Wednesday, November 29, 2006

In Memoriam

On Saturday night, one of my classmates from medical school died.

She was in her intern year, like me. Doing med-peds, like me. Blonde, like me. We had the same big sib in the class ahead of us. She was AOA, like me. She thought she might have gone into adolescent medicine, like I might. She got her top choice residency, like me. She'd just gotten married. Her life seemed to be everything she wanted. And now it's over.

She was on call at Children's when she died. She was in the call room. The nurses kept paging her and she didn't answer. Finally her resident went up to check on her and found her "unresponsive" (medical lingo for dead). Still, they tried to bring her back. Other interns from my class had to code her. For forty-five minutes they tried. I imagine they put in lines, intubated, did chest compressions. But she never came back.

She had just been married earlier this past summer. She'd been with her boyfriend forever. I remember the day we ran into each other at work and I noticed the ring for the first time. She'd just gotten engaged and told me the whole story. She was glowing. She usually did, though. She has this funny smile into uncomfortable-sounding laugh that she did.

I guess her husband and parents came to the hospital; they were freaking out. Police were there. It must have been unthinkable. Surreal in the worst way.

It was when I heard about it. My friend S. texted me and I got it when I got off the plane back in San Diego. I called her back but she said to wait and talk when I was in my car. Something was wrong. Then J. called me, too. He said he had to tell me something, too. "Something happened here in Cincinnati," he said. He wanted me to wait until I was alone, too.

I called when the shuttle dropped me off at my car. "You know xxxx xxxx?" "Of course." And he told me the news. How? So young? So much work. So much life ahead of her. So much promise. So many things not done. So young.

When I talked to S. later, I told her I already knew. She filled in some blanks. I guess she had a brain tumor diagnosed in our first or second year of med school. It was slow growing so they didn't do anything. But she had a secondary seizure disorder from it. Maybe she had a seizure, in her call room, alone. Then she would have vomited and inhaled her vomit and choked on her own gastric contents. Maybe that's what happened. They have/had to do an autopsy. The pathologists who taught us for four years now have to do an autopsy on her. On her. On one of our own.


This morning as I left grand rounds to come home for a bit before returning the VA urgent care, I heard a story about "Marine Cpl. Kyle W. Powell" who had been killed in Iraq by a roadside bomb. He was 21. His boyscout leader was proud of him; didn't want him to die, but said there was no better way to die than serving your country. He was 21! He was young, strong, healthy, a leader, a brother, a son, a fine person. He had a life ahead of him that did not include this. His family is proud, too, though. They love him. They miss him.


It's all a big jumble in my head, of youth and death and promise gone and futures lost and pasts glorified and life. On one of my past entries, someone wrote that, as a doctor we witness the the brilliant candle of someone else's life flicker and fade.

What about when that flame is so bright and it doesn't flicker, it just stops. Mid-flame. It's just gone.

If she hadn't been sleep deprived, would she have had the seizure? If she hadn't been on call, would her husband have been beside her and been able to save her? If she hadn't been alone?

Would she have chosen to spend the last years of her life studying the Krebs cycle in the library? Sacrificing late nights with her boyfriend, now husband, to cram for the next test? Spending nights at the hopstital with sick patients instead of at home with her own love, or her own family?

These are decisions we make based on the promise of a future result. They are plans for the future. It's not fun to study the Krebs cycle, but it gets you where you want to go. What if you never get there, though? What if you're gone before you get to where you want to go, and all you have left is that time that you spent planning and working toward a future that will now never be.

Her husband is probably 26; and now he's a widower. He parents are in their 50s and they've lost a daughter, one whom they loved, one who they'd watch grow and learn and work and work and work toward her goal of being a doctor.

She was always fun on a night out. We were out once celebrating something and she told me a story once about a guy hitting on her (he was still there, so it was sort of a warning, really). She had to have a guy friend (who is probably gay but doesn't know it) pretend to be with her and the would be creep of a suiter asked is he were "tappin' that ass?" The moments that make up a life. Moments you remember.


I keep trying to wrap my mind around it. But I can't.

I finished a book recently, "Suzanne's Diary for Nicholas." I was sobbing nearly hysterically by the end. Suzanne died. Her one year old son died. Her husband, who'd found the love of his life then lost her, was flattened. Suzanne had a heart condition that she told him about early on, but he already knew, he loved her anyway. "Isn't it lucky that Suzanne didn't die when she had her heart attack. Isn't lucky that we have this time together?." And then they had a new catch phrase to share and love and pour more of their overflowing love into: isn't it lucky.

Isn't it lucky that Sarah lived for a while. Isn't lucky she touched patients lives. Isn't it lucky that we knew her. Isn't it lucky that she was happy. Isn't it lucky that she and her husband were so in love, if not long enough, at least for that time. Isn't it lucky?

