ICU

Kind of your job

signout — Fri, 14 Nov 2008 15:22:22 +0000

Kind of your job

I've been away from the blog for a while, working on fellowship applications and riding the wave of the ICU. Thank you for your patience, as ever.

As you might remember from my days as an intern, I used to love the ICU. That love is no longer: doing procedures to people whose fate is inevitable isn't as much fun as it used to be, and I feel powerless in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

This most recent time in the ICU, I worked with an intern who seemed to me less eager than some to take on the burden of her responsibility. About three days into the rotation, she--let's call her Dawanna--remarked to me with some irritation that "all I ever do is put in orders."

"Yes," I replied. "That's kind of your job."

Of course, that's not her entire job--she is also meant to evaluate patients, make plans (or try to) for their care, and learn about their disease processes and our interventions. However, the intern is meant to be the first line for nursing concerns, and a large part of her job is therefore to write orders.

I was annoyed by her implication that this was a waste of her time, and that there was nothing to learn from this exercise. After all, I told her, when she is an upper level and her intern asks how to do things, how will she provide instruction if she hasn't ever done those things, herself?

Only a year and a half ago, I was an intern. I remember feeling demoralized at the paperwork--especially that involved in discharging patients. But the lists of orders carried with them a certain amount of satisfaction in their doing. I felt like the engine that made the hospital run, writing hundreds of action verbs every day: admit, administer, place, remove, flush, drain, call. While others ruminated, I did.

I remember cursing at computers, printers, and occasionally, behind their backs, other people--but I never questioned whether the job was mine to do. I was astounded that Dawanna did.

One of the things Dawanna didn't want to deal with was patient deaths. I know this because she remarked repeatedly that she hoped patients wouldn't die while we were on call. In my irritation with her, I related this to her lack of enthusiasm: patient deaths require an exam for pronouncement of death and a small stack of paperwork, which can be time-consuming. Not wishing to hear more about her distaste for her job description, I did not inquire further.

Today, I woke up and started reading "Final Exam," by Pauline Chen, a liver transplant surgeon. In it, Chen writes about the ways in which doctors are trained to deal with death, or not, and uses as illustration vivid tales from her own training. Early in the book, she captures quite beautifully what disturbs her most the first time she pronounces a patient dead:

I had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.

Until I read this, it hadn't occurred to me that in Dawanna's anxiety over patient deaths was more than mere laziness--that there was fear of what it might mean and what it might feel like to be the pronouncer of a person's passing.

Only a year and a half ago, I was an intern. I feared this, too.

In retrospect, I really should have asked what she dreaded about the pronouncement, and should've given her some space to talk about what it means when someone dies, or what it feels like to be present at a death. Even if it was just the paperwork she didn't want to do, it would have been good for her to feel able to explore her feelings around other--especially senior--residents.

Who thought I'd ever feel guilty about not being touchy-feely enough?

signout Fri, 11/14/2008 - 10:22

Tags

End-of-Life Care

ICU

medical education

Wonderful post, Dr. Signout!! BTW, I loved Chen's book.

Any chance you could take another crack at that conversation?

Have been missing you.

PP: Aw, thanks! I am loving her book, too. She makes very sensible points with great humility. I would submit to her scalpel any day.
Also, in your screed about Rahm Emanuel, you neglect the fact that he is So Freaking Hawt. Could you please consider that before you blather about him any more?

Heather! Absolutely.

Yay! Great to see you back! I'm catching up on blogs because I can't get out of bed, and a new post from you is almost as good as antibiotics.

Incidentally, I heard Rahm Emanuel was the inspiration for Josh Lyman, my unrequited West Wing crush. Good times.

Even if it's annoying, I don't think you should ever judge someone on the fact that they find the utterly meaningless aspects of our job, well, meaningless. Yes, it has to be done, and yes, someone the least senior has to do it, but that doesn't change the essential rationality of wondering why you're doing something that sucks when you could presumably be somewhere else, doing something else.

There's probably more going on here, but simply complaining about stupid stuff may be the only reason most of us don't hang ourselves in the bathroom at the end of every day.

Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.

It's funny, I never had any feelings of irritation or superiority when I was an intern doing the "scutwork". It was simply the stuff that needed to be done, and I accepted it wholeheartedly as an intern. I knew it had to be done, so why waste time and energy on hating it? I also looked at it as an opportunity to talk to the patients and nurses and get to know them, since we couldn't manage a social life outside of the hospital!

