Discharge to Home
Sunday night was my first 30 hour shift in a while. And the first one when I got no sleep at all in an even longer while. Usually I can rest for a couple hours, but not that night. One of my patients died--little red-bearded bald Irish man with a very big sweet personality and a very sick liver. He hadn't woken up in four days. He had been staring off to his left with glassy dolls eyes for two. The med student who has been following him stood at his bedside and held his hand. I had told her he was dying and she didn't want him to be alone when it happened. She left at 8:30 pm. His body struggled to breath erratically for another hour and then it began to breath in whispers. I'd given him morphine earlier because his heart was beating fast, telling me the only way he could that he was in pain. The nurses called me before 11pm to tell me his pulse was in the 20s. I had nothing left to offer him. I had not been able to fix him when he was awake and talking to us. He needed a new liver, but had still been drinking so couldn't get on the transplant list. And then he kept getting sicker. Just earlier that day he'd had a partially collapsed lung which we re-expanded. We could fix the little things, but the over all body was too broken.
He would be my med student's first patient who died. She took it hard when she realized what was happening, "I've never seen anyone actively die before." She'd spent quite a bit of time with him when he was alert and talking. He was a nice man. We all liked him. Toward the end I talked to his brother in Seattle daily, encouraging him to change his brother to "comfort care" so we would stop trying to fix every minor thing and fix the big thing and make him comfortable as he moved away from this world. But I was reluctant to say that death was inevitable. "Very likely," I said. "Short of a miracle," I tried to convey to him. But I do not presume to know for sure what will happen. In my heart I believed he was dying. My clinical and guttural knowledge had wanted to stop trying to save him days sooner when he still had the ability to talk to us and tell us what he wanted. But even then he'd said he wanted to keep trying, "Might as well try," he'd say. He was a fighter.
At 10:52 pm that night he could not fight anymore. "The patient has expired," the nurse said to me on the phone. "Okay," I say and collect myself for a moment before going to pronounce him dead. When I get to his room, the curtains are drawn between him and his roommate--a patient I took care of days before when he stroked and no one believed it until it was too late. My dead patient's hands already felt cold. The nurses had put patches over both of his eyes--they didn't like the unblinking blue eyes that stared even when he still had breath barely in him. But now, he wasn't breathing. His heart wasn't beating. When I removed the eye patches and touched his cornea with a tissue he didn't offer to blink or move. He saw no more here. He had wanted to make it back to his home in Mexico--to his friends. Even as he'd asked me days ago, I felt that he never would. I didn't want to take away his hope, though. Sometimes hope for life wins against all medical odds.
His brother told me he wanted to be cremated, but he didn't know where he wanted the ashes spread, or if he did. His family granted permission for an autopsy, feeling that their brother would have wanted to help contribute to medical knowledge; he'd have wanted to help. From what I'd known of him, I thought he would have wanted that, too. They did the autopsy today. I'll hear the results tomorrow.
When a patient dies, I do death note and a discharge summary where I answer prompted questions like: "discharge diet" and "discharge activities" and "discharge location." In this case, what was I to answer? Diet: whatever he wants, ambrosia and honey perhaps. Activities: the canned answer is "as tolerated." I suppose that could apply here, but I chose to type in "not applicable." Whatever activities he would not undertake would not be tolerated by this body, perhaps with the next he would drink less and take care of his liver. Or perhaps he lived briefly (he was only 58) and brightly and hard and happily. The quality of time, for him perhaps, trumped quantity. I wonder if he thought that at the end. I'll never know.
In answer to the question discharge location, I usually get to answer, "discharge to home." I suppose that could apply to him as well, the final discharge--to home.
And hours and hours later, I would discharge myself to my much more earthly and tangible home. All I wanted was food and shower and bed. I was so tired. So very very tired. And yet. I ate. I showered. I'd ran out of energy to find my PJs so just climbed into bed (benefit of living alone, I suppose). Then I hear Jane outside my door discussing if she thinks I'm home and awake. It's only 8pm by that time. I hear her and get out of bed to say hello without thinking. I could have laid there and been asleep in about ten seconds but I wanted to connect with live people. I wanted to say hello to my friend. I didn't want work to drain the life energy from me so I would not have time to do things that are important to me. It nearly does. Everyday it tries.
