Talk about a tough crowd: on making a dying man laugh

I haven't posted in the past few days because i have been relatively depressed by medicine in general. I have found my niche, so things are getting better, but it still tends to NOT be how I want to spend my days. I miss the lab so much more than I ever thought I would. A few of the recent things that have happened in my last 4 weeks. I have spent the last 2 weeks in the ICU at Memorial Sloan Kettering Cancer Center, the 2 before that in the Coronary Care Unit (CCU) in NY Presbyterian.

In the CCU, we "round" for 5 hours each morning. This is where you walk around to each room with the housestaff (Residents) and the Attending (older doc thats in charge). One morning on presenting my patient I said "he had a thrombus (clot) in his (specific vessel) so they went in and removed the occlusion". My attending is crazy. She was like "woa woa woa, they removed an occlusion? How do you remove an event???" I reply, "like i said, the occlusion was a thrombus, they removed the thrombus" "RIGHT, they removed the thrombus, ...." on and on she went.

As busy and stressed as drs are I cannot imagine this helps, especially as we know stress, fatigue, etc leads to many errors.

Rounds today is this intimidating time when everyone tries to shine and the attending picks at whomever they can. I actually don't mind it - I often just laugh at the attending. BUT, I do not think this is good for patient care - but people don't seem to care so much about that it seems. As one prominent physician that trained at Harvard told me "at rounds it was a feeding frenzy - you came ready to knock anyone down you could and show your stuff - if a little patient care came out of it, fine, but that certainly wasn't the goal."

In the ICU, I had an attending correct me for giving him the Ventilation settings NOT in the order he wanted. This is more humorous when you consider that I was giving the info in the order that the last person I was with wanted it in. I just laughed and said, "ok, what order do you want?" And he said about 8 things more quickly than I could write them down, when it was obvious i was trying to write it down. The point wasn't to do it that way, I learned, it was to lightly haze me. Patient care? Not so sure that is high on the list.

Actually, things have gone quite well. I guess I am giving you only recaps of the things that bother me. In reality, I have had some AMAZING residents take me under their wing and help train me. Both of my last 2 weeks I had a patient mainly to myself. Both pts will die sooner rather than later, which it turns out is where I excel. My gift so far has been talking to families about diseases and what they mean, particularly with an eye on death.

Turns out I love nothing more than making a dying man laugh or explaining to a spouse what a disease means and putting all the articles on treatment I read the night before in context of the patient. My lab interests fuel my interactions with patients. Particularly, I find that as much as I want to leave medicine and go into comedy or some other public speaking avenue where i can tell jokes on stage, I have found nothing more fulfilling than making a dying man laugh.

I'll close with this, about my patient with incurable and untreatable stage 4 (spread everywhere) esophageal cancer:
I watched as people came in and out of his room, the psychiatrist, the family, the cancer team. All with the same looks, all with the same news. Time to be comfortable, we cannot treat you - you are too sick. Any chemo would kill you. We are sad the family says. Can't you fight more the wife says? Can you help him suffer less the mother of the man says to me. In and out of the room they go, he sits there, stoic. I talk to him often. In fact, I am in there with every team that comes in, and unlike the docs from different teams bouncing in and out on to different rooms or lunch, i began to feel the dreary mood in the room. He never has the luxury of escaping it. I share with him that my grandpa was a merchant marine like he was. He smiles politely and says nothing. I let him be for days.

After some days, many with intense talks of death and DNR orders, I walk in to update him. "Matthew," he says. "Yeah?"

"What did they find on the spit - the test where they had me spit up stuff?"

"Oh, nothing really. They found bugs, but its the usual bugs that live in your mouth"

I realized immediately that explaining this concept was probably fruitless- I should have just said "they found nothing" rather than try and explain they found normal oral flora which means nothing.

"Bugs???" He said wide eyed.

"NO no" I said, "you know how those yogurt commercials talk about how its for the good bacteria of your gut?"