I am glad you recognized her dread about pronouncement as something more than paperwork. One part of my residency I loved was the once a week the hospital chaplain/counselor/ethics professor would round with us. He was great at asking these probing questions and helping us to recognize our own individual feelings and how to approach situations and the individuality of patients on high risk OB or gyn oncology.

Good luck with your Fellowship applications!

I used to hate deaths in the ICU, too. It may have stemmed from an unfortunate experience during my rookie days. Recently I worked in an LTAC and was gratified to see that I'd gotten more "comfortable" and thus felt more able to concentrate on being more empathetic with the patient and their family. Hopefully your colleague will keep growing in her position. (PS I'm just a nurse.)

hey Signout I've missed you and your touchy-feely posts.
I think I made a similar comment on a previous post but again as the mom of a NICU baby I have to tell you that doctors who are able to calmly deal with end of life conversations are a treasure.

Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.

thanks for sharing.

its very nice

Any chance you could take another crack at that conversation
Have been missing you.

Any chance you could take another crack at that conversation?

Have been missing you.

Lovely post, Signout, and a great reminder that we don't all interpret every aspect of our job the same as our colleagues do.

Even if it's annoying, I don't think you should ever judge someone on the fact that they find the utterly meaningless aspects of our job

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doing procedures to people whose fate is inevitable isn't as much fun as it used to be, and I feel powerless in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

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if you like. But more importantly, it is down-to-earth, pragmatic and action-oriented. This is illustrated by many cases from real life, telling us about inspiring people and

I've been away from the blog for a while, working on fellowship applications and riding the wave of the ICU. Thank you for your patience, as ever.

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in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

I feel powerless in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

I feel powerless in the face of a culture that doesn't

Even if it was just the paperwork she didn't want to do, it would have been good for her to feel able to explore her feelings around other--especially senior--residents.

We've gotten alot of messages regarding our dropping off of the Kylesa tour and yes

rless in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

o do, it would have been good for her to feel able to explore her feelings around other--esp

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I feel powerless in the face of a culture that doesn't exactly embrace the avoidance of unnecessary intervention.

n other words, in Turkey, the conduct of foreign policy is more institutionalized. It is not entirely dependent on Erdogan. The same cannot be said for the conduct of, say, Egyptian and Jordanian policy in the region.

Getting the Google Apps Migration for Microsoft Exchange (GAMME, for those who might not know exactly what Rob is referring to) to work was a huge pain, although once I figured out the right settings it was a piece of cake. I guess it would have been nice if I would have documented the entire process in detail, but I didnât, and now it has been a little while, so Iâll relate the tale as best I can remember.

I understand that residency is an education, but if medicine TRULY is about helping the patient and minimizing I read doctor blogs, you see, and they assure me that all is well.

Stand up straight

signout — Wed, 13 Aug 2008 06:22:26 +0000

Stand up straight

You know how, when you squint at a colorful tree, the borders disappear, and all the leaves merge together into one big mass of green? Turn that inside out, and you have my relationship with The Hospital. At times--especially difficult times--all the departments and interests and people in that place start to merge. Their demands and rules start to become one entity's demands and rules, and their borders disappear. I have to squint hard to separate the strands that come together to form the rope around my neck.

My friend Jack was in a terrible accident last week. I heard about it the evening it happened. After emergent surgery, he was rushed to the intensive care unit, where his chances of surviving the night were estimated at 50/50.

That night, I dreamt that when I went to visit Jack in the morning, he had done so well that he had been transferred to a non-critical floor. I smiled as I walked down crepuscular hallways, looking for his name on the lavender-colored room doors inside my head.

I woke up early to see him, and when I swiped my badge at the entry into the unit, he was still there. I waited outside his room--after all, I am his friend, not his doctor--and when his nurse came out, I asked if I could see him. She frothed at me: I could not see him. I should have entered the unit as a visitor rather than with my badge, since I was coming as a friend and not a provider. I would have to come back. And no, she could not tell me how he was doing.

I did not ask her why, if I was a visitor, I was being chewed out as though I were merely a resident. I instead burst into tears and left.

I stood in front of the window outside the unit, watching the early morning creep into the parking deck across the street. Downstairs, my own work--in a different intensive care unit, with different patients--was to take care of patients exactly like Jack. I knew exactly what we whispered to each other about people with his injuries, and I wished now that someone would tell me that it was all lies.

