Wednesday, May 25, 2005

Exit Stage

A thought occurred to me today that I know has been hashed out by cultures, religions, and societies for thousands of years, but that for the first time really made sense on a practical level. Death is almost exactly like birth, but instead is the opposite.
This month on the oncology service has been among the most remarkable thus far. In a way, it has been so remarkable that I have had a difficult time remarking on it. I have seen how precariously life can hang in the balance, how fiercely it can be fought for, and how easily it can be let to fade away. All of the patients I have seen this month are sick. This sounds a bit silly, given that I have been seeing sick people for almost a year now, but this month the patients are sick. They do not simply have a sickness. They, in a sense, are their sickness, because cancer, no matter how valiantly it is fought, will, at a minimum, take over a life, and when fulminant will simply take the life.
The patients that we see range from those who are admitted for "routine" chemotherapy to those whose bodies are losing their last battle. For the most part, every patient we have seen has been nothing but wonderfully kind and thoughtful and a true joy to know. We don't just get to know the patients, we get to know their families, and we get to know their stories. This makes it all the more difficult when they leave the hospital, all of us knowing that they are going home to die. This event of dying is one that I have feared witnessing. Every doctor has their story of their first patient that died. It is just one of those touchstones along our path. I haven't yet made that part of my journey, but today I came very close.
We have a lovely older woman in her late 70s who has widely metastatic breast cancer, including metastases to her liver, lungs, and brain. She came to us having seizures and extreme shortness of breath. For the past two weeks, we have been working on getting her to a point of having her pain managed well enough for her to be able to leave the hospital. Her family has decided that she should receive only comfort care, and that we should not make attempts to resuscitate her or intubate her should her heart stop or should she stop breathing (doctor lingo: do not resuscitate, do not intubate, or DNR/DNI). She has made steady improvement, but there have been several setbacks along the way, including her becoming delirious and needing to be sedated because she was taking swings at every one who came into her room, and a run in with pneumonia. Over the last few days she has seemed to become a bit more coherent, but still confused, and plans were in the works for her to go home with her family on Friday.
This morning the other medical student on service with me commented that this patient seemed a bit more confused and lethargic. Later in the morning, our senior resident rushed into the resident room where we all do our work, asking, "Mrs. E is a DNR/DNI, right?"
"Yes," several of us said in unison.
"Okay. She's dying."
The three of us who were in the room jumped up from our chairs and walked across the hall, following our senior resident into the patient's room. Her nurse and the nurse's aide were with her. Her eyes were closed, she was breathing very rapidly, her heart rate was less than half the normal, and she was unresponsive to us, but seemed to be trying to utter something. The four of us who had just entered the room gathered around her bed, and watched.
The thought kept going through my head, "This is death. This is the last battle for her." It felt like some kind of out of body experience, just too surreal to actually be taking place in front of me, with all of us just standing around watching it happen. There were questions flying around the room about calling her daughters to let them know what was going on, paging our attending and updating him, running checks of her vital signs to see if this would somehow pass, theories about what might be happening other than simply death. At that point, the four of us all had a task to accomplish to make sure things went smoothly and that all the proper people were called.
We left the room, did our tasks, and by the time we got back, she seemed to be improving. Her breathing was slowing, but still irregular. Her heart rate was approaching normal, and her blood oxygen level had started to creep back up from the depths. Then she started whimpering, "It hurts. It hurts." Again, a flurry of activity. When was her last chest x-ray and what did it show? Could she have just had another seizure? Is this something that actually could be easily treated? So again, we left the room.
After a few more gatherings around the bed, we drifted back into our resident room, and waited. We soon realized that she had, indeed, faked us out, and that although her death would likely be soon, it was not imminent.
It all reminded me so much of the nights on the labor and delivery floor, the waiting, the checking, the watching, the progressing of labor and the failure to progress. The knowledge that a life changing event was about to take place, and that it could be neither hurried nor delayed. Life, it seems, comes and goes as it pleases despite our best efforts to command it.
In experiencing these moments, I have noticed the division beginning to develop within me. There is the side that must think, "What do I do now with my knowledge and my skills to help this person medically," and the side that thinks, "Given my lack of real knowledge or experience, what can I do to make up for my lack of skills?" This is the same side that wonders, "Do I pray now?" and "Do I try and say something soothing or calming."
Not exactly being a churchly person, ahem ahem, I find the idea of actually praying a bit awkward, but for some reason, I find myself hardly being able to keep myself from simply thinking, "God please help this person and help us help them." Not having ever been in the position of having my legs in stirrups with all my goods showing while a small human is ejected from my body, I have an equally hard time mustering up the courage to say something as ridiculous as, "Keep pushing." Or even being able to imagine the feeling of hearing that first cry, that first breath.
And, not having ever been in the process of dying, it seems grotesquely inadequate to try and think of anything at all to comfort someone who is about to breathe their last, or to their families watching the last breath be drawn.
In both of these moments, I feel so small.

Tuesday, May 24, 2005

Four More Weeks

after this week, i will have only four more weeks left of my third year of medical school.
i still do not know what i want to go into after all this is over, and i have really just stopped trying to figure it out.
as has now happened 6 times previous, i am finding that i unexpectedly enjoy this rotation. i had really convinced myself that i would hate everything about internal medicine, from the hours to the patient population to the subject matter. i kept thinking," this rotation is going to make me learn about all that stuff i hate, like the kidneys." when i shared this thought aloud, the reactions i got were along the lines of, "well, i hope a doctor would know something about the kidneys..."
um, true.
so, here i am, finally actually understanding material that has evaded me for so long. i am not sure if it is because i can think, "oh, mr. so and so has kidney failure, and this is what happened to him, let me read about it so i understand more." maybe it is because my brain just needs to read about kidney failure 28 times in three years to finally get it, in which case, i will be about 78 before i am able to understand every organ in the body.
the other thing i feel i need to share right now is actually an answer to a question that has recently been asked of me several times.
the question is, "have you been watching that new show 'grey's anatomy?'"
answer: no.
i was intitally intrigued by it, and i watched a short part of maybe the second episode. it had to do with some guy dying and the interns deciding to try and get his organs or something. what i remember most are things like, " we're doctors, aren't we supposed to save lives?" delivered with such emotion that i nearly gagged on the puke welling up in my throat.
i have been warned that any form of entertainment involoving the medical world would one day be ruined for, and i think it now finally is. the thought, "that could never actually happen," has gone through my head several times, each time annoying me because i do not want to be "that girl" who always says things like, "oh, that would never really happen because blah blah blah," thereby ruining the show or movie for all the other people who are just trying to be entertained. so, i have now started avoiding any medico-fiction-drama in order not to have to see myself as "that girl."
and, since i am married to an attorney who has a very difficult time watching any legal fiction-drama, and since 90% of television shows have something to do with medicine or law, we have no choice BUT to watch intellectually stimulating shows like "America's Next Top Model" and "Showdog Moms and Dads." i suppose the one exception to my rule is "dr. 90210," a show on E! that i fond very amusing because, unfortunately, it is a pretty accurate portrayal of the kinds of personalities that flock to surgery as a career.
thank you for excusing the lack of proper capitalization.