15 November 2010

On Love and Medicine

I think a lot about “for better or for worse” these days. In medicine, you see a lot of “worse” and “worse”, and I see a lot of partners who are there for both. For anything. Siblings, children, grandchildren, nieces, nephews, friends. I guess these would be the ‘chicken soup’ or whatever stories (are they even still publishing those?) But it’s true – rushing around, where so many things are difficult and sad – it’s something to stop and think about. Or try to remember to stop and think about. With the sickest patients, it’s their loved ones that I know. The ICU patients, the altered mental status patients, dementia, kids…whatever. I’ve spoken with a lot of family members. In anesthesia, wheeling people into surgery, you leave Loved Ones at the corner. (They call it the ‘kissing corner.’ Really). And you see them into the waiting room, point it out, say go get coffee or whatever, we’ll be ____ hours, and don’t worry, we’ll take really good care of X. Your X. I’ve seen the wide eyes when we push through the doors again, X is barely waking up from surgery, likely has an oxygen mask over her face, and we’re rushing into the PACU. It doesn’t mean anything’s wrong. It’s normal, and it means the surgery’s over, and if people don’t look like they’re freaking out (The doctors), everything is probably fine. It’s a vulnerable position to see someone in. And in the OR, they’re alone.

There’s the couple who came in with the wife’s entire medical history typed out – each had their own version – with a list of questions. She suddenly went blind, no one has any idea why, no one has any idea if it’s part of something more progressive – probably. So they’re searching. And with each doctor, they get more frustrated at not having answers. But the other point, to me, is that it’s always both, it’s really about their health, and the patient is – almost – both. Making sure you do speak to both.

There was the man whose wife died of ALS (Lou Gehrig’s disease). She lived with it for twelve years, far longer than the average prognosis. At the end she was, as they are, completely paralyzed, ventilator-dependent, and could not speak or do anything independently. He ran marathons with her – there were photos of the special chair he ran with. For ALS research. There were vacations…. everything you can imagine that is so hard to imagine in those circumstances. So when she died, he wanted to donate all of her special equipment (hundreds of thousands of dollars, I think), some of which he had designed or modified, to other patients. He drove across the country with this. He’s still working with ALS.

And there’s the patient who had a second stroke on top of her first one and was almost comatose. Before the second one, she and her husband had been living with their daughter, just while she was doing rehab. He kept trying to convince us – again, again, again – that she was fine, that they could go back to their own home. They’d been together over 60 years. All he wanted was to take her home. And then there was the second stroke, and she wasn’t talking but I saw him every day, the daughter, the granddaughters. He left to get food sometimes, when his daughter was around. Otherwise.

There is love in medicine. And it’s the patients who don’t seem to have that support who are the hardest, for me. Almost doesn’t matter what the diagnosis is. When you can’t send a patient home because there’s no one to help, there, or the people there will not help… it’s hard. And it does change the medical plan. It’s been gratifying to me to realize how much this is taken into account. Teams don’t – or try not to, anyway – discharge patients without knowing where they’re going, and how. (and yes, then they pawn the patient off onto a social worker. but that’s why everyone is expert at different things).

But medicine has to be a little bit about love. It has to be about healing. When we’re in surgery waiting for pathology to call back – cancer or not cancer – everyone is holding their breaths, a little bit. Everyone wants to know what is finally said. And yes, people get jaded when they are overworked and overtired and it’s overwhelming to care individually about every single person in a day that you’re caring for, and if you’re in the hospital, some of them will die. I’ve heard  people comment about the annoying paperwork of death certificates, rolling up the sheets (like we do with everything else) and sticking them into a pocket. Everyone’s job has lots of paperwork and bureaucracy. In this job, the papers can say things like “full code/do not resuscitate/ do not intubate.” A progress note can describe a scene of death, at what time, what exactly happened, who was there. And it can also describe a birth – clinically, the first moments of someone’s life, and not just that but exactly what happened before. And who was there. And what happened. It’s a little bit of personal history before the lungs are even shocked into expanding and the fetal vessel connections close, and, and….