I don't know if it's lucky or not.

It just is.

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That's her behind me, at graduation. Looking to her right. Looking forward.

Thursday, November 23, 2006

Happy Thanksgiving

Another world is not only possible, she is on her way. On a quiet day, I can hear her breathing. -Arundhati Roy

Sunday, November 19, 2006

Emmetropia

"parallel rays from infinity are focused perfectly upon the retina"

"Sadly, this condition is enjoyed by only a minority of the population."

Tomorrow morning I will be in optometry clinic again. Last week I watched the eye exams for a couple veterans. I've never had an eye exam myself so all the fancy equipment was relatively new to me.

I learned that age-related eye changes start at age 42 and stabilize by age 60. The lens becomes less flexible.

The pressure of the eye fluid changes throughout the day.


Pressures change thoughout the day. Your stress hormone levels change throughout the day, too.

I feel pressures beyond those in my eyes today.

Saturday, November 11, 2006

Sunset

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Patients call me Laurie

Now my most recent addition to the "Who do you look like" saga consists of a patient calling me Laurie (when I'm not there--the nurses ratted him out, much to his chagrin).

He thinks I look like Laura Ingells--from Little House on the prairie.

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Why is it always frontier women? First Dr. Quinn, and now this. I don't churn my own butter, you know. Besides, butter clogs your arteries.

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Happy Veterans' Day

For Veterans Day, not only did I get a day off yesterday, but I have good news about Mr. W: he was extubated (tube out of his mouth) and was clearing mentally. I am off of the VA service now, so I won't get to take care of him out of the ICU, but I plan to stop by when I have clinic there. He still has a feeding tube down his nose and breathing tube and catheter, but at least it's a little progress...if progress is what we call healing still.

"I wish you'd sit and talk with me," he said when I went to visit him. I pulled up a chair. We got to chat about submarines. He fought in WWII and was a first gunner's mate on four different submarines, the names of which he rattled off for me. I didn't know what a gunner's mate was so asked him, but could see it was an effort for him to talk much more and his pain medicine was kicking in again.

He kissed my hand when I left and offered to walk me out (which would be impossible; he was getting a little more confused). I told him thank you, but he just needed to rest...and that I would be back soon. "I'm glad," he eye smiled.

Monday, November 06, 2006

Vanilla

"I wab a midshk," he sort of croaked through the oxygen face mask obscuring the bottom half of his face. No matter how many times I adjusted it, it still slipped up too high and pushed a little on his eyes. I knew if I took it off, he would desat to 83% (that's not good).

He wanted a milkshake. It was the first really coherent thing he'd said to me in the two days I'd been taking care of him. He was still in soft restraints because he'd already pulled out his urinary catheter and given himself quite the bleeding prostate lesion requiring the urologist to grudgingly come relieve his 810 ml of bloody urine in his bladder (normal you'd feel about ready to burst at around 300 ml). The nurses had struggled for hours on that task. When they finally called me, he was sprawled out naked on his bed with blood all over his penis and a gowned nurse holding a tube only partially in the opening.

But after that episode, he started to clear mentally. He started to talk to me more. He had this great North Carolina accent. We were going to start a smoothie company together and make our fortunes. Or I was, at least, he said I could go ahead with it. He was too old to take on a new project. He wanted to name it Triple H. We hadn't decided what they all stood for yet, but on of them was "Healthy" and he was working on the graphics in his head.

He lived alone in town. His ex-wife was the only person in town that he knew and she was dying. His brother was worse off than he was. The only family member who could consent for the blood he needed when he hemoglobin dropped below 10 (tranfused for heart failure) was his nephew who still lived in North Carolina. He seemed so alone. No one came to visit him.

He'd been transferred out to our general medicine team--one of the Intensive Care Unit "bombs," who can be total wrecks. He was confused and clouded and altered and had an O2 requirement and bloody urine, and a chronically failing heart. About a week before he'd been going about his business, just made a trip into the hospital to refill his medications. When his heart decided it had had enough. He lived in atrial fibrillation (the top chamber of your heart not beating very effectively), but he suddenly switched into ventricular fibrillation which is much much worse.

He was on the elevator at the time, and one of my fellow interns called a code blue and started compression while trying to keep his foot stretched out in the elevator so the doors wouldn't close him and my patient in there without any other help. In the process of manually pumping his heart through his chest, he broke three of his ribs, but after 15 minutes, they got him back. His heart started beating a bit on it's own and they put a tube down his throat to help him breathe for the next couple days.