Somewhere in my subconscious, however, the words that the Reverend had reiterated in that Sunday's service about Bhuddism must have echoed. He ended the sermon with them:
"Life and Death is a grave matter
time passes quickly away, and opportunity is lost
each of us should strive to awaken
take heed, do not squander this precious life."
At 5:30 Monday morning, after I'd been up all night, covering every single medicine patient in the hospital, a man in his a t-shirt and tighty whities with a cane had cornered me in my workroom and demanded my name because he'd told me to come fix a bed and I'd passed on the request instead of doing it myself right away. I'd heard him down the hall as he hunted around for "the nurse in white." When he asked the nurses (who wear festively colored scrubs) where she (I) was they said they don't wear white. The hallway where I work is deserted that time of the morning. And he stood ominously in the doorway when he found me and waited as I finished up the current crisis and phone call. "I want your name!" he barked at me. I tried to surmise why he was so upset but he was cryptic about it. I explained that I'd passed on the message about the bed and that someone had planned to come fix it for him. I hadn't come to tell him because I didn't know his name or which room was his. He was silenced for a moment, but stuck to his guns, "I want your name!" I wrote it down on one of the index cards we use to write down daily labs and "to do" lists and test results and patient histories so we can keep track of caring for our patients. I added the "MD" to the end of my name. I haven't heard any repercussion from the incident since.
In retrospect, I should have documented it immediately. Who I talked with, etc. But in those sleepless moments, I felt too hurt and abused to act logically. I took it too personally. I was upset that I'd been up all night (and the prior day--and as it turned out the day to come) taking care of patients who now take out their frustrations on me. I thought this way because I was frustrated too. Frustrated that I'd been up all night. Frustrated that I could not "save" my patient. Frustrated that the rules had been bent yet again that night so that my last admit had been hours after our team was supposed to stop taking new admits. Frustrated that my resident had been yelled at about something that she felt she'd done right. And frustrated that soon I would be a resident; and I really don't like to be yelled at.
I recollected myself while doing a little of the more mindless, but required, paperwork. I reminded myself I was tired, not to take things personally. His anger was not about me. I
thought of some of my happy thoughts. I remembered my WWII vet patient who had broken his leg and who had celebrated his 49th wedding anniversary in the hospital where his friends brought a cake with a picture of him and his wife on it for all to share (that day I let it slide about his diabetes). His wife brought us all hats she'd hand-crochetted. I picked out a brown and black and cream fuzzy one to go with the scarf I got in Spain. And there was another happy thought: Spain. Even when I'd talked to the brother of my patient who had died, through his grief he'd thanked me and the rest of his brother's doctors. "You all did a great job. We appreciate you so much." And I felt better remembering these things. Incidents like patients yelling at me used to upset me for days; I think getting the upset down to hours is progress--progress I'll have to accelerate when I'm a resident myself. Either get over it faster, or spend more time crying. In reality, I think I'll end up doing a combination of both.
So, exhausted after my long long day, I still found myself not squandering this precious life, but instead out with my neighbors in hastily thrown on clothes, putting up all of our collective Christmas lights until I simply could not remain vertical any longer. On my way home, Jane had
sent me a text excited for me to see their project. She had been ambitious and put up a feel lights around her apartment. Jane's were in a perfect Martha Stewart style shaped into Christmas trees all in white. As we put up more lights, every one's part seemed to reflect some bit of their personality. Judy's were random and ended abruptly. Bob didn't want any up by his place. Everyone helped put mine up in a green Christmas tree shape next to my framed kitchen window.
I laughed uncontrollably with them because it felt good; and I was too tired to remember how to stop. Judy kept saying how "glad this made her heart" to have all of us out and decorating for the season. She hugged everyone many times. And she kept finding more lights in her apartment and coming out with them and directing Joseph (the tallest) where to hang them. Sean produced a couple strings of lights also and wrapped them around the little tree by his door (his aunt died unexpectedly the other night and he rushed home to see me so I could fix it--I couldn't fix that either). As he put up the lights, he started to smile a little again, too. I drug the ones I'd had around my inside window outside and contributed to the lighting effort. Doug even came out of his door to which Randy had donated lights with bulbs the size of fists that made you feel like you could walk into the twilight zone coming out of it. He smiled and planned a disjointed string along the corner of the red termite-eaten fence at the edge of the property. Randy fiddled with the 15 automatic settings of his perfectly turned blinking lights next to the Santa and Rudolph lighted figures in his window. It was quite a show. Quite a show.
