded, tired, angry residents. I now introduce myself automatically as "Dr" over the phone, learning long ago that this is the most efficient way to get what I need. I refuse to prescribe pain medications to people left and right without a twinge of pity. I yell at nurses and Starbucks baristas and Continental representatives with indiscretion when they are being inefficient, rude, or insufferable know-it-alls. I get to work at 4:30am, and I leave at 8pm (or noon the next day on overnight call). My hours are filled with paperwork, ceaseless pages from nurses asking to clarify orders, irate patients who complain about the gravy the hospital cafeteria insists on serving them. I'd love to tell those patients that they're lucky to have food at all, as usually I end up missing all my meals and am lucky if I get a chance to pee once a day. And I am angry... all. the. time. They never tell you when you're pre-med or in medical school that you must sacrifice compassion to become a doctor. I hope it's only temporary.
My lowest moment was a few months ago. It was the middle of the night, and things had slowed down just enough for me to run down to the cafeteria for my first bite to eat all day. I had gotten to work at 5am, and it was now 2am. I was starving. But there was this long line at the cafe. By the time it was my turn, all they had left were microwavable meals, and a few lone pastries. I put my meal in the microwave and unwrapped the little chocolate muffin I had bought for dessert, intending to just nibble a small piece while I waited. But at the first taste of food, my body went crazy. It suddenly awoke from a numb state to realize just how hungry it was. Unable to stop my own hands, I began to shove chocolate muffin into my mouth. Tears flowed down my cheeks as I turned to face the corner, hoping nobody would notice the streaks of chocolate around my mouth.
I know what you're thinking as you read this. Why does the system do this to doctors? Why can't the medical profession be civilized and limit work hours? Because people are selfish. Patients are selfish. In healthy times, people generally agree that they want well-rested doctors. But when they are sick, they want everything done ASAP, damned if there are 50 other patients, and they want their doctor to be at the bedside at all hours to answer questions at their (the patient's) convenience. My most furious patients got that way because a) something in their care plan did not get delivered in a timely fashion (timely as judged by the patient) or b) they were told I could not answer their questions because I was just covering for their primary doctor (who was at home getting a few precious hours of sleep). More restrictions on work hours would mean less continuity of care, and while I need that extra sleep and time to eat/pee, I can't see how all the work would get done.
Yesterday, I walked into an interesting room. 2 men lay in 2 hospital beds. One speaks only Russian. He is paralyzed from the chest down, from 3 gunshot wounds, lying motionless in the glow of a Russian lamp that his mother brought from home. The other patient would speak only Korean if he would wake up. But someone T-boned his car, and now he is missing half his skull. Both men are silent. The room smells like a mixture of sweat, fresh lilies, alcohol, and leaking diarrhea. It is a sad room, a reminder of death and possibly something worse: 2 people under 30 who will never walk or talk again. I only know sketches of their stories and the circumstances around how they got hurt. It is a deliberate thing that I don't know more. What if it's their own damn fault that they got shot/hit? I may stop caring for them altogether.
I wish... I don't know what I wish anymore. That people would stop driving? Stop carrying guns? Stop getting cancer? That humans would stop being human? It's an awful thing, being a doctor... charged with restoring something that can't be restored, that maybe is not worth restoring. You realize pretty quickly that if there isn't something outside of us that can save us, something untrapped by all that is rotten in our natures, something divine perhaps... then this world really has gone to shit.
Do you believe in God? Do I? How long, O Lord? Why do you hide your face from me? | | |
| Doctor I wore my long white coat for the first time this week. For those of you not in the medical field, the long coat is traditionally worn by people who have earned their MDs, while the short coat is worn by students. It felt odd billowing down the hall with a train of extra white cloth behind me (being 5'3", even the smallest sized coat is unnecessarily long). When I tried it on in the privacy of my apartment, my ego definitely grew with the length of the white hem... but the moment I stepped in the hospital, I found myself wishing that I could run and hide again in the safety of the truncated coat. Wearing the long coat means I ought to know something. It means I'm "Dr. S---" instead of just Cheryl. I'd really rather be just Cheryl. The weeks since my last post in March have been a whirlwind of movement and activity. A trip to the British Virgin Islands for a wedding, two graduations on opposite sides of the country, a journey to a small village in China where my father was born, a huge move from Houston to Seattle, a week of frantic furniture-purchasing and errand-running, a few days of rather useless orientation, and then I found myself standing in a patient's room last Wednesday introducing myself as the doctor who would be taking care of so-and-so's very sick mother. I could write a novel about each of those events, and maybe one day I will. But today on my one day off, I just want to mention a single moment this afternoon. It's been a rough week. I can't remember another time when I felt so inadequate and frustrated, doubting everything I've done over the past few years and everything I've believed. Exhaustion and stress have a way of making you question your very existence. I took a walk down to the bay (I live 2 blocks from the water) and sat watching the sailboats motor by on their way to the sound. I jotted a few things in my journal and sat talking to God. I guess that's praying, although for months now I've struggled with prayer. I'm not sure God talked back to me. But I did begin to notice again the beauty of the sun sparkling on the water. Some of you would say the newfound hopefulness is just a result of a good night's sleep. I obviously think it's more than that. I may never ever understand Him, but I take comfort that He's there. Be strong and courageous; do not be frightened and do not be dismayed, for the Lord your God is with you wherever you go. | | |
| 2 Old Men
I've got a new man in my life. Two, actually. And both are well over 80. I really often feel that I was born in the wrong century. Underneath the thinning white hair, the sagging pale skin, the wheezing cough of a too-many pack-year tobacco history, I can sometimes glimpse the strapping young men these two octogenarians used to be. I can almost picture them boarding the ship in their crisp uniforms, off to join their comrades on the front lines of WWII. It's such a tragedy that time makes a mockery of our youth.