Soon after he was extubated (the tube came out), he was transferred out to me. I scoured his records for information as any good intern would do--a "chart biopsy" we dorkily call it. In talking to another of my fellow interns I learned what my patient had been like before he became confused with what we would later determine was probably ICU psychosis (basically being old and confused about all the craziness of the hospital environment and losing your bearings on your life). "People want to write him off," said the other intern, "but he's really a cool old guy. Just think of him as you would your grandfather." He wanted me to see the person behind the tubes and mask and confusion. The vet who had lived a full life.

"I want a milkshake."

"What kind?" I asked as I held his arm and hand to try to hold him in this world.

"Guess."

"Vanilla?"

"You guessed it!" He gave me an eye smile and squeezed my hand.

I later called dietary and they don't make milkshakes at the hospital. I told him I'd pick him up one on my way into work one day.

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The next day I was running quite late and didn't have time, but I stayed late and got to know him better. He was well out of restraints by now and I helped him feed himself. He didn't have much of an appetite; his belly was still full of stool despite the suppository we'd tried earlier that day. He liked the canned fruit: peaches and pineapple. We discussed what type would be good in the smoothies we would make together.

I always told him I'd come back to see him. "Good," he would smile, "I enjoy your company," he'd say in his southern gentleman accent.

The next morning I remembered the milkshake. It melted a bit on the way in, and by the time I got there he'd already had a recent dose of morphine (for his broken ribs) and was too sleepy to eat it. I asked the nurses to put it in the freezer with his name on it and would come back to try later.

Throughout that day, I'd pop by whenever I wasn't swamped with other things to do. He seemed to be sleepy that day, like something wasn't right. I tried to help him eat the milkshake a couple more times, he was appreciative, but just didn't feel like having it.

By that evening, when it was time to go home, I was reluctant to leave him. He'd started sundowning by the time I left (getting confused more again at night) and was confused again, "Are you taking me home?" "No, but you're getting better," I held his hand and stoked his hair back. I wanted to believe it when I said it, too. Like maybe saying it outloud would make it true. "Is she taking me home?" He pointed to one of the nurses. "No," I said. And then he looked right in my eyes. The man who must have once been strong as he fought for his country, he looked at me with the pleading eyes of a child, "Am I ever going to go home?"

I wanted to tell him he would. I wanted to believe he would. So I told him he was getting better, that he just had to hang in there with us and we'd get him through this.

I told him goodnight eventually. When I went to sign out to my nighttime cross cover, I warned them that he'd become confused and might need some of the antipsychotic he hadn't needed in a couple days (haldol).

When I came in the next morning, I ran into the ICU intern on the elevator, the one who'd told me to think of him as my grandfather, "We got your guy back last night." What? my mind spun and sank. I must have looked stunned. "He's yours, right? Mr. W?" "Yeah, yeah. What happened?" Not even sure I wanted to know. "We think he got volume overloaded. I just came from intubating him." He had another tube down his throat and another ICU admission. "Not good prognostic signs," my attending would say later that morning.

I was upset. I visited him the next day. He was back in restraints, the tube down his throat, tied in placed with gauze and pulling at the corners of his mouth. He was writhing and fighting to get it out. He looked at me with little recognition, but I calmed him down some, "Just rest and heal. Just rest." I stroked his hair back again. I couldn't bear to stay long. It was too sad and too hard.
That day the team thought he'd come back to me on Monday, today. But today I found out he's still intubated. "It doesn't look good," she said, "He might not make it out." I looked at the intern who'd known him from the beginning, too. "You'd better go visit him," he said. "Go see him."

I try to rationalize it, but I can't. If he hadn't been picking up his medications, he would have died alone at home. But had I messed up? Had I given him too much fluid to keep his pressures up? Had I missed the pneumonia he was brewing? Had I killed him? Had I gotten too close? Had I done too much?

My attending could see I was upset when I first told her where he'd been transferred, "Jeez, what did you do, try to kill your patient?" she teased. I didn't think it was funny. I almost started crying, to tell the truth. "Don't worry, you'll get a thicker skin." Great. That's comforting.

I miss him. I did feel like he was my grandfather in a way. And I felt like he was lonely. And he needed me. And I liked his eye smiles. I guess I needed him, too.

"You're too sensitive!" I would be told a few days later. "I can't even begin to reach your level!" Maybe I'm too sensitive for this job. I don't like it when patients get sick and die. I don't like being there just for the end without knowing the beginning and the middle. I don't like being the one who can't help them hold onto the scraps of life they have left. I don't like being part of the mentality that death is failure. That death is the enemy. And if I can't battle it successfully, I have failed.

I guess I am too sensitive.

He never got to drink his milkshake.

I miss my patient.

I enjoyed his company.