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.