This is our bureaucracy. This is our paperwork. Birth, death, prescriptions, and “orders.” And “progress notes.” And more “orders.”
To me, it’s a heady thing to decide how much pain medication to give someone – what drug, how much of it, how often can they take it, and how many (the decisions are often left up to me, with the attending shrugging “sure!”. Then the attending signs the prescription I’ve pre-written). I write admission notes and orders, and yes, everything I do gets co-signed, but not every resident is going to re-read every line. I wrote out the medications and dosages. It seems like a small thing, maybe. But from my scrawled handwriting, faxed to the nurse’s station, to the patient’s chart, to the pharmacy… I’ve decided something, I might have changed it, I might have screwed it up. I decide a lot of things for patients, now, and as long as it’s a “fine” idea, it generally gets signed. There are a lot of choices, a lot of not-right/not-wrongs, and it can be unnerving. For another patient, her subspecialty doctor decided to proceed to surgery for her rather than medical management – based partly on my exam. My exam which had not been verified, up to that point, but done and recorded by me. I was terrified of this responsibility until we went to the other specialist who confirmed my exact findings. I wasn’t wrong. But I could have been. Easily. (and residents are, too. and attending are. this happens). There are so few things directly in my control, currently, that each thing that is can be terrifying. Shattering. What if I’m wrong. I’m in no life-or-death position, yet. Yet. It’s really not very far away.


Another patient hugged me today.

I’m not exactly sure why. I told her nothing was abnormal with her on my exam – which sometimes, under the circumstances of having annoying/uncomfortable symptoms – I would think would be frustrating to hear. Apparently, she had been worried about “something wrong”, however, even though she hadn’t said it. And so she hugged me.
This was in urgent care – we hadn’t talked for more than 10 minutes, my whole exam was five, then 2? 3? discussing results and giving her a prescription.
And she hugged me.

Another patient today, when he started discussing serious depression (this is not in psych clinic) said “wow, I’ve never talked about this with anyone before…”
I get that a lot.
And it sure as heck is ego-boosting.

Is it true? Who knows. Yes, probably. But it’s the white coat, the concerned look, leaning forward, attentive body posture, language (is it true? Yes……is it true every minute? …no). I am listening, caring, I am making notes. I’m also conscious of what I’m doing, though it is becoming fairly ingrained. (And I have an agenda, and questions I want to make sure I get to, I have a time frame, and I do have to redirect and interrupt). It’s not anything anyone can’t do. The mistake people make sometimes is forgetting all the human skills they already have, had before medical school. The best, most rewarding, most meaningful things I have managed to do, have, for the most part, drawn upon things I’ve had for years.
And maybe I’m more comfortable now than I was pre-med school in discussing difficult topics.

I’ve got the… license to do it (technically speaking, 1/3 medical license). I have gone through all these years and still am going through them in order to be…trusted? Trustworthy? Organic chemistry certainly didn’t make me that way.

I am engaged in each encounter. I try to be. But there’s also the walking briskly down the halls, always, around people in the hospital, looking busy-and-important. And trying to read my watch while a patient goes on and on and on because I’m going to be late for rounds and I still have to write down the vitals and the labs and do my assessment and plan and I have to present and I’m already supposed to be on the 9th floor and I keep interrupting anyway but…


In a hospital (this isn’t true of all of them) with widespread, good, easy-to-access wi-fi and cell service, I walk down the hall reading and answering email (thank you, ipod touch, and medical school that requires PDAs in the third year, and younger sister with a job and a penchant for buying the latest gadgets and sending the older ones to me…). I know where I’m going and I don’t need to look. I can do this at the same time, and I’m not wasting time. I’ve walked down the hall writing progress notes, before. It saves time. Today, between 7 am and 4:30 pm, I found 5 minutes in which I could – between dropping off orders on the second floor and running back to meet my resident in the ER – sit for 5 minutes and have cereal left in the resident lounge.
(This is a sometimes-but-not-always-necessary occurrence. As is the 4.5 hours of sleep – some things are self-inflicted, as I sit writing this rather than reviewing current guidelines for opportunistic infection prophylaxis, adrenocortical insufficiency and leukocytosis, or TIMI scores. Or differentials of syncope and alcoholism and dehydration. Or bullous pemphigoid. Or altered mental status.)
But I digress. AGAIN.

Here is an interesting exercise. “What is your name?” Correct answer. “How old are you?” Correct answer.
 “What is the date?” Confused mutterings, similar to “what is the day?” and “where are you?” This is where, in psych, we start in with choices. (Psych or neuro. same diff). “Okay. Are you in a store? A hotel? A hospital? your house?” Still no answer. I think maybe next time I’ll make it more interesting and add zoo or something…. heck, I have a friend whose grandmother had Alzheimer’s and lived in a delusional world that consisted of a perpetual cruise ship. Not bad, as far as delusions go).
Yet – the patient knew – “What city are we in?” “What state?” and “Who is the president?”

The things we retain.


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