And Hanukkah starts today--the Festival of Lights. We got our lights up just in time. And I made it to bed way past time, but well worth it. And tonight, I must do the same. Discharge thoughts to dreamland. Discharge to home. Good night...
He would be my med student's first patient who died. She took it hard when she realized what was happening, "I've never seen anyone actively die before." She'd spent quite a bit of time with him when he was alert and talking. He was a nice man. We all liked him. Toward the end I talked to his brother in Seattle daily, encouraging him to change his brother to "comfort care" so we would stop trying to fix every minor thing and fix the big thing and make him comfortable as he moved away from this world. But I was reluctant to say that death was inevitable. "Very likely," I said. "Short of a miracle," I tried to convey to him. But I do not presume to know for sure what will happen. In my heart I believed he was dying. My clinical and guttural knowledge had wanted to stop trying to save him days sooner when he still had the ability to talk to us and tell us what he wanted. But even then he'd said he wanted to keep trying, "Might as well try," he'd say. He was a fighter.
At 10:52 pm that night he could not fight anymore. "The patient has expired," the nurse said to me on the phone. "Okay," I say and collect myself for a moment before going to pronounce him dead. When I get to his room, the curtains are drawn between him and his roommate--a patient I took care of days before when he stroked and no one believed it until it was too late. My dead patient's hands already felt cold. The nurses had put patches over both of his eyes--they didn't like the unblinking blue eyes that stared even when he still had breath barely in him. But now, he wasn't breathing. His heart wasn't beating. When I removed the eye patches and touched his cornea with a tissue he didn't offer to blink or move. He saw no more here. He had wanted to make it back to his home in Mexico--to his friends. Even as he'd asked me days ago, I felt that he never would. I didn't want to take away his hope, though. Sometimes hope for life wins against all medical odds.
His brother told me he wanted to be cremated, but he didn't know where he wanted the ashes spread, or if he did. His family granted permission for an autopsy, feeling that their brother would have wanted to help contribute to medical knowledge; he'd have wanted to help. From what I'd known of him, I thought he would have wanted that, too. They did the autopsy today. I'll hear the results tomorrow.
When a patient dies, I do death note and a discharge summary where I answer prompted questions like: "discharge diet" and "discharge activities" and "discharge location." In this case, what was I to answer? Diet: whatever he wants, ambrosia and honey perhaps. Activities: the canned answer is "as tolerated." I suppose that could apply here, but I chose to type in "not applicable." Whatever activities he would not undertake would not be tolerated by this body, perhaps with the next he would drink less and take care of his liver. Or perhaps he lived briefly (he was only 58) and brightly and hard and happily. The quality of time, for him perhaps, trumped quantity. I wonder if he thought that at the end. I'll never know.
In answer to the question discharge location, I usually get to answer, "discharge to home." I suppose that could apply to him as well, the final discharge--to home.
And hours and hours later, I would discharge myself to my much more earthly and tangible home. All I wanted was food and shower and bed. I was so tired. So very very tired. And yet. I ate. I showered. I'd ran out of energy to find my PJs so just climbed into bed (benefit of living alone, I suppose). Then I hear Jane outside my door discussing if she thinks I'm home and awake. It's only 8pm by that time. I hear her and get out of bed to say hello without thinking. I could have laid there and been asleep in about ten seconds but I wanted to connect with live people. I wanted to say hello to my friend. I didn't want work to drain the life energy from me so I would not have time to do things that are important to me. It nearly does. Everyday it tries.
Somewhere in my subconscious, however, the words that the Reverend had reiterated in that Sunday's service about Bhuddism must have echoed. He ended the sermon with them:
"Life and Death is a grave matter
time passes quickly away, and opportunity is lost
each of us should strive to awaken
take heed, do not squander this precious life."
At 5:30 Monday morning, after I'd been up all night, covering every single medicine patient in the hospital, a man in his a t-shirt and tighty whities with a cane had cornered me in my workroom and demanded my name because he'd told me to come fix a bed and I'd passed on the request instead of doing it myself right away. I'd heard him down the hall as he hunted around for "the nurse in white." When he asked the nurses (who wear festively colored scrubs) where she (I) was they said they don't wear white. The hallway where I work is deserted that time of the morning. And he stood ominously in the doorway when he found me and waited as I finished up the current crisis and phone call. "I want your name!" he barked at me. I tried to surmise why he was so upset but he was cryptic about it. I explained that I'd passed on the message about the bed and that someone had planned to come fix it for him. I hadn't come to tell him because I didn't know his name or which room was his. He was silenced for a moment, but stuck to his guns, "I want your name!" I wrote it down on one of the index cards we use to write down daily labs and "to do" lists and test results and patient histories so we can keep track of caring for our patients. I added the "MD" to the end of my name. I haven't heard any repercussion from the incident since.