That afternoon, I was pulled aside by a superior and told that something I had said had caused a patient's family member to raise an eyebrow. A few days prior, I had been post-call--awake for 30 hours--and on rounds, I had mumbled, "God, I'm so tired I can barely stand up." This, he said, had been seen as unprofessional.

I turned to face him and marveled at the strange blur before me. No eyes, no ears, no chin--just a building with a big, flapping mouth for a door and an inconvenient parking structure tacked awkwardly onto the back. Flap, flap, flap went that mouth.

Here is the message the hospital was giving to me: I am expected to maintain firm boundaries, refrain from complaining; and provide to patients' families exactly what they want, whether it's reasonable or not. However, I should not expect that when I am the loved one of a patient, I can demand any of the indulgences that families can demand of me--not kindness, not time for my own grief and anger, not a sensation of loss of control. I am a pillar of professionalism at all times, and even when I snap in two, both halves need to stand up straight.

I squinted, trying to pick out details, perhaps an element of misunderstanding, or spaces where I could come clean about my sadness. But I was too tired, and whatever it was I was seeking was hidden behind that blurred facade.

Sure, there are faces in that building that express compassion--it's just not compassion for me.

signout Wed, 08/13/2008 - 02:22

Tags

ICU

Hang in there, Signout! I hope your friend Jack is doing well - fingers crossed.

To my mind, this is a by-product of the mentality that views patients as "customers". You? Why, you're just the help.

Very nice post, Dr. Signout! I am sorry about your friend.

The sort of compartmentalization you describe between "professionalism" and "compassion" is very typical of professions in which one owes a special duty to someone else, such as medicine and law. It does serve a useful purpose, but also has unfortunate side effects, as you point out so eloquently.

Your concern for your injured friend and your dismay at the misguided professional environment emanate pain and compassion. We wish for your friend's successful recovery, and are appalled at the way you were treated by your peers. You may not be able to change the world today. But knowing that you can see and guide a way for change, we know there is hope for all of us.

I send my best wishes to you, Jack, and Jack's family.

I forgot how beautifully your write. Welcome back.

The day we allow physicians show their humanity is the day medicine will take a giant step forward.

Too much humanity may not be a good thing - see:

http://www.boston.com/news/local/articles/2008/08/10/hospitals_try_to_c…

I'm so sorry to hear about your friend, and about your hospital situation. How dehumanizing. *hug*

mdiehl - while that's an interesting link, I really don't think it has anything to do with the situation that Signout's describing. A resident trying to visit an ill friend or commenting on how tired they are is certainly not the same as a surgeon throwing scissors at someone.

I am so sad for you, and so sorry for your friend Jack, and I hope he will get better. I hope they don't grind that compassion out of you. Wish I could come by for a cup of tea and just to give you a hug.

And damn, I wish I could write like you! I'm sorry you have such a heartbreaking story to tell, but you tell it so very well.

mdiehl, I read a similar article in another paper recently, and I don't think "humanity" is exactly the right word for throwing things, swearing, and put-downs. Those things might be human, but they're not humane. I don't think Signout is making an argument here for that sort of arrogance or temper, and I'm guessing Abel Pharmboy didn't intend to, either. It isn't so much a matter of "too much" humanity as of what KIND. No work environment benefits from the presence of violent, condescending blowhards. They blow up because of the stress? Puh-lease. What about the anxiety they create in everyone around them? And what about all the people who manage, every day, to do so much better?

Signout, I've been missing you. Sending all my love, and very best wishes for Jack.

You are all far too kind. Thanks for the warm welcomes back! If Jack weren't intubated, I'll bet he'd thank you for your kind thoughts, too.

Brian, you're right on. I'll probably discuss that mentality in a later post. There's a fine line between providing care that meets peoples' needs and providing customer satisfaction, and it's not always clear which side I'm on.

Ophir, are you the Ophir I know? If so, hooray! If not, just hooray, without the extra punctuation.

MDiehl, I am going to stab you in the eye with these scissors. Kidding! Thanks for sharing.

Ctenotrish, you are always so encouraging. Thank you.

Heather, I miss you, too, and your always-thoughtful words. I want to come to the prairie and eat your cooking.

And to my fantastic Scibs: if I hadn't met (or re-met) all of you last weekend, I'm pretty sure I'd have already sent in my letter of withdrawal from SB. Thanks for reminding me what a great place this is.