One of these gentlemen I've known since I moved to Houston. He parks his old green Ford Taurus in the parking space next to mine. When he first crossed the parking line to say hello, his hair was gray, his walk was steady, and his handshake was strong. He was a retired high school teacher, recently divorced. He liked driving down to Galveston to walk the beaches at sunset. I think he was a little lonely, but otherwise living a peaceful retirement. Then he disappeared for a few months. I thought nothing of it, since I was too busy with school to really notice. One day though, I noticed the Taurus back in its spot, and there was a stooping figure next to it. The change over my friend was staggering. His neat gray hair had become a disheveled shock of white. His cheeks and eyes had sunk into his face, and he walked with a telltale shuffle. Where had he been? In the hospital, he said, for depression. Over the next few months, I watched sadly as he gained weight, shrunk in stature, and developed the purposeless tongue movements of tardive dyskinesia. For Easter two years ago, I left a card and a Tea Forte teabag on his Taurus window. I don't know... maybe I was hoping he'd feel a little less alone. Last night, I stopped at CVS for some shampoo and accidentally stole a parking spot from a car that was trying to back in. In the dark, I didn't notice the dark green Taurus, but a few minutes inside CVS, a familiar figure came shuffling down the aisle towards me. My friend was actually headed for the burger joint next door, but he had seen me get out of my car, and he came in to find me. Turns out he remembers the Easter card and tea... he actually quoted to me word-for-word what I had jotted on the card. He asked for a hug before leaving for his burger. It wrings my heart to think of how lonely he must be.
The 2nd gentleman was a patient of mine. An old Navy vet who smoked for too long and has a horrid infection in his tobacco-destroyed lungs. The bug is related to TB. It will probably claim his life. But we still want to treat it with 3 different intravenous antibiotics for a total of a month. Maybe it'll buy him a good year... he's otherwise pretty healthy. Here's the rub: IV drugs can only be given in the hospital, unless we get the interventional radiologists to place a PICC line, but in a socialized system like the VA the wait for a PICC is several days/weeks, by that time he'll have finished his course of antibiotics. But this man wanted to go home, so desperately that he stopped eating. Every morning, I'd walk into his room to see him curled miserably in bed, his wife of 63 years standing by his side, tears running down her face. "We've lived a good life, can't I just take him home, I think I could get him to eat at home..." She has stage II cancer herself, but refuses to start radiation while her husband's still in the hospital. Oh for the love of all-things-sacred. I spent my mornings cajoling him to eat a corner of toast, my afternoons hounding the social workers/surgeons/radiologists for a PICC, my evenings on the phone with both his daughters and a smattering of grandchildren trying to explain why their father/granddad could not yet go home. The man was a pleasant guy (if you made allowances for his frustrations), and his wife was a sweetheart. But 3 weeks at the VA would try anyone's patience, especially if the night float occasionally orders you to be put into restraints for tugging on your (understandably uncomfortable) Foley. When I rotated off the service last week, he was still there, faithful wife by his side. I went in to say good-bye. He shook my hand and held it, thanking me for what I had done for him. I felt like I hadn't done anything helpful and wished with all my might that our healthcare system wasn't so daggone uncompassionate.
These 2 men haunt my thoughts. Why do we condemn our elderly to loneliness, to the indignities of useless hospital stays? Why are our youth so darn eager to journey to faraway places and "underserved nations," but unwilling to pay attention to the quiet man in the parking spot next door? Why are we so damn busy that we can't have a burger with an old man, and so scared that the thought actually crosses my mind that this would be an imprudent thing for a single woman to do? Why do I only care about these 2 men because they were literally thrown into my path, to be forgotten by the time next week rolls around?
The more I think about it, the more vivid my hypocrisy stands out, the more shallow the American Christian church seems. Simon, son of John, do you love me? Feed my sheep.
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