In retrospect, I should have documented it immediately. Who I talked with, etc. But in those sleepless moments, I felt too hurt and abused to act logically. I took it too personally. I was upset that I'd been up all night (and the prior day--and as it turned out the day to come) taking care of patients who now take out their frustrations on me. I thought this way because I was frustrated too. Frustrated that I'd been up all night. Frustrated that I could not "save" my patient. Frustrated that the rules had been bent yet again that night so that my last admit had been hours after our team was supposed to stop taking new admits. Frustrated that my resident had been yelled at about something that she felt she'd done right. And frustrated that soon I would be a resident; and I really don't like to be yelled at.
I recollected myself while doing a little of the more mindless, but required, paperwork. I reminded myself I was tired, not to take things personally. His anger was not about me. I
thought of some of my happy thoughts. I remembered my WWII vet patient who had broken his leg and who had celebrated his 49th wedding anniversary in the hospital where his friends brought a cake with a picture of him and his wife on it for all to share (that day I let it slide about his diabetes). His wife brought us all hats she'd hand-crochetted. I picked out a brown and black and cream fuzzy one to go with the scarf I got in Spain. And there was another happy thought: Spain. Even when I'd talked to the brother of my patient who had died, through his grief he'd thanked me and the rest of his brother's doctors. "You all did a great job. We appreciate you so much." And I felt better remembering these things. Incidents like patients yelling at me used to upset me for days; I think getting the upset down to hours is progress--progress I'll have to accelerate when I'm a resident myself. Either get over it faster, or spend more time crying. In reality, I think I'll end up doing a combination of both.So, exhausted after my long long day, I still found myself not squandering this precious life, but instead out with my neighbors in hastily thrown on clothes, putting up all of our collective Christmas lights until I simply could not remain vertical any longer. On my way home, Jane had
sent me a text excited for me to see their project. She had been ambitious and put up a feel lights around her apartment. Jane's were in a perfect Martha Stewart style shaped into Christmas trees all in white. As we put up more lights, every one's part seemed to reflect some bit of their personality. Judy's were random and ended abruptly. Bob didn't want any up by his place. Everyone helped put mine up in a green Christmas tree shape next to my framed kitchen window.I laughed uncontrollably with them because it felt good; and I was too tired to remember how to stop. Judy kept saying how "glad this made her heart" to have all of us out and decorating for the season. She hugged everyone many times. And she kept finding more lights in her apartment and coming out with them and directing Joseph (the tallest) where to hang them. Sean produced a couple strings of lights also and wrapped them around the little tree by his door (his aunt died unexpectedly the other night and he rushed home to see me so I could fix it--I couldn't fix that either). As he put up the lights, he started to smile a little again, too. I drug the ones I'd had around my inside window outside and contributed to the lighting effort. Doug even came out of his door to which Randy had donated lights with bulbs the size of fists that made you feel like you could walk into the twilight zone coming out of it. He smiled and planned a disjointed string along the corner of the red termite-eaten fence at the edge of the property. Randy fiddled with the 15 automatic settings of his perfectly turned blinking lights next to the Santa and Rudolph lighted figures in his window. It was quite a show. Quite a show.
And Hanukkah starts today--the Festival of Lights. We got our lights up just in time. And I made it to bed way past time, but well worth it. And tonight, I must do the same. Discharge thoughts to dreamland. Discharge to home. Good night...
posted by S. at 8:17 PM
2 Comments:
i stumbled upon your blog way back when you were in med school and having bf troubles. i too was going through similar relationship issues and also being a med student really connected with your writing...i've been busy with im residency, and just recently resumed reading your blog...i had 2 days off and spent the vast majority of my time readig... your strength and grace to everything thrown at you has been an inspiration. i hope you continue writing for a long time...
thank you,
liv
Thank you, Liv. I've read your comment several times now; it gives me strength too. Sometimes all we can do is just keep going. And sometimes we can do more...
Happy Holidays!
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