Any surgeon who would ever throw a pair of scissors at someone must be a lone wacko. That kind of behavior couldn't possibly reflect anything in general about the medical profession, because the medical profession has been completely expunged of all paternalistic, patriarchal, and/or arrogant attitudes on the part of physicians and surgeons towards patients and/or other participants in the medical enterprise.

PP, I am going to hack off your junk with a wooden tongue depressor--not because I am threatened by your notion that patients and physicians should be equal parts in medical decision-making, but because I HATE YOU.

Big love,
Signout

Holy shit! Drink some coffee, quick!

I know I'm late to this thread, which is a pet peeve of mine, but I can't help but...aw crap, your posts always make me write my own, so I'll finish my thought over there.

Oh, and if you perform a successful orchiectomy on PP with only a tongue blade, I'm pretty sure there's a Lasker prize waiting for you.

I think a lot of visits are more for the parents than for the kids. You identified what her real concern was, which is not as easy as it sounds. Nicely done.

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The day we allow physicians show their humanity is the day medicine will take a giant step forward.

Coping is fun

signout — Wed, 07 Feb 2007 20:31:25 +0000

Coping is fun

I'm always a little restless the night before a new rotation. Sunday night was no different, and I laid awake in my bed for longer than I'd hoped to, worrying about leaving behind the intensive care unit (the ICU) and switching to the general medicine floors.

At about six o'clock Monday morning, I walked into the room of a 91-year old guy admitted with antibiotic-related diarrhea. "How're you doing?" I asked. "Anyone I can get my hands on," he said, and cracked a little grin. Instantly, I was back.

What I worry about most prior to starting rotations is whether anything in the new place will make me laugh. It's not an issue in adult intensive care units; staff humor in the ICU is notoriously dark and free-flowing, and that's part of the unit's appeal. In my most recent ICU rotation, I overheard a fellow prognosticating based on the shapes of her silent patients' gaping maws: an "O" sign (patient unconscious, mouth open and toothless) was bad, but a "Q" sign (same, but with the tongue hanging out the side) was worse. An intensivist who is locally famous for taking on patients with complex social and medical problems named a quotient after himself to predict his patients' lengths of hospital stay: (age ÷ trailer park lot number) + I.Q. One attending signed out to another that he planned to discharge a patient upstairs within several days (our ICU is on the top floor of the hospital). Others tell dirty jokes with reckless abandon, send residents on false and improbable consults--Siamese twins! With necrotic livers!--and giggle wildly at references to poop.

Death is all around them; they're coping, of course. And the coping is fun.

When none of my patients can really talk--and most of them in the ICU cannot--I forget that sick people need to cope, too, and that some of them want to laugh as much as I do. Apparently, some of them even want to make me laugh.

I'm happy to oblige.

signout Wed, 02/07/2007 - 15:31

Tags

ICU

Internal Medicine

Trusted to take care

signout — Fri, 02 Feb 2007 20:34:30 +0000

Trusted to take care

A few days ago, I posted here about a recent ICU admission of a patient with pancreatic cancer. Her admitting diagnosis was septic shock, and I'd initially included some detail about septic shock to help illustrate a clinical dilemma in her treatment. Although that portion was ultimately edited out, this is how a snippet of it read:

In septic shock, the blood itself is infected, and byproducts made by the infectious organisms cause the blood vessels to become dilated and leaky. The danger of septic shock is poor perfusion of important organs, like the brain, the heart, the kidneys, and the intestines. Naturally, antibiotics are a mainstay of therapy for septic shock, but intravenous fluids play as critical a role by supporting the blood pressure within the now much larger system of blood vessels.
Fluid support isn't without its own problems, though: Because the blood vessels of the septic patient are both dilated and leaky, a large proportion of the fluid you put into them goes out of them and into tissues elsewhere in the body. Much of the fluid poured into septic patients ends up in their arms and legs, but more often than not, a lot of fluid also ends up in their lungs. For this reason, septic patients sometimes end up intubated and requiring mechanical ventilation. This buys some time for their infection to be treated and for fluid to be drawn out of their tissues and circulation. Depending on their prior state of health, patients with sepsis can recover from all of this with little lasting morbidity. And because it's much harder to recover from a non-existent blood pressure than from pulmonary edema (fluid in the lungs), patients with sepsis always get lots of fluids, period.