"yeah" he said.

"Well they found some of the good bugs like that - so you have no infection...think of this way, from mouth to butt, you got bugs, and that's what we all have, its normal."

He just broke up laughing, the first time I had seen him laugh. I cannot explain the feeling.

"From mouth to butt, I have bugs, eh?" He says and then laughs more.

"I like that, you're funny man," he says.

I wasn't sure why it was so funny, but I just laughed with him.

I've made big groups of people laugh at me while on stage, or college classes laugh as i taught, or my family laugh at the dinner table. But none of these compared to the feeling I got from making a dying man laugh. It is all worth it, it turns out. For that one laugh. My grandfather died years ago from esophageal cancer. My mom wanted me to travel up there with my dad so I could keep the mood upbeat, be funny, lighten the atmosphere some in the tough times. I'm not sure I did anything particularly special on that trip, but it opened my eyes to how my gifts could help the dying.

We all die, there's no reason to be in a bad mood as it approaches.

Goal: Family Medicine...in Rad Onc

I noticed that I get the most satisfaction out of the patients that have extended stays - particularly the ones that we end up providing palliative care to so they can die in peace. The patients here emergently or just for a day or two bring me no pleasure- for me there can be real care in taking care of someone over a long time.

Thus, today I had a vision of Family Medicine for my career, but within Radiation Oncology. I could provide palliative care to my patients or whatever their need might be, but they would become part of my "family." They would have email and phone access to me as they went through their cancer struggle. Just like family it would not be for emergency purposes (yes, I would still go on vacations, live life, etc), but it would be like family - they could call when things got difficuly, particulary if they were left with no family to be there for them.

I have noticed that both my grandmother and mother (and father) would take people into their house at all times, making many of our friends part of our family. And it wasn't unique to any of us - I have a brother that my sister once dated and a best friend who visits my family without me sometimes!

My vision is to have a small practice with cancer patients like this...unfortunately, this niche is hard to carve out in our current, fragmented system!

Watching Death

The weekend was WONDERFUL - a sad reminder that I just dont like practicing Medicine, atleast not how it is practiced here. In fact, more and more each day I understand why Docs seem to pick their specialty based on the people in it with them. I understand why a 55 yo Dr contacted our lab at Auburn because he was sick of spending his days with MDs...I get it. Its a nasty group. As I explained to Mandy tonight, they all think they are so pleasant, so clever, yet most of them are complete bears to be around, atleast so far. Felt like they were rushed or rude to you at your last visit? Join the club - they re like that to me too...When I arrive in the morning no one says hello. I simply join the room. When I leave, I say bye, but to whom? Myself mostly. And the bad choice I made by pursuing a life in medicine. I will be clinically depressed if I don't find relief. The only way I have learned to do this so far is by getting up and just walking into one of our patients rooms...I continue to be AMAZED at how wonderful patients are.



I have also learned that I want to do palliative care and NOT round with a team each day. I want to TEACH the concepts of medicine (does anyone do this anymore??); ideally I would teach most of years 1-2 in a medical school AND practice where I can make complicated, calculated decisions for my patients. Ideally as they face life and death. Radiation Oncology continues to be at the top of my list. I HATE how in medicine we "hear" a case from a colleague in 3 minutes, make huge decisions, and move on to assimilate the next data on the next patient in 3 minutes. It really is crazy. I want to follow patients long term, ideally dying ones. Its hard to explain why, but I like helping people at the dark time when so many seem so timid. It's part of life, death it, we all go through it at the end. Rich, poor, famous, etc.

Today we had a patient who looked wonderful get terminally extubated. I heard it was coming (we had her in the ICU for the last week+ and I thought she was one of the healthiest in there!!) Her only problem was that she couldnt breathe on her own. Today I heard she was going to be extubated so she could die in peace. All of her loving family were there to say goodbye. She was alert, oriented, and answered with nods of the head and facial expressions (Cannot speak with trach tube in!).