I retroactively present you with these paragraphs to show you that I know what septic shock is; that I can identify it fairly well; that I know how to manage it; that I know what some of the challenges to its management are; and that I know how to overcome some of those challenges. I'll add to this that in the past few days, I have been reading quite a bit about septic shock, and can currently quote at least two seminal papers demonstrating the importance of early therapy in treating it.

I tell you this because today, I was peripherally involved with the admission of a man with a story suspicious for septic shock--and because I made some major mistakes in taking care of him despite knowing his illness very well.

He'd come in from home, where he'd had a few days of fever and shortness of breath. He'd coughed up a little blood earlier today, had gone in to his local hospital, and had been intubated for severe shortness of breath. At this point, his blood pressure had plummeted. The staff in the emergency room had started him on intravenous medicines to increase his blood pressure, but had kept him on modest intravenous fluids because of their concern for pulmonary edema.

I had the first look at the patient when he came in, and got a slightly less detailed version of the above story from the EMT's who had transferred him to our hospital. My role in his admission--there was another intern taking charge--was to write his orders.

When I first heard the story, I said, "We should give him a few liters of fluid as quickly as possible." His nurse commented on her fear of flooding his lungs, and I backed down, keeping his fluids at a relatively low rate. Additionally, confused by the many conflicting options on a new sepsis order set, I folded it up and stuck it in the pocket of my white coat to deal with later. Once I'd written the basic admission orders, I went back to the main priority of my evening: checkyboxen.*

About an hour later, I overheard the attending doctor in the patient's room. "This man needs fluids. Bolus two liters of normal saline. Why isn't he getting more fluids?"

I have been asking myself the same thing for the last four hours. Sure, I am ashamed and embarrassed--although I'm not really in this to impress attendings, I definitely didn't impress anyone today. But I'm also scared of myself. It's enough that there's so much I don't know; if there's something I do know and I still don't act on it, how can I possibly be trusted to take care of people?

There are many things I can try to blame for my failure: the absence of senior leadership in the ICU at the time of the admission; inexperienced nursing; my fatigue at fighting with ICU nurses; my fatigue in general; those effing checkyboxen. None of these, however, takes the place of my responsibility for knowing what to do and doing it. And none of it explains how and why all the things I knew didn't come together to move me to action. I don't know how late that will keep me awake.

It's possible that this, too, is part of my training. If I don't make some scary mistakes, maybe I'll stop taking the details seriously--maybe I'll never really stretch myself.

I wish there were a less frightening way to learn.

*Checkyboxen: the small, meaningless tasks that take up most of the time of the average intern. The word originates in the small boxes scrawled next to tasks on an intern's to-do list. Completion of each task is signified by checking its neighboring box. "Hey, medical student! Can you go find this x-ray? I'd do it myself, but I have too many checkyboxen."

signout Fri, 02/02/2007 - 15:34

Tags

ICU

Whoopsie

Shock

signout — Wed, 31 Jan 2007 21:17:38 +0000

Shock

At about 8 a.m. today, the code bells sounded. ("I love the smell of chaos in the morning," said a nurse nearby.) I ran to the code, but because I had to schlep over from the intensive care unit (the ICU), I was late, and I didn't make it into the room. Scowling, I trundled downstairs to get back to pre-rounding.

Half an hour later, the ICU fellow came and tugged on my sleeve. "The code upstairs? She's here, and she needs lines." I jumped up, gathered supplies, and went into the room.

The patient was lying in bed, her eyelids stained violet as if with makeup. I began to announce myself brightly, the way I do with all my comatose patients ("Good morning, Mrs. Smith! Why, your nurple is exceptionally purple today!"), when I realized she was not intubated. This was very nearly alarming: I have never actually witnessed a code where the patient was not intubated.

When I began to lower the head of her bed, she shouted. "Ow!" I stopped and apologized. "It's OK, but girl, they hurt my chest something awful this morning. I feel like I've been beat up."

She had been beat up, so to speak. Her heart had stopped completely, and she had received chest compressions and one electric shock to her chest wall to restart her heart rhythm.

Still, I had to step back and verify that I was in the right room. That she was breathing independently was surprising enough, but that she was completely lucid just seemed improbable. And yet, it was true. For several reasons--among them the fact that her pulseless arrest was witnessed--her resuscitation worked.

I am so used to participating in minimally successful resuscitations of very medically fragile people that I was utterly stunned by this positive outcome. This, of course, speaks more to the population that is both electing and requiring CPR in hospitals than it does to the CPR procedure or practitioners--which, of course, speaks to the need for providers to be brutally honest about how well CPR works.

Otherwise, we just end up being brutal.

signout Wed, 01/31/2007 - 16:17

Tags

Codes

ICU

Hey there, Signout.

Great story. You raise an important point: there are mismatched expectations as to the success of CPR. One of the culprits is TV and the movies. I wrote a little about this here, especially a fascinating study quantifying the disparity between CPR rates on television versus those in real life.

Best,

Blog, MD

Clearly I am a neophyte, but what's a "code"?

A code is an inpatient cardiopulmonary resuscitation--but it's also so much more than that. I meant to link to an earlier post that explains this. Sorry to be obtuse.

Different conversation

signout — Sun, 28 Jan 2007 16:39:07 +0000

Different conversation

Back in October, I admitted a patient to the general medicine service with a three-week history of abdominal pain and progressively yellowing eyes. She was a large, pleasant, quiet black woman who was almost always accompanied by her husband, a broad man with laughing eyes and a white beard who wore an old-fashioned train engineer's cap. Her history was suspicious for pancreatic cancer, as was the flurry of radiologic studies and biopsies that followed her admission.

On a Saturday morning shortly before I finished the rotation, I had a long conversation with the patient and her husband. During this conversation, I told them that although a diagnosis was not yet confirmed, cancer was one of the more worrisome and likely diseases she could have. They were both quiet, and his eyes became wet. That afternoon, on my way out of the hospital, I saw her husband alone in the lobby. He took me by the elbow and asked if he could speak with me. Of course, I said.

We sat on a bench in a quiet hallway nearby. He had questions about some of his wife's studies, so I drew him some pictures and explained the tests until he seemed to get it.

Afterward, he asked, "Doc, what's your specialty?"

"Um, nothing yet," I said. "I'm still too early in my training to have a specialty."

Then, in the space where I was anticipating a small flood of gratitude, he asked, "What do you know about honey?" Over the next thirty minutes, he shared with me his bizarre and rambling theories about the healing properties of bee products as influenced by his readings of the Bible and the collected works of Louis Farrakhan. The conversation was a bit surreal and the logic impossible to follow, but I sat through it.

I later asked myself why; although I love talking to my patients, I'm normally very good at weaseling out of long, tangential conversations, especially ones that involve the Nation of Islam. I suppose I listened to him because I felt bad about telling him that his wife might have cancer.

Now, four months later, I am on a rotation in the intensive care unit (where, by the way, I am happy as pig in slop). This morning, we got signout on a patient whose name I knew instantly--it was the lady with pancreatic cancer, and there was her husband at her bedside once more, wearing the same funny cap.

I was instantly glad I'd sat through his entire half-hour of crazy without finding an excuse to leave. I'd happily sit through another hour if it meant avoiding the very different conversation that we'll probably have tomorrow.

signout Sun, 01/28/2007 - 11:39

Tags

End-of-Life Care

ICU

Internal Medicine

Your ability to empathize with someone whose outlook is so at odds with your own is admirable. On a more literary level, your ability to deliver a clear message while leaving much unsaid is nothing short of masterful. Anyway, I have been a fan of medical literature for a long time (Oliver Sacks, Richard Selzer, Atul Gawande), and I look forward to a book by you some day. Of course, I'll have to be able to discern the style, since a name is absent. :)

I hear your about the pig in slop in the ICU. It's bad, bad for my future as a well-rested human being. But I'm SO happy to hear that you're happy to be back in the adult world!! And amen to the "book by you some day" comment from penseroso!

Sheesh, don't they teach you any of the human side of medicine?

The next time the whole family is in the ICU, just make a point of saying to one of the other residents, "Of course, she would never have had to come to the ICU if we had just treated her with BEE POLLEN!" in a loud, sarcastic voice. Do it at a distance, but make sure the volume is high enough to be overheard. That will ensure that he doesn't waste any more of your time with his crackpot theories.

Of course, you don't want to make enemies out of them, so bring up some packets of honey from the cafeteria and leave them on her night stand.

Hey, plenty of healing power is to be found in honey. My grandfather was a bee keeper and he was never sick a day in his life. Well, except for the cripplingly bad back pains. And the copious amounts of alcohol he used to numb the back pain. Come to think of it he did get sick quite a bit but his Germanic stoicism had him work through everything. But it was the honey ... was VERY healthy for him! Really!

I'll offer a third voice in support of a book. And I can hear you already, "I'm still young. I haven't done anything worth writing about." And I would disagree, of course.

I'd point out that you have some amazing life experience to share. That your path has been an example of self-determination, of choices and experiences leading you to become a doctor on your own terms. And your slice-of-life style of essays would be an engaging format for younger readers. That as a primer your course through life, mistakes and all, would be an inspiring read for young women seeking their own future.

But no pressure. ;-)

Besides, it would be a perfect morning read accompanied by a cup of tea with honey. And we all know how healthy honey is.

What not to become as you grow in your chosen field. Best to you.

Empathy is an art as is Medicine. You have already mastered writing and it appears that you are well on your way to mastering the Art of Medicine. RCTs, scientific method etc. have their place in medicine, but they are an incomplete picture. Human beings are much more than a collection of scientific analysis and study they bring other dimensions which set them far above any other creature. Your exploration and insight into these dimensions will serve you and hopefully others very well.

Everyone just settle down. There is no book, no book deal, no novel, no screenplay, and no agent. I have a job, kids.

Thank you, regardless, for the generous and kind comments.

Reading this entry, I'm wondering if we are at the same hospital...I could swear I took care of this woman today.

Hmm. Although you don't look familiar to me, it's certainly a possibility. Far more likely is that there are several women in this country who have both pancreatic cancer and wacky husbands who wear funny hats. Regardless, thanks for the comment, and good luck!

Avoid peoples' stories

signout — Sat, 01 Jul 2006 20:25:10 +0000

Avoid peoples' stories

My parents call me every few days and ask to hear stories. Sometimes I'm contrary about it, and just rattle off a list of diagnoses and interventions. But I know that's not what they want. They want a heroic ideal. They want a dramatic arc. They want a story.

To get to the ICU, you have to be unable to either breathe or maintain a blood pressure on your own. Most of our patients are mechanically ventilated and quite heavily sedated, and all require careful attention to the tiniest minutiae of their conditions. We rarely know what our patients were like before getting, as one of my residents says, "shlogged." I suppose this makes it easier to focus on the doings of their protoplasm instead of the drama of their survivals-or of their deaths.

I guess what I'm trying to say is that the ICU is a place where it's easy-and maybe even beneficial-to avoid peoples' stories. Even when a patient's chart suggests good buildup or interesting characters, those things easily get lost in the thicket of tasks surrounding the gathering and management of their medical information. Maybe that's why I don't love the ICU: although my colleagues are quick-witted and entertaining, I only get the faintest outlines of what, other than physiological parameters, defines my patients.

On call nights in the ICU, I'm responsible for covering not only patients in the unit, but also "weaners"-patients elsewhere in the hospital who are slowly coming off mechanical ventilation. At about midnight last night, I was called to see a weaner for "poor toleration of feeds." I did, and then sat down to order some tests and write my note.

Here is how I started: "Called to see patient to evaluate for poor toleration of tube feeds." What I meant was: This man, who breathes with the aid of a machine through a surgically created hole in his neck and eats 70 milliliters an hour of a light brown solution through a different, also surgically created hole in his abdominal wall, just vomited out of the surgically created hole in his neck.

The next sentence: "Patient is an 85-year old man with quadriplegia and global cognitive impairment following a motor vehicle accident one year ago." What really happened: An old man drove his car into a building and nearly killed himself, but someone was able to keep his organs perfused and his lungs inflated. Although he can't move or think or speak or understand, he can blink, and because of that, his wife can't let him die.

And the punchline, my assessment and plan: "Flat plate abdominal film shows evidence for abdominal ileus. Recommend holding tube feeds, continuing insulin coverage as necessary. Reassessment in a.m." Translation: I hereby pretend to subscribe to whatever logic has made it possible for this man's existence to get to this point, and tomorrow morning, you should, too.

It sometimes seems that the sicker patients get, the more their real stories reflect doctors as villains. I'm not sure how much people want to hear about who we really are.

signout Sat, 07/01/2006 - 16:25

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ICU

I think people differ greatly on this issue. For example, if it were completely unidentifiable as my own, I would have no problem with a picture of my naked ass being posted on the Internet. Others would be absolutely horrified by the prospect.

Others would be absolutely horrified by the prospect