Later in the day, I saw the resident directly in charge and simply said to him "I am very interested in palliative care, and I dont want to get in the way, but iw ant to learn about how these things work."

"sure," he said.

"So i can follow you?" I asked.

"yes" he said.

And I did. The pulmonary specialist, the resident, and me joined the family in the room. We answered the woman's few remaining questions. Her husband sat teary-eyed holding her hand the whole time.

"You've been very brave," the specialist said. "We are not going to let this be uncomfortable for you."

There was a sad smile in her eyes. Her daughter in the corner of the room cried. She was certainly too young to die, but her lungs refused to work, and the only option left was a nursing home, where we would just wait for infection to kill her as she lived out her final days away from her family on a ventilator).

They then explained to her how it would go. "We are going to up the morphine and then we will pull these tubes out...it will make you cough and choke. Before you breathe in, I need you to couch and spit as I pull it out." She nodded sweetly.

The morphine went up. People cried.

I stood at the bedside, trying to not be in the way. About 10 family members were in the room with us. The pulmonary specialist, a resident, and a nurse stood there too.

The tubes came out. She choked and coughed.

Her husband encouraged her to cough and patted her back. People cried. I stood there.

Coughing went on for about 2 minutes, then she layed her head back, eyes open and breathing.

The respiratory doctor said she did good and "goodbye." He left the room. I was confused, I thought we would all stay as she died...

Next my resident left and the nurse stepped out. It was just me. I was confused. Now what? Luckily, nurse and resident came back, and then when resident left again I left with him.

Oddly she was still alive and eyes open as her family held her.

I found a senior pulmonary care doctor I knew from class in the hallway to ask him what was going on.

Basically he expected her to live for several hours after extubation.

"Oh, she will live for hours like this" he explained.

"At some point the CO2 will get too high and simply put her to sleep as her breathing fails."

I realized I knew the physiology very well, it just never occurred to me how this might play out in a person in ventilatory failure - it could take hours, not necessarily minutes.

I also thought it was one for the nice perks of medicine that we supply high narcotic doses so patients do not have to choke and drown and suffocate as they leave this world.

Yes, more and more Radiation Oncology captures me - a chance to do calculated, precise work and palliative care with a large amount of research.

Time of death for her? I dont know, she was alive when I left tonight. I am quite sure she will fall peacefully asleep tonight. Forever.

What's this VO2max stuff?

All week I have been in the Cardiac Care Unit (Cardiac ICU). What an experience.

Medicine culture is really silly. By law, you are not allowed to listen to anyone "below" you. Good example: my PhD is in Exercise Physiology, where one of the things you do ALL THE TIME is measure gases that people breath during exercise testing. You might have heard of VO2max- the max amount of oxygen your body can use. Thus the equation is just VO2 = bloodflow X difference in arterial and venous blood oxygen. Thus, you know how much oxygen was used by the body. It is that simple. In the resident room a Cardiology Fellow (has been a dr for several years now) was trying to figure out cardiac output of a patient. Use that (VO2max) equation someone says.

"Yeah, VO2max - what does that mean again?" he asks.

They google it.

I sit smiling, thinking "really guys??"

"You must be able to estimate it from body surface area" he says.

I cant take it anymore "you definitely CANNOT estimate it from body surface area" I say.

They dont even turn around. "yeah, maybe not" one says.

"No, you definitely cannot," I say. "the variability is huge."

they ignore me and move on.

They go on to discuss what VO2max is. It is funny to me b/c this is my bread and butter. And it aint like I "Studied it as an undergrad" or even "did a thesis on it" as many young doctors like to say. (e.g. "yeah, my masters thesis was on heart failure"). My PhD is in this stuff AND i taught it for 4+ years at a University.

Sadly, in medicine it's all about ego. Why would i ever be able to teach them ANYTHING, i'm below them!! It's a sad